LONDON, SATURDAY 17 JANUARY 1976
MEDICAL JOURNAL Asylums
are
still needed
The year 1975 was to be Britain's psychiatric millenniumor so we were led to believe. That was the date the recommendations of the Royal Commission on Mental Health Law (1957)-written into the Mental Health Act, 1959, and adopted as official policy by successive governments-were to come to fruition. But the arrival of the brave new era depended on the achievement of two objectives: a reduction by nearly half in the number of local mental hospital beds, and the development of a whole range of services collectively known as "community care." Now 1975 has come and gone, and not even the most starry-eyed supporters of the official policy-and they were in a substantial majority-would assert that any more than limited progress has been made. The opinions expressed in the BMJ have not been on the side of the big battalions; indeed, we have been conFtantly critical not so much of the policy itself as of its practicability. "No one tested the situation to see indeed if the community cared," was our comment in September 1966.1 Not long afterwards2 we questioned how much the reduction in the population of mental hospitals was the result of restoration to health through therapeutic advances and how much was a sociological conjuring trick. Again, in 1971, we asserted3 that community care, as it existed then, had still to be proved much more than a resounding catchphrase. That, indeed, has been the disastrous fault in the policy; for, as a result of the muddling ineptness of a succession of governments, the rundown of the mental hospitals has led to an increase in the numbers of men and women condemned to a life of rootless wandering in which reception centres, common lodging houses, prisons, and park benches have become the only available resting places. "It is hard to believe," we said4 in 1973, "that such an existence of aimless destitution is preferable to the organised and structured life in a well-run mental hospital." It is against this background of disillusionment and disenchantment that the recent White Paper,5 Better Services for the Mentally Ill, can be judged. Although it sets out to defend official policy as best it can, it acknowledges some at least of the failures in the 15 years since the Mental Health Act came into being, and it even sheds a few repentant tears. For instance, the paper admits that the term "open door hospital" has, like "community-care," become with time something of a catchphrase and that those who require continuing care, though not necessarily medical or nursing care, are particularly vulnerable to the present virtual total absence of long-stay sheltered accommodation in the community. I BRITISH MEDICAL JOURNAL 1976. All reproduction rights reserved.
In what reads like a quotation from our own columns the White Paper states that "Families and relatives, and indeed the public at large cannot be expected to tolerate under the name of community care the discharge of chronic patients without adequate arrangements being made for after-care who perhaps spend their days wandering the streets or become an unbearable burden on the lives of their relatives." But the real hammer blows come from the Secretary of State for Social Services, Mrs Barbara Castle, herself. In her foreword she makes a confession of failure about as dismal as a Minister of the Crown can afford to make (though the blame is largely laid at the door of the local authorities). "Yet, although it is 16 years since the Mental Health Act of 1959 gave legislative recognition to the importance of community care, supportive facilities in a non-medical, non-hospital setting are still a comparative rarity," she laments. "In March 1974 31 local authorities as then constituted had no residential accommodation for the mentally ill and 63 no day facilities," she goes on. Nor in the light of present economic circumstances does she offer much hope for the future: "It is unlikely that we shall be able to see in every part of the country the kind of service we would ideally like within a 25 year planning horizon." Two papers6 7 we published last month served in their separate ways to emphasize these failures in official policy. A census of patients at Tooting Bec Hospital in London showed that 60"/, were unlikely ever to be discharged. Over 400 patients had been inpatients for eight years or longer, and most of these were in reasonable physical health. Some could have been discharged to community care had places been available in hostels and residential work units; and, as Fottrell et a17 observed, unless local authorities provide adequate accommodation and after-care facilities in the community for these patients they will remain in hospital for the rest of lives. Others will never be suitable for discharge, but, as Bewley6 reminds us, some mental illness is not curable and some illnesses produce lifetime incapacity. Mental hospitals provide asylum as well as treatment and look after people who may otherwise be neglected. But, while psychiatrists assume their differing philosophic postures and politicians perform their expediential somersaults, the welfare of sick people continues to be put in jeopardy. Mr John Pringle of the National Schizophrenia Fellowship, a watchdog society concerned with the fate of schizophrenics in the community, states bluntly :8 "The closure of mental NO 6002 PAGE 111
112
BRITISH MEDICAL
hospital wards, which at least provided the basic minimum shelter and life support, goes on, leaving nothing in their place."
Medical_Journal,
1966,2, 655. IBritish 2 British Medical3Journal, 1967, 2, 781. 3 British Medical3Journal, 1971, 2, 351. 4British Medical_Journal, 1973, 3, 1. 5 Department of Health and Social Security, Better Services for the Mentally Ill. London, HMSO 1975. 6 Bewley, T, et al, British Medical_Journal, 1975, 4, 671. 7 Fottrell, E, Peermohamed, R, and Kothari, R, British Medical J'ournal, 1975, 4, 675. 8 Living with Schizophrenia. Surbiton, Surrey, National Schizophrenia Fellnwshinp 1974.
