regard myself as extremely lucky to have had the wonderful support and encouragement of colleagues and friends: Janet Chapman, Elizabeth Collier, David Edmondson, Akwugo Emejulu, Paul Michael Garrett, Maria Grant, Marian Foley, Jameel Hadi, Stephen Jones, Emma Kelly, Gavin Kendall, Martin King, Karen Kinghorn, Jane Lucas, David McKendrick, Bernard Melling, Lisa Morriss, Muzammil Quraishi, Kate Parkinson, Donna Peach, David Platten, Nick Platten, Sarah Pollock, Barry Schilling, Jonathan Simon, Imogen Tyler, Joanne Warner, Stephen Webb, Joanne Westwood, Toni Woods.
I am extremely grateful to Gavin Davidson, Hester Parr and Cheryl McGeachan all of whom took the time to read a draft of the book.
I completed this project during a period of study leave. I am grateful for the School of Health and Society at Salford for facilitating this. I would particularly like to thank Professor Joanne Westwood, who was very supportive of my initial application.
I have also enjoyed virtual support from @asifamhp, @SchrebersSister and @Mental_Elf
Most importantly of all, I would not have been able to complete this work without my wife, Marilyn, my sons, Elliot and Nelson, and his partner, Eilidh.
When Theresa May became Prime Minister in July 2016, she made a speech on the steps of Downing Street in which she outlined a series of ‘burning injustices’ her administration would seek to tackle. Many were struck by the irony of this commitment to tackling inequality and disadvantages coming, as it did, from a senior member of the coalition and Conservative governments that since 2010 had introduced a series of policies which had targeted those living in poverty and the most vulnerable. The scandals of the revelation of the real impact of the ‘hostile environment’ created by May’s Home Office and the appalling treatment of the Windrush generation lay ahead. In May 2017, May announced that a review would be undertaken of the ‘flawed’ Mental Health Act (MHA). In making the announcement she stated:
‘On my first day in Downing Street last July, I described shortfalls in mental health services as one of the burning injustices in our country. It is abundantly clear to me that the discriminatory use of a law passed more than three decades ago is a key part of the reason for this. So today I am pledging to rip up the 1983 Act and introduce in its place a new law which finally confronts the discrimination and unnecessary detention that takes place too often.’ (Savage, 2017)
It was later announced that the MHA review would be chaired by an eminent psychiatrist, Sir Simon Wessely. The review was completed in December 2018 (Department of Health and Social Care, 2018). Its recommendations are discussed in the final chapter of this book. In his foreword to the final report, Sir Simon outlines the case for change. The increase in the number of detentions – formal admissions using the powers of the MHA – was one of the factors highlighted. This is not a new issue. The process and rates of detention under the MHA, coupled with the conditions on wards and patients’ negative experiences have been long standing issues. The review also examined an issue that has long been a scar on modern mental health services: over-representation of people from black and minority ethnic (BAME) groups among patients detained under the MHA. Finally, there were concerns that the current mental health legislation in England and Wales did not comply with international standards on human rights.
The issues that the Wessely review was asked to consider are not new. They have appeared at various points, perhaps in slightly different configurations over the past 50 to 60 years. This is the period of deinstitutionalisation – the closure programme of long stay mental hospitals that was announced in Enoch Powell’s Water Tower speech in 1961. Despite their closure, these Gothic decaying institutions have cast a long shadow over mental health services. This volume examines the policy of community care that followed deinstitutionalisation. Community care is used as a shorthand for a range of community based mental health and other welfare services that support those experiencing mental distress. I should note here that terminology in the field of mental health is a problematic area. I use a range of terms in this volume: mad, the mentally ill, service user, people with mental health problems. This is not laziness or sloppiness on my part. The terms have all been and continue to be used in popular and academic discourse. I am not aware that there is a term that is widely accepted or not seen as problematic in some way. The terms reflect underlying values. I accept that some of these terms might be offensive. I apologise in advance for any offence caused to readers. This was not my intention.
The volume presents a critical history of deinstitutionalisation and the subsequent policy of community care. This, of course, points to one of the major criticisms of the policies. One should not have replaced the other, they should have gone hand in hand. In developing this analysis, I have been influenced by Rose’s model of a ‘history of the present’ (Rose, 1994: 53). This requires an investigation ‘from the point of view of a problem that concerns one today, the diverse connections and liaisons that have brought it into existence and given its saliency and its characteristics’. As part of this process, the current and historical ‘practices of truth situate persons in particular relations of force’ are analysed.
Chapter 1 provides a short introduction to deinstitutionalisation and community care, outlining the fiscal and ideological drivers of the reforms. The following chapter uses critical notions of space and place to explore the meaning and values attached to the terms ‘asylum’ and ‘community’. It argues that reductionist binary notions that present the community as an inherently progressive alternative to the asylum proved at best optimistic, at worst naive. Community care was introduced at a time when the impact of neoliberal economic and social policies was doing huge damage to the structure of local communities. The book then focuses on the development of mental health policy in the late 1980s and the early 1990s, outlining the way the pressures on mental health services developed. It examines the way that a series of high profile crimes committed by people with serious mental health issues and the subsequent inquiries led to call for reforms of the MHA. The period of deinstitutionalisation has been accompanied by a huge expansion of the use of imprisonment. Chapter 4 discusses the way that the penal state has become, in many circumstances, a de facto provider of mental health care. The reforms of the MHA and the introduction of Community Treatment Orders (CTOs) are then discussed. I argue that the introduction of the CTO marks the end of an official commitment to ‘community care’. Deinstitutionalisation is a policy that has been adopted in the majority countries in the world. Examples of its impact are discussed. The final chapters examine the landscape of contemporary mental health services.
Community care: a brief overview
Introduction
This short chapter provides a brief overview of the development of community care. It examines the way that the asylum became an obsolete institution – certainly one that had few defenders in the early 1980s. In giving a brief overview of the intellectual underpinnings of community care, the chapter introduces a series of issues – deinstitutionalisation and the penal state, community care inquiries and the asylum/community binary – which are examined in depth in subsequent chapters. Community care is a complex and highly influential shift in mental health services. As with all policies, there were a series of drivers behind the policy. I would summarise these as a combination of progressive idealism that attacked the whole notion that institutions could ever provide humane, dignified care and fiscal conservatism. Progressive idealism and fiscal conservatism are unlikely and
