Through the decades: A deep dive through 75 years of NHS history
05 July, 2023
On the 75th anniversary of the NHS, we explore the history of psychiatry within the NHS and its close ties to RCPsych. Read on to find out about the journey from the National Health Service Act to the recent election of Dr Lade Smith CBE as the College’s newest President.
On 5 July 1948, the National Health Service Act came into effect, signifying the launch of the NHS in Britain. Preliminary proposals for the NHS had left out mental hospitals since they had different legal requirements from general hospitals. However, bodies such as the British Medical Association (BMA), exerted pressure which resulted in mental hospitals coming out of local authority control and into the national service.
The NHS took over around 2,600 hospitals across England and Wales, including the mental hospitals. Almost half, 190,000, of all the beds the NHS took over were in mental hospitals, and psychiatrists, in common with other doctors, were now employed by the State.
Even so, upon its introduction, the NHS had minimal impact on the hospital system, some of which had existed for over a century. The mental healthcare landscape needed vital developments, a process which would continue for years to come, including improving training for psychiatrists and policies to expand and implement community care.
One early and direct result of establishing the NHS, was that the Bethlem and Maudsley hospitals were brought together. This facilitated the opening of the first proactive 'geriatric unit' in a mental hospital, in 1949. The first consultant in this unit was Dr Felix Post, a refugee from Nazi Germany.
In 1959 the Mental Health Act was passed. It gave psychiatry greater flexibility to function alongside other specialties in the general hospitals and in the community. Today, this might be referred to as a step on the path to 'parity of esteem'. New treatments like neuroleptics and antidepressants were also introduced in the 1950s and early 1960s.
Into the 1960s: A critical decade for psychiatry
More young doctors were recruited into the profession and more academic departments of psychiatry were established in medical schools in the 1960s and into the 1970s, providing systematic training courses alongside a focus on research. Enthusiastic psychiatrists working within the NHS fought for the development and recognition of new specialties.
In 1962 a bold programme began, which set out to overhaul the entire physical infrastructure of the NHS. A Hospital Plan for England and Wales proposed the construction of new District General Hospitals (DGHs) and substantial modifications to existing hospitals. Initially devised as a 10-year programme, it took twice as long to implement, at a cost much higher than originally estimated. The Plan also signalled a policy shift from standalone, long-stay psychiatric hospitals to integrating mental health services into general hospitals and facilitating community mental healthcare. It aimed to close all large mental hospitals, although no mental hospital had closed completely until two decades later, in the 1980s.
Parts of former mental hospitals have been repurposed, such as for housing, colleges, theatres, leisure centres or offices. Some sites still have NHS units, with links to community services and general hospitals. Scotland, unlike England, has retained many of its psychiatric hospitals, such as the Royal Edinburgh Hospital.
In 1963 the Journal of Mental Science became the British Journal of Psychiatry (BJPsych), see the October 1949 edition, free for public viewing throughout July, which includes an article focusing on the mental hospitals in the NHS.
The 1970s and 1980s
In 1971 the Royal Medico-Psychological Association received its Supplemental Charter and became a Medical Royal College, prompting a name change to the Royal College of Psychiatrists (RCPsych). It continued as an important NHS stakeholder, holding formal policy development annual meetings with the Department of Health and Social Security from 1977 onwards: a selection of these minutes are available in the College’s Archives. Royal Colleges required a membership exam, and trainee psychiatrists emphasised the importance of good training. No longer were budding psychiatrists recommended to take the membership exam of the Royal College of Physicians!
The decade also saw the advent of a more diverse workforce. Dr Pearl Hettiaratchy, then an NHS trainee psychiatrist, later went on to become the first South Asian Vice President of the College. She also became the first practicing female NHS consultant in Winchester, of any specialty, to wear a saree to work. Joan Bicknell, an NHS consultant in 'mental handicap' in the 1970s later became the first British female professor of psychiatry. In 1976 Aggrey Burke was the first black consultant psychiatrist within the NHS. Over the span of a more than 40-year career, Dr Burke made strides in confronting racial bias in the medical school system. In 1986, he published a ground-breaking paper with his colleague Dr Joe Collier, exposing the racist and sexist student selection procedure in London medical schools, leading to reforms in selection processes.
In 1983 the Mental Health Act was passed, influenced by the Royal College of Psychiatrists. Today the College estimates that mental health is the specialty area subject to the most healthcare legislation.
In 1989, forty years after the first mental hospital NHS 'geriatric unit' opened, old age psychiatry was officially recognised as a specialty by the Department of Health.
The 1990s to today: A matter of trusts
In 1990, the National Health Service and Community Care Act was introduced, establishing NHS Trusts.
In 1999, the Government published the National Service Framework for Mental Health. It cited, as an example of good practice, the Royal College of Psychiatrists’ new national campaign Changing Minds – every family in the land, aiming to reduce stigma attached to mental illness.
In 2001 NICE (then, National Institute for Clinical Excellence, now National Institute for Health and Care Excellence, but retaining its original acronym) commissioned National Collaborating Centres with the Medical Royal Colleges to develop guidelines for treatment, setting out how “whole disease pathways should be approached and what standards patients should expect”. The Royal College of Psychiatrists collaborated with University College London (UCL) to establish the National Collaborating Centre for Mental Health (NCCMH). The first ever NICE clinical guideline was published in 2002, focussing on schizophrenia, the most common form of psychosis. Since then, NCCMH has developed over 30 more NICE guidelines. These have been translated and adopted/adapted by other public healthcare systems, including in Italy, Australia and Slovenia. NCCMH currently works at a local, national and international level, to aid the improvement of mental health services and redress mental health inequalities.
In 2005 the Mental Capacity Act enshrined the right of every adult to make their own decisions unless lack of capacity is established. Any decision made on behalf of someone who lacks capacity must be in their best interest.
In 2017 RCPsych launched its successful Choose Psychiatry campaign, led by Dr Kate Lovett, encouraging junior doctors to enter the profession leading to 100% fill rate for training posts.
Two years later, in 2019, the NHS Long Term Plan was published. It heralded a major expansion of mental health services in England, including psychological therapies for common mental disorders and 24/7 crisis response services. The 10-year plan included significant additional funding and roll out of new community services for adults with severe mental illness. The new community set-up brings NHS, local government and voluntary sector teams together to provide holistic and person-centred mental health, physical health and social care to individuals.
To improve public mental health, in 2022, RCPsych launched the Public Mental Health Implementation Centre (PHMIC) to improve implementation of evidence-based interventions to prevent and treat mental disorders and promote mental wellbeing and resilience. This was considered necessary because, in the UK, only a minority of those with a mental disorder (psychosis excluded) receive treatment and far fewer receive interventions to prevent associated impacts. The Centre publishes and provides advice to NHS commissioners, trusts, and others on how to bridge the implementation gap. This includes identifying proven strategies to tackle the root causes of mental illness including inequality, barriers to treatment, discrimination, racism and poor physical health.
This year, 2023, Dr Lade Smith was elected President of the Royal College of Psychiatrists – the first Black woman elected to lead a UK Medical Royal College.