Operation baby lift Large capacity jumbo-jets have made it possible for vulnerable groups such as infants to be evacuated rapidly and efficiently from disaster areas. Some practical lessons may be learnt from an American experience' when 1600 Vietnamese orphans, many aged under 6 months and at least half requiring medical attention and potentially infectious, arrived in San Francisco within one week. First of all there must be a single, organised group ready to assume full responsibility for the planning and mobilisation of resources at short notice. In San Francisco it was found that doctors fulfilled this function because of their familiarity with the requirements and structure of medical care and their commitment to child health. In Britain paediatricians should probably form the core of such a planning group; and the subject might well be considered by the British Paediatric Association. The planning group must be psychologically prepared to adopt the somewhat stark triage or sorting out procedures, in which priorities have to be defined to fit available resources. It should have in readiness a sufficient store of paediatric supplies (listed in the American article); current lists of accommodation, hospital cots or beds, and staff available at short notice; and the names of "contact individuals" in both government and voluntary agencies-who can help with transport, documentation, food supplies, nursing, sanitation, security, foster care, and adoption. Today all large cities with a major airport should have plans for the reception of a planeload of infants. Up to half of them might need medical care and barrier nursing and all would need feeding, mothering, and quarantining for up to a month. Ideally accommodation should be found within a single area for up to 1000 within a short distance of the airport. The increasing emphasis on home care of infants in Britain has probably released a number of long stay or convalescent hospitals which could be earmarked for this purpose. It might still be possible to maintain one or two of the units opened for the Asian immigrants from Uganda. There is an enormous scope for volunteers in an emergency of this kind-no fewer than 3200 of all types were used in the San Francisco operation-but they need to be organised and their roles defined. The plans should, however, envisage their phasing out as soon as possible, for the American experience underlined the falling off that occurs in volunteer effort if demands on their time are prolonged: inevitably interest wanes and other demands are made on individuals' time. The last step is the absorption of the infants into the community. Faced with a large-scale influx adoption and fostering
JOURNAL
17
JANUARY 1976
agencies would be stretched to their limits, but this makes it all the more important that they should be included in the plans for such an infant deluge. It might be possible to have a panel of foster homes which had agreed in such an eventuality that they would be prepared to take in orphaned infants and children. I 2
Stalcup, S A, et al, New England Journal of Medicine, 1975, 293, 691. Shattock, F M, Lancet, 1970, 1, 461.
Doctor abroad? As Mr Enoch Powell makes the headlines again with comments about immigration statistics, doctors will remember the vehemence of his denials when Minister of Health that medical migration was a source for anxiety.' Then, as now, the great difficulty was the collection of reliable data: for in a democratic society there is no obligation on an individual leaving the country to say why, for how long, and whether or not he intends to return-if indeed he knows himself. Yet some estimate of the likely movements of doctors into and out of Britain is essential for any planning of the future staffing of the NHS, and this was one of the subjects discussed at the third session of the BMJ conference on medical manpower (see p 134). Without doubt there will be a greater exchange of doctors within the EEC as a result of the directives on mutual recognition of medical qualifications. One crucial ruling may be the legal obligation laid on each member state to ensure that any medical migrant becomes competent in the new language he will have to use. Britain is firmly at the bottom of the league table of European medical salaries, and the gap is so wide that there is virtually no prospect of it being closed in the foreseeable future. How many British doctors decide to try their luck in Europe depends on imponderable factors such as morale in the NHS, the quality oflife in our society, educational opportunities, and future trends in income tax: no estimate can be better than a guess. In contrast, there can be a fair certainty that fewer doctors will come to Britain from Asia, Africa, and the Middle East. The TRAB tests have abolished the role of Britain as a staging post for would-be migrants to the USA who had failed the ECFMG; and more important, many Asian and African countries are now building their own systems of postgraduate training, better suited to the problems of the third world. Medical graduates seeking specialist training will still come, but the "pairs of hands" are likely to disappear. These trends should not have come as a surprise to Health Service planners, for the winds of change have been blowing for several years. Nor are they the only factors to be taken into account when plans are prepared for the future staffing needs and resources of the NHS. In our previous two issues2 3 we have discussed the disparity between the output of graduates from our medical schools and the numbers required to provide hospital junior staff for the NHS and the increasing proportion of women graduates, many of whom will want to train and work part time for at least some of their professional careers. In the words of Mr Rudolph Klein, the current NHS manpower policies "were devised for a great imperialist power and not for Europe's poorest offshore island constantly sinking into genteel poverty." So far we seem to have been reluctant to contemplate any radical change in that system. A combination of inertia and conservatism within the medical profession
