Plans and Provisions for the Mentally Handicapped

Margaret Bone, Bernie Spain, F. M. Martin

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9781032060088
• eBook ISBN: 9781000438550
• Edition: 1
• Topic: Medicine
• Subtopic: Social Work

The lack of good statistical information had been a major factor in the poor planning of services for the mentally handicapped in the late 1960s. The principal object of this book was to provide an accurate factual basis for the planning of future services.

Originally published in 1972, this title is based on three years' extensive research and consists primarily of statistical studies rather than case studies. There is a survey of facilities provided by hospitals for the mentally handicapped and a sample survey of three Hospital Regions indicating the characteristics and disabilities of the mentally handicapped inpatients. Also included are two cohort studies, one of the subsequent experience of patients after their first admittance to a hospital, and one of the subsequent experience of all first referrals to a Local Authority service. Both studies were carried out to determine trends in the patterns of care. This was the first time that cohort techniques had been applied in this field in this country.

Since effective long-term planning depends upon the coordination of the work of Local Authorities and hospitals, it is unrealistic to divorce the need for hospital beds from community provision. This book, therefore, examined the present services for the mentally handicapped in the round. It is supplemented by an extensive bibliography and numerous tables and diagrams. As a result, it should be of particular interest to psychiatrists, clinical psychologists, hospital administrators, senior nursing staff and Local Authority social service administrators.

This book is a re-issue originally published in 1972. The language used is reflective of its era and no offence is meant by the Publishers to any reader by this re-publication.

1 Mental Handicap as a Hospital and Community Problem

This study arose from a concern with the adequacy of services for the mentally handicapped. At the time we commenced the project a good deal of research and investigation was in progress into various aspects of hospital and community services for the mentally ill. The facilities provided for the mentally handicapped, however, have always attracted less, and certainly much less well-publicized research. There has been an increasing acceptance, at any rate among the educated public, of the view that mental illness is a hazard from which no one could assume himself to be wholly immune. But mental handicap can very rarely be considered in any ordinary sense a condition which one acquires. There is a small risk that healthy adults will produce mentally handicapped children, but this is a chance that seems to concern most people – if indeed it does at all – only during those relatively brief periods of anxiety that precede childbirth. In addition, mental handicap does not yield to dramatic cures, is usually depressing to contemplate and, unlike mental illness, is never the subject of fascinating psychological or literary speculation. Consequently the level of public interest in mental handicap appears in general to be relatively low.

More recently, with the publication of the Ely Report (1969), there has been more public discussion of the problems of the mentally handicapped, and more regard given to the fact that these citizens have not in the past received the attention and resources which are needed if they and their families are to achieve the standards of comfort and freedom which are their right. Over the last year or two more consideration has been given to these issues, and in particular to the situation of the mentally handicapped who cannot live in their own homes. However, because of the low level of interest in them over past years, little statistical material has been available until recently about mentally handicapped patients or their needs.

Over 60,000 mentally handicapped patients are housed at present in hospitals in England and Wales. At the national level there is little information about the characteristics of these patients and only speculation about the way in which the resident population may change in the future. During a period when the planning of future hospital requirements has been much discussed, this seems to be a serious gap in knowledge. Not only the absolute number, but the type of patient involved greatly affects the kind of accommodation, staffing and facilities required. Patients of very low intelligence with physical handicaps, who may spend the rest of their lives in hospital, have very different requirements from high-grade patients with behaviour problems who need rehabilitation, and different again from medium-grade patients, who may or may not be able to return to the community, but who are mostly trainable. Recently there have been several publications from the Wessex Regional Hospital Board study, which was partly financed by the Department of Health. These give details of inpatient characteristics which should be generalizable to the country as a whole. Pauline Morris’s report Put Away also gives some details of inpatient characteristics in the sample of hospitals she studied. However, there is still quite inadequate knowledge of patient turnover or of the factors which influence the decision to admit or discharge patients.

In January 1962 a Hospital Plan for England and Wales was published (Ministry of Health, 1962). This collected together the separate plans for hospital development produced by the fifteen Regional Hospital Boards in the country for a period of fifteen years (1960-75) and was complemented by a similar plan for the development of community services by the (then) 146 Local Health Authorities. Commenting on the provision of beds for the mentally handicapped, the authors of the Hospital Plan pointed out that the bed provision which should be made by 1975 was difficult to estimate. They suggested various factors which might influence need in conflicting ways and concluded by making the tentative assumption that these would offset one another, so that no change in the level of provision need be anticipated. Such assumptions are hardly an adequate basis for designing an effective hospital service (Rehin and Martin, 1963). A better basis can only be constructed by the provision of more information about the mentally handicapped and their needs.

