NAMH Annual Conference, 1963,



when we were about the theme of this we were thinking how tar we had to go before community health services were what we should all desire to see," said the Earl ?f Feversham, Chairman of the Council of the N.A.M.H. in opening the Association's 1963 Annual Conference House, Westminster. We hoped, however, that we should nave been a step nearer than we find ourselves today. We hoped that the Local Authority Ten-Year Plan which 'ne Minister intends to present to complement the Ten-Year Hospital Ian, would be in our hands. As you it is not. We hoped that the of Health at this Conference ?uld be able to comment upon that uen~Year Plan. He cannot. Instead we "ave to examine the background which ?nust be ." influencing his thinking. summer,





at(Church ,







r v a







-A-M.H. had called on Febrary 28th (and March 1st to debate the distant t

of community j-^?al .'y disordered. This

of the menwas taken up by H. L. A. Hart, of Jurisprudence, Oxford in the opening address he posed difficulties of communication care


''^mediately ^ofessor ^hen h 1, '



'',utWeen )' 9s? who

are engaged in the mental services [and] have at their fingerand on their lips its terminology, ''.specialised classifications and cate>k?ries, its leading ideaSj jts therapeutic its administrative and c principles




*nd the layman. In his view the could never e i ei sufficiently often reminded of how and difficult to grasp all this is 'ue layman, ,,i especially if he is?as are?without some still npbtless -K rs?nal experience of mental disorder. Association in its explanatory jiir.s uiphlets has recognised, there is_ here serious problem of communication."

J?*Pert .


THE DISTANT GOAL Professor Hart pointed out that programme to which we are committed, of a vast expansion of community care and a reduction to the minimum of the segregation of the subnormal and mentally ill really implies that the lay public will be at least a benign sleeping partner in the business of caring for mental disorder. This in its turn implies a degree of understanding of the world of mental health most much greater than people have." "the







More admissions and readmissions Next to address the Conference 1962 Reith was lecturer G. M. Carstairs, Professor of Psychological Medicine, Edinburgh, who posed the question: "What is happening in psychiatry in Great Britain today?" He reminded his audience that "since 1947, up to two years ago first admissions [to hospital] had increased by two-thirds and in the same period the readmissions had increased 400%. Recent studies have shown that in spite of the more frequent readmissions, the actual duration of hospital stay for. patients is less now than it was a few the general pattern, as years ago increased all know is of you amount of stay in the community. Professor Carstairs expressed his concern about patients who had relapsed and had had to return to hospital, citing as an example a group of discharged schizophrenic patients of whom a follow-up study had been he had been with which made associated. "More than half of them had deteriorated before a year was out, and had to go back into hospital. We were curious to know who had helped them while they were out. Nearly all of them left their hospitals with a prescription for a tranquillising drug, and with an appointment to meet a psychiatrist. Some of them came, some of them did not. But, in the first month after discharge their principal contact was with the out-patient clinic. Contacts with psychiatric social .

Lord Feversham had set the prac(llCal, often critical keynote which














workers rare.




rare, because p.s.w.s In the later months out of the hospital,





of the

to loom large. He was sometimes consulted by patients when they were still comparatively well, but rather often he was consulted only when they had relapsed and his task was to pick up the pieces, to call for help, and to steer the patient back to the out-patient

also a black spot, problem-adolescent and alcoholics did not receive adequat1 treatment, and more should be dofl on the forensic side of psychiatry.

general practitioner began



Mental health threats Professor Carstairs concluded ^ lecture by looking at some of tfe threats to mental health in Britai1 today. He put first the threat 0 mutual destruction through $ existence of the H-bomb. Anotbe threat was unemployment. A thft element was big-city and conurbatio' living. Yet another was the intefl5 pressure of the 11+ examination afl' competition for too few higher educ2 tion places. But he ended his addre-'

back into hospital."





mented : "There is one basic reality in the present state of our psychiatric services, and this is that we do not have enough after-care. We must use everything we have we should got exchange information about our respective local ...

experiences." He






developments in Edinburgh where the monthly meetings of a City Medical Co-ordinating Committee on Mental

on a

"I believe

Health in the office of the Medical Officer of Health enabled regular exchange of information and ideas between the Chiefs and Superintendents of the three mental hospitals catering for Edinburgh, representatives of general practitioners, of the Regional Hospital Board and of the Department of the M.O.H. with an ad hoc arrangement to call in other representative people when a specific health topic is under discussion. The Committee helped in practical ways, too; by immediately informing G.P.s of the drugs being given to patients at the time of their discharge from hospital, mental health by implementing courses for health visitors, by



we are growing, howevj haltingly, in our capaci

"Towards Self Help" was ^ theme of the Conference's secoD session. As opening speaker, Dart Olive Wheeler, Emeritus Professor ? Education at the University of Walff stressed the effects of "the secofl industrial revolution" which ba already caused some redundancy afl "may in future decrease workin hours for the majority". It had als tended to increase repetitive opef3 tions and to produce feelings c




optimism, saying:

for widening our concern from mere' selfish interests to ever greater und^ standing, compassion, and determi^ tion to better the lot of our fell"' In this constructive expression 1 men. 'divine discontent' with our prese[ way of life I believe that the Natiofl: Association for Mental Health b3 played, and will continue to play, most important role."