MEDICAL JOURNAL Asylums
are
still needed
The year 1975 was to be Britain's psychiatric millenniumor so we were led to believe. That was the date the recommendations of the Royal Commission on Mental Health Law (1957)-written into the Mental Health Act, 1959, and adopted as official policy by successive governments-were to come to fruition. But the arrival of the brave new era depended on the achievement of two objectives: a reduction by nearly half in the number of local mental hospital beds, and the development of a whole range of services collectively known as "community care." Now 1975 has come and gone, and not even the most starry-eyed supporters of the official policy-and they were in a substantial majority-would assert that any more than limited progress has been made. The opinions expressed in the BMJ have not been on the side of the big battalions; indeed, we have been conFtantly critical not so much of the policy itself as of its practicability. "No one tested the situation to see indeed if the community cared," was our comment in September 1966.1 Not long afterwards2 we questioned how much the reduction in the population of mental hospitals was the result of restoration to health through therapeutic advances and how much was a sociological conjuring trick. Again, in 1971, we asserted3 that community care, as it existed then, had still to be proved much more than a resounding catchphrase. That, indeed, has been the disastrous fault in the policy; for, as a result of the muddling ineptness of a succession of governments, the rundown of the mental hospitals has led to an increase in the numbers of men and women condemned to a life of rootless wandering in which reception centres, common lodging houses, prisons, and park benches have become the only available resting places. "It is hard to believe," we said4 in 1973, "that such an existence of aimless destitution is preferable to the organised and structured life in a well-run mental hospital." It is against this background of disillusionment and disenchantment that the recent White Paper,5 Better Services for the Mentally Ill, can be judged. Although it sets out to defend official policy as best it can, it acknowledges some at least of the failures in the 15 years since the Mental Health Act came into being, and it even sheds a few repentant tears. For instance, the paper admits that the term "open door hospital" has, like "community-care," become with time something of a catchphrase and that those who require continuing care, though not necessarily medical or nursing care, are particularly vulnerable to the present virtual total absence of long-stay sheltered accommodation in the community. I BRITISH MEDICAL JOURNAL 1976. All reproduction rights reserved.
In what reads like a quotation from our own columns the White Paper states that "Families and relatives, and indeed the public at large cannot be expected to tolerate under the name of community care the discharge of chronic patients without adequate arrangements being made for after-care who perhaps spend their days wandering the streets or become an unbearable burden on the lives of their relatives." But the real hammer blows come from the Secretary of State for Social Services, Mrs Barbara Castle, herself. In her foreword she makes a confession of failure about as dismal as a Minister of the Crown can afford to make (though the blame is largely laid at the door of the local authorities). "Yet, although it is 16 years since the Mental Health Act of 1959 gave legislative recognition to the importance of community care, supportive facilities in a non-medical, non-hospital setting are still a comparative rarity," she laments. "In March 1974 31 local authorities as then constituted had no residential accommodation for the mentally ill and 63 no day facilities," she goes on. Nor in the light of present economic circumstances does she offer much hope for the future: "It is unlikely that we shall be able to see in every part of the country the kind of service we would ideally like within a 25 year planning horizon." Two papers6 7 we published last month served in their separate ways to emphasize these failures in official policy. A census of patients at Tooting Bec Hospital in London showed that 60"/, were unlikely ever to be discharged. Over 400 patients had been inpatients for eight years or longer, and most of these were in reasonable physical health. Some could have been discharged to community care had places been available in hostels and residential work units; and, as Fottrell et a17 observed, unless local authorities provide adequate accommodation and after-care facilities in the community for these patients they will remain in hospital for the rest of lives. Others will never be suitable for discharge, but, as Bewley6 reminds us, some mental illness is not curable and some illnesses produce lifetime incapacity. Mental hospitals provide asylum as well as treatment and look after people who may otherwise be neglected. But, while psychiatrists assume their differing philosophic postures and politicians perform their expediential somersaults, the welfare of sick people continues to be put in jeopardy. Mr John Pringle of the National Schizophrenia Fellowship, a watchdog society concerned with the fate of schizophrenics in the community, states bluntly :8 "The closure of mental NO 6002 PAGE 111
112
BRITISH MEDICAL
hospital wards, which at least provided the basic minimum shelter and life support, goes on, leaving nothing in their place."
Medical_Journal,
1966,2, 655. IBritish 2 British Medical3Journal, 1967, 2, 781. 3 British Medical3Journal, 1971, 2, 351. 4British Medical_Journal, 1973, 3, 1. 5 Department of Health and Social Security, Better Services for the Mentally Ill. London, HMSO 1975. 6 Bewley, T, et al, British Medical_Journal, 1975, 4, 671. 7 Fottrell, E, Peermohamed, R, and Kothari, R, British Medical J'ournal, 1975, 4, 675. 8 Living with Schizophrenia. Surbiton, Surrey, National Schizophrenia Fellnwshinp 1974.