The present study arose from concern about these deficiencies in the Hospital Plan and had two principal aims in view: firstly to examine the characteristics of the resident hospital population and secondly to enquire into recent changes in the numbers, characteristics and outcome of patients admitted to hospital, and what changes, if any, in community services have influenced these. The general intention of this approach is to provide information which can be used as a basis on which to assess the effectiveness of services and as a means of predicting future needs.

Because of the primarily quantitative nature of the material used in this report, there will be little reference to the practical consequences of inadequate services for individual people. Perhaps therefore it should be emphasized at the outset that the adequacy or otherwise of residential accommodation has far-reaching effects upon the families of many defective patients as well as upon the patients themselves. During the course of this study we encountered much distress resulting from the failure of services to provide for particular needs: marriages which had apparently broken down because the patient’s presence at home imposed too great a strain on the relationship; mothers who, having made the difficult decision to place the subnormal child in hospital in the interests of other children in the family, found that there was no hope of the patient being admitted for several years; there were other cases where the child was eventually admitted, only to be taken from the hospital by his parents shortly afterwards because they considered that the hospital environment produced a deterioration in the child’s condition. We quote these examples not because they are typical – we do not know that they are – but because they illustrate the kind of situation and the problems which made the study necessary.

Recent Attitudes to Subnormality Services

Although public interest in the problem of the mentally handicapped has only recently been aroused, over the past decade or so more attention has been paid to this subject by research workers and practitioners, not only in this country, but also in other parts of Europe and in the U.S.A. It seems important to discuss briefly some of the issues which have been raised because the results of the present study have some bearing on them.

In the post-war period the idea has developed that mentally handicapped patients might be cared for better and achieve a greater degree of social and economic independence if they lived in the community rather than in hospital. This view arose in Britain as a belated reaction to the attitudes enshrined in the Mental Deficiency Act of 1913, passed at least in part to enable high-grade defectives to be placed in custodial care, for fear lest their freedom to propagate should contribute to national degeneracy (Hilliard and Kirman, 1965). The newer approach is based primarily on the results of more sophisticated genetic research, but in addition observations of the effects of environment on intelligence and the success of training programmes in improving the social competence of defectives have also led to more optimistic attitudes.

The view that the mentally handicapped should remain in the community has usually related to high- and medium-grade patients. However, the Royal Commission, reporting in 1957, recommended that hospitals should provide care for ‘helpless patients in the severely subnormal group who need continual nursing if proper care cannot be provided at home’ together with ‘in-patient training ... for severely subnormal and psychopathic patients if such training requires individual psychiatric supervision’ (our italics). In other words, the Royal Commission considered that, even for the most handicapped and disturbed patients, hospital accommodation should be provided only when medical, psychiatric or full nursing care was necessary and could not be provided elsewhere. Even before the Mental Health Act of 1959 or the Royal Commission Report two years before, there had been a gradual expansion of community services for the mentally handicapped, and during the 1960s Local Authority services continued to develop at an accelerated rate. In particular there has been a growth in residential accommodation provided by Local Authorities, especially since 1960 (Ministry of Health, Annual Reports 1960-9), as an alternative to hospital care, and an increase in the number of special care units which provide day care for the very handicapped and low-grade patients. Although these services originally expanded as a result of the positive belief that community care was preferable to hospital care, the trend may to some extent have been strengthened by purely practical considerations, such as the size of the waiting-list and the sheer inability of hospitals to cope with the increased demand which a growing population alone placed upon them. By 1959, however, and as with the mentally ill, the assumption had clearly been made that keeping patients within the community was the right and proper objective.

Although there can be no doubt that the intention is humanitarian, it is of dubious value to implement a policy of retaining the mentally handicapped in the community without at the same time examining the effect of this on the patients and, equally important, on his family. In the field of chronic mental illness, for example, Brown and his colleagues (1966) have shown that a policy of retaining schizophrenic patients in the community can lead to an increase in problems for their families even where community services are provided. Only careful study can reveal what kind and what level of services are required to allow patients to live outside hospital without placing undue strain on their families. This is not to say that changes should never be made in services without elaborate prior experiment, but that where such experimentation is not practicable, then, at the very least, the consequences which follow from administrative decisions should be observed, monitored and analysed.

A further issue concerns the mixing of patients of different grades. It was recommended to the Royal Commission (Minutes of Evidence, 1954) that high-grade and low-grade patients should be treated differently and housed separately, particularly if the former are within the normal I.Q. range. Subsequent research (Stein and Susser, 1960; Leeson 1963) has developed this argument, and it was reiterated in the Hospital Plan. It is not clear, however, to what extent this policy has been put into effect, and indeed there may actually have been an increase in the number of patients of normal I.Q. admitted to subnormality hospitals over recent years (Craft and Miles, 1967).