symposia on general practitioners, by circulating a monthly bulletin giving news from the Committee to G.P.s and producing an mental

note of


index of facilities for the chronic sick and the mentally infirm.

insignificance in

many workers. "It is therefore not surprising tb! it is estimated that at least one-tbi' of all absenteeism from work is $ to mental ill-health"; most of it co' sequent upon boredom and insecure In examining ways in which peop could help themselves to com# mental ill-health Dame Olive stressf the need to participate in activity

But so many problems needed attention?the special problems of the elderly?pressure on geriatric beds in Edinburgh was immense; the further development of day hospitals and ex-patient clubs; the rise in cases of

attempted suicide?in Edinburgh they

had amounted to over 500 in 1962, than one in every 1,000 of the city's population. Child psychiatry was





work which provide and pointed out that tt



of adult education in this j"?le tlad to be

hardly begun hospital and family ?/\


to psychiatrist with the






City of Salford, ?^alt examined hospital and the family. practical aspects of establishing a satisfactory hospital/ family linkthewhen a patient was in need n?spital; for adequate ^siting of the patient by his rela-

tives?financial ^stances could

e*Plaining about

circumstances and make this difficult; the relatives something




relatives ^vising "est live with the



"how they can patient after dis-


charge". But the patient's family was a "therapeutic force". Ind a^wa^s a

recent study suggests that some at home may have very few close contacts with people who can be considered to be in good mental health, .'he patient may be much better off n an atmosphere less charged with where relationnips are at lowerinter-personal_ intensity. Living near he family, rather than with it, may be .






useful compromise."

analysing the family unit, jln rr- Freeman spotlighted the decline size and the relative rarity of }Jhe its"extended as

family"; people change of



^derating which makes

stranger to factors were




the increased and "the

our culture, generation a




Ve.ry armg

relevant to the problems of for psychiatric patients in the If enough support cannot c?me from the extended family it must come from the general community, in ,ne shape of extra money, home helps, nurseries, visits from social workers, d old people's homes?to mention I st a few facilities. ." >.In a hard-hitting speech, Miss esta Roberts, London News Editor The stressed the Guardian, .'"erence between accepting the prinClPle of community care in theory and in practice; the difference?for Sample?between agreeing in prinClPle with the need for training







mentally handicapped having a centre at

and of

the bottom of your own street. She felt that the simplicity with which the intentions of the Mental Health Act and the enlargement of community care had been presented had But misled the lay public gravely. some people had had doubts and "no amount of pink paint on the walls" would shake their belief that mental illness was a serious matter.




The spirit of criticism remained when Dr. Russell Barton, Physician Superintendent of Severalls Hospital, Colchester, opened the next day's "Towards debate on the subject: Family Care". He believed that anyone who was psychiatrically-ill and could not be managed at home needed to be in a psychiatric bed in hospital, but that anyone who was well enough to go home should be at home, and that if a certain amount of assistance were needed for the patient to live in with the family then we should see to it that that assistance was forthcoming. Dr. Barton was deeply critical of the level of psychiatric training for many sections of the medical profession. On the general practitioner, he commented: "The general practitioner has had very little psychiatric training; one or two teaching hospitals today in London are doing their best, but there are only 83 beds in all the teaching hospitals in London and five teaching hospitals have no beds for psychiatric patients. It may be they teach the students how to discern one psychiatric illness from another, but it is quite certain that they do not bring all the social needs, all the problems of transference and so forth which the general practitioner needs' to the attention of the student. ." Dr. H. S. Pasmore, general practitioner in London, next took up the debate to give the viewpoint of the G.P. on community care of the mentally disordered. He commented .



"There is lack of liaison between the G.P.s and the consultants in many cases of mental disorder. There is also a certain amount of natural aggression towards mentally disordered patients, because they cause strain and disorder wherever they go, and the G.P. already

suffers from enough disorder caused by thoughtless patients, endless telephone calls, and so on. It needs the patience of Job to give patients regular supportive therapy when the State makes no provision for giving the N.H.S. .


assembled to examine the theme "Towards the Supportive Services" Mr. J. E. Westmoreland, M.B-& Mental Health Officer for Nottingham, commented: "Supportive services are part aH parcel of community care [bU1 "only so far as the community cancan a community service be


the time to carry out the job properly. The G.P. really needs the direct help of a psychiatric social doctor


worker to ease this burden for him. He would be more prepared to take on the full responsibility for these patients if he had some ancillary help."