Operation baby lift Large capacity jumbo-jets have made it possible for vulnerable groups such as infants to be evacuated rapidly and efficiently from disaster areas. Some practical lessons may be learnt from an American experience' when 1600 Vietnamese orphans, many aged under 6 months and at least half requiring medical attention and potentially infectious, arrived in San Francisco within one week. First of all there must be a single, organised group ready to assume full responsibility for the planning and mobilisation of resources at short notice. In San Francisco it was found that doctors fulfilled this function because of their familiarity with the requirements and structure of medical care and their commitment to child health. In Britain paediatricians should probably form the core of such a planning group; and the subject might well be considered by the British Paediatric Association. The planning group must be psychologically prepared to adopt the somewhat stark triage or sorting out procedures, in which priorities have to be defined to fit available resources. It should have in readiness a sufficient store of paediatric supplies (listed in the American article); current lists of accommodation, hospital cots or beds, and staff available at short notice; and the names of "contact individuals" in both government and voluntary agencies-who can help with transport, documentation, food supplies, nursing, sanitation, security, foster care, and adoption. Today all large cities with a major airport should have plans for the reception of a planeload of infants. Up to half of them might need medical care and barrier nursing and all would need feeding, mothering, and quarantining for up to a month. Ideally accommodation should be found within a single area for up to 1000 within a short distance of the airport. The increasing emphasis on home care of infants in Britain has probably released a number of long stay or convalescent hospitals which could be earmarked for this purpose. It might still be possible to maintain one or two of the units opened for the Asian immigrants from Uganda. There is an enormous scope for volunteers in an emergency of this kind-no fewer than 3200 of all types were used in the San Francisco operation-but they need to be organised and their roles defined. The plans should, however, envisage their phasing out as soon as possible, for the American experience underlined the falling off that occurs in volunteer effort if demands on their time are prolonged: inevitably interest wanes and other demands are made on individuals' time. The last step is the absorption of the infants into the community. Faced with a large-scale influx adoption and fostering
JOURNAL
17
JANUARY 1976
agencies would be stretched to their limits, but this makes it all the more important that they should be included in the plans for such an infant deluge. It might be possible to have a panel of foster homes which had agreed in such an eventuality that they would be prepared to take in orphaned infants and children. I 2
Stalcup, S A, et al, New England Journal of Medicine, 1975, 293, 691. Shattock, F M, Lancet, 1970, 1, 461.
Doctor abroad? As Mr Enoch Powell makes the headlines again with comments about immigration statistics, doctors will remember the vehemence of his denials when Minister of Health that medical migration was a source for anxiety.' Then, as now, the great difficulty was the collection of reliable data: for in a democratic society there is no obligation on an individual leaving the country to say why, for how long, and whether or not he intends to return-if indeed he knows himself. Yet some estimate of the likely movements of doctors into and out of Britain is essential for any planning of the future staffing of the NHS, and this was one of the subjects discussed at the third session of the BMJ conference on medical manpower (see p 134). Without doubt there will be a greater exchange of doctors within the EEC as a result of the directives on mutual recognition of medical qualifications. One crucial ruling may be the legal obligation laid on each member state to ensure that any medical migrant becomes competent in the new language he will have to use. Britain is firmly at the bottom of the league table of European medical salaries, and the gap is so wide that there is virtually no prospect of it being closed in the foreseeable future. How many British doctors decide to try their luck in Europe depends on imponderable factors such as morale in the NHS, the quality oflife in our society, educational opportunities, and future trends in income tax: no estimate can be better than a guess. In contrast, there can be a fair certainty that fewer doctors will come to Britain from Asia, Africa, and the Middle East. The TRAB tests have abolished the role of Britain as a staging post for would-be migrants to the USA who had failed the ECFMG; and more important, many Asian and African countries are now building their own systems of postgraduate training, better suited to the problems of the third world. Medical graduates seeking specialist training will still come, but the "pairs of hands" are likely to disappear. These trends should not have come as a surprise to Health Service planners, for the winds of change have been blowing for several years. Nor are they the only factors to be taken into account when plans are prepared for the future staffing needs and resources of the NHS. In our previous two issues2 3 we have discussed the disparity between the output of graduates from our medical schools and the numbers required to provide hospital junior staff for the NHS and the increasing proportion of women graduates, many of whom will want to train and work part time for at least some of their professional careers. In the words of Mr Rudolph Klein, the current NHS manpower policies "were devised for a great imperialist power and not for Europe's poorest offshore island constantly sinking into genteel poverty." So far we seem to have been reluctant to contemplate any radical change in that system. A combination of inertia and conservatism within the medical profession