Another controversy concerns the best way in which to organize residential care for long-stay patients who obviously require a different environment from the acutely ill. As far as is possible long-stay establishments should provide patients with homelike surroundings. This is particularly true for the mentally handicapped who in the main are not ‘sick’ at all, but merely slow learners or backward. This viewpoint has been developed in the work of Tizard (1964) and Kushlick (1967), who have pioneered the idea that subnormal children who require residential care are best placed in small ‘family units’ similar to those considered most suitable for normal children unable to live at home. As a result, the advantages are being explored of a different approach to the organization of children’s wards (Stephens, 1972) and of the development of small homes for children within the community, as an alternative to hospital admission (Kushlick, 1967). A somewhat conflicting viewpoint is expressed by McKeown in his concept of the district general hospital (Leck, Gordon and McKeown, 1967), in which it is envisaged that the mentally subnormal and other long-stay patients will be housed under the same roof, if they require hospital care, as acutely ill patients requiring surgical or medical treatment. To apply either method of care more widely and to determine which would be most appropriate in different Regions, it would be useful to have much greater knowledge than is presently available on the inpatient population, especially for children, and of the effect on the demand for residential care of providing more effective community services.

Interest in the conditions under which subnormal inpatients live has given rise to a further controversy about hospital size. Reformers have generally argued that large hospitals, however well-intentioned their administration, inevitably produce a degree of standardization in the treatment of patients, and in the organization of wards and staff which makes it difficult for patients to achieve maximum freedom and independence (Pilkington, 1963; Tizard, 1964; Mathews, 1969). On the other hand, it is claimed that only a large hospital can provide the variety of services which make comprehensive care of patients possible (Shapiro, 1963, 1969; McCoull, 1965. While the present study is not specifically concerned with resolving this problem, it is obviously important, in moving towards a solution, to know among other things what kind of services and training are likely to be required by hospital inpatients and whether these are such that large units are essential.

Some Questions to be Answered

The officially published statistics of admissions to and discharges from hospitals for the mentally retarded have till recently, at least been less illuminating than they might have been. They were examined at the beginning of the present enquiry, and the main findings of that examination are set out in the following chapter. On the whole we found that the published statistics raised more questions than they resolved, and these unanswered questions formed the starting-point of our own researches, so it may be helpful to set out briefly what were the questions which seemed to us to be of primary concern.

In the first place we thought it would be useful to gain some information on inpatient characteristics which would supplement the data published by the Department of Health’s Annual Reports and in the Department’s inpatient census (Brooke, 1963). We decided to do this by looking at a sample survey of patients in three hospital Regions. Secondly, since there was no published information on hospital facilities, training, teaching etc., we attempted a national survey of subnormality hospitals to gain some idea of what facilities are provided in relation to the type of patient they house. We also used this opportunity to test whether our sample survey appeared to represent the national inpatient population, by comparing them on simple demographic factors, such as age and sex.

However, we also thought it necessary to consider what changes had occurred in the demand for and the use of hospital care, since in this respect official statistics are particularly deficient. What actually happened after 1959 when the Mental Health Act came into force? Did admissions really show a sharp increase, as Department of Health figures suggest (see Diagram 2.3) and, if so, what type of patient accounted for the increase? Even for the earlier years, when fuller details were published, it is still not clear which kind of patient was being discharged, since the statistical tables showing length of stay for discharged patients gave no analyses by age and grade.

In order to find out what has happened to patients admitted to hospital during a particular period of time and how this differs from the experience of patients admitted during another period, that is to discover what trends are affecting and will affect the demands made on hospitals, a cohort analysis of admissions is necessary.¹ Consequently we undertook an analysis of patients admitted to one hospital Region, in the years 1949, 1959 and 1963, to discover their characteristics in relation to the changing patterns of discharge, to discuss how patterns of hospitalization had changed and to detect whether any of these could be attributed to changes in policy, and in particular to the 1959 Mental Health Act.

A further problem we sought to answer was why, if the published s...

Table of contents

• Cover
• Half-Title Page
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Members of Steering Committee
• Acknowledgements
• Preface
• Table of Contents
• Tables
• Diagrams
• 1. Mental Handicap as a Hospital and Community Problem
• 2. The Official Statistics of Mental Handicap: Their Uses and Limitations
• 3. A Survey of Hospital Facilities
• 4. Capacities and Handicaps of Hospital Patients
• 5. A Cohort Study of Hospital First Admissions
• 6. A Cohort Study of Referrals to a Local Health Authority
• 7. Conclusions
• Appendix 1 Hospital Cohort – Procedure
• 2 Ward Questionnaire
• 3 Hospital Survey
• 4 LHA Cohort Procedure
• Bibliography
• Index