It was the vital need the supportive services of patients which was the next speech?from




The community must care sufficient to be prepared cheerfully and heir fully to accept the mentally disorders in their midst. The greatest difficult facing the mental health service 3 present is to establish and maintain proper climate of public opinion. At the present moment, many of doubt whether the community's attitud' to the mentally disordered has bsej modified sufficiently to stand the strai(

for help from for the family underlined in the wife of an








Courageously, movingly,

she recounted how for 14 years she had looked after her schizophrenic husband with practically no help at all from the supportive services which were supposed to be available. She told how her ex-prisoner-of-war husband had moved through a succession of situations: private hospital with locked doors; treatment by psycho-therapy; refusal to be treated; passing through stages when there was no communication between them and she could do nothing but "put something in his hand and hope he would use it". She recounted how she had finally decided to send their two children to boarding-school, how after his mothers death her husband had become very ill and was unemployed for a year. She also spoke of the jobs he had done when working. Despite a good degree, he had worked at spreading manure on a mushroom farm and had held about 14 posts in travel agencies, never understanding why he was dismissed from his posts. Last year he had been working steadily for some while, but recently he had thrown up this job and departed to unpaid work as a ski representative. When he came home once again he would have no post to go to, and she had no idea in what state of mind he would come back to her. The speech was received with great warmth and sympathy. It was a


that it to

are increasingly putting up?t: by giving too wide a definition community care, all the old hostilitif we






re-awakened and result


rejection of the mentally di^ ordered, with mounting public pressuij1

for a return to the old system ^ immediate admission and long-ter^1 ?1 detention of all disturbed people. But he pointed out that: "Given positive direction and th'1 necessary financial assistance, the locf authorities could initiate mental health services deliberately devised to fit tb?! special needs of the area to be served; Such a service would be essentially caf by the community, and local pride woul' be so stimulated that a suitable clima'1 for the general extension of care in tb' * community could be secured." .



authority position

Dr. F. R. Dennison, Medical Office' of Health for West Ham, looked _a'( the position of the local authority in the mental health services,





deceptively easy to measuf progress in terms of training centre5 hostels, clinics, and so on; but in tbl long run the achievement of all the$' brick-bound services are depended upon the quality of the social wof' available for their support. If there ?' indeed to be 'a general reorientatio', towards community care' I0C3; authorities will have to provide th' right kind of social work as the founds tion for their mental health services." Dr. Dennison examined the^ requirements, commenting that in tW" .






disturbed situations resulting from c?ntributing to mental disorder:



people may be affected, and necessarily the patient showing symptoms who is the principal th ^rer-of It is no longer realistic to nink mental care as something for ne individual patient, but for all those




in the Participating nink we must now ne



regard the family



normal unit for social casework in mental health field. .

Integration The



attempts to integrate the Psychiatric and local hospitals services were important, authority ut

Dr. Dennison wondered whether: should not first aim at integrating local authority mental health services ?niong themselves? Perhaps this confePt of family casework as the t


of foundation ?tter-care to

all of them, from mental the care of the mentally child guidance and prevenHandicapped, c'?n, will help us io do so. It means nat our social workers will be applying tle-same kind of techniques throughout. Jttied only in detail by the nature 9f mental disorder and the setting in "ich the social work is done." Dr- F. M. Martin, Director of R Community Mental Health Services Study, P.E.P., also felt that :an integrated mental health service

.^search, ;


I w?'l

was easy to talk about but not to achieve. Co-ordination and planning of staff and accommodation were There were too essential. many slogans circulating about psychiatric It was all too easy to forget care. that to keep patients out of hospital was a retrograde step if they actually needed hospital treatment. Tt had also never been apparent why the number of psychiatric social workers should be so incredibly low, when they were so vital It was to the mental health services. extraordinary that the only large training centre for P.S.W.s was obliged to turn down suitable entrants because they did not have sufficient training facilities. On the other hand existing staffs throughout the health and local authority services should be used to the full.

One cardinal sin His whole

closing spirit of

of need to lookout




cardinal sin?comservices. I think I think we us can claim this. be constantly critical and on the to improve the quality and the of what we provide."

"There is only





in book form, "The Distant Goal". This will contain verbatim reports of speeches biographical notes about Chairmen and speakers.

NAMH Annual Conference, 1963, Debates: Community Care-The Distant Goal.

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