The NHS at 75 - What do mental health services owe to the NHS?
This month the NHS celebrated its 75th birthday. Hooray for the NHS! Born after the second world war as part of policies to improve the delivery of essential social and health services in the UK, it has been a key part of the modern British Welfare State. Despite its loyal support by the public, over the past 13 years we have witnessed a decline of our health services – under-funding, increased staff turn-over and vacancies, reduced staff morale, longer waiting lists, and more recently increased difficulty in accessing primary care and a reduction in public confidence.
A recent report by the King’s Fund has revealed that our NHS compares poorly on many indices with the health services of other high-income nations – with fewer resources and worse health outcomes. A separate King’s Fund report pointed to a decline in NHS performance since 2010 owing to poor funding and workforce planning. Austerity has certainly taken its toll on the delivery of essential health and social services as well as on housing and education provision and the safety net for some of the most vulnerable people in our society.
In celebrating the NHS’s 75th anniversary we may have cheered the advances in physical health care along with the skilled and devoted staff who provide this, but what has the NHS done for mental health services since 1948?
The historical trajectory of mental health services in the UK is strongly linked to the development of the Poor Laws dating from the 1600s and the development of the public provision of care dating from the creation of County Asylums in the 19th century. The Poor Laws were finally abolished with the welfare-related Acts of the 1940s and the Asylums reached their peak occupancy in 1955.
The creation of the NHS provided the ground on which our modern mental health services could be built. The care of people with mental ill-health became an integral part of the NHS, the mental hospitals were nationalised and became part of NHS provision. Mental health services may have since lagged behind physical health provision, but the NHS did allow for an increased parity between mental and physical health services.
The provision of social welfare benefits meant that it was no longer necessary to remove the unwaged mentally ill to asylums and the provision of public housing meant that they could be sheltered outside institutions. In addition, the development of an improved system of primary medical care allowed general practitioners to provide drug treatments in non-custodial settings, and the consolidation of medical and psychiatric social work within local authorities allowed for supervision outside hospitals.
In the 1950s a new Mental Health Act emerged, and community-based mental health services were planned, although these were slow to develop and lagged behind the running down of the traditional asylum system. A blueprint for modern community-based mental health services was drawn up in 1975 (‘Better Services for the Mentally Ill’ - DHSS, 1975) and this prophesised that without a long-term national programme it would take 25 years to create a safe community-based system.
In the 1980s and 1990s these community-based services grew but it was not until 1999 that a national plan was produced for adults of working age (the National Service Framework - NSF) was created. This set out for the first time a set of officially sanctioned minimum standards which adult mental health services were expected to attain. The NSF ended in 2010 – as NHS provision began to deteriorate.
The NHS and the associated growth of the British welfare state has provided the essential base for the development of our modern mental health services. These services have emerged slowly during the past 75 years and those that were developed by 2010 for working-age adults were relatively new. It seems scandalous to have let these services deteriorate so rapidly and perhaps it is now time to look closely at the important role that the state plays in providing these essential services for a group of vulnerable and often excluded people.
What have we learned? Some suggestions are:
Growing quality services takes investment – the NSF was supported by increased spending.
It takes a skilled multi-professional workforce – working with people with lived experience of mental health conditions.
Mental health services can only succeed with the support of other essential services – personal social services, housing, education, employment, and welfare benefit provision.
It requires an integration of physical and mental health services, primary and secondary care, community and hospital care, public health, local authority and voluntary sector provision.
It is dependent on the support of the state, not the markets, and is subject to the whims and ideologies of politicians.
References
Ham, C. (2023) The rise and decline of the NHS in England 2000–20. How political failure led to the crisis in the NHS and social care. London: King’s Fund.
Anandaciva, S. (2023) How does the NHS compare to the health care systems of other countries? London: King’s Fund.
Boardman, J. (2020) Dismantling the social safety net: social security reforms, disability and mental health conditions. BJPsych Bulletin 44, 208–212.
