Yesterday

Having been told to speculate on the future of psychiatric services, I remembered that there was a time when psychiatrists were presumed to have a crystal ball in the cupboard, as well as a trick cycle in the back yard. Those happy days were before society saw psychiatrists as the psychiatric fuzz or more recently as unnecessary jacks of all trades. Never effective with my crystal ball I decided to follow the advice of Aneurin Bevan who said ‘why study the crystal ball when you can read the book?’. With this advice it is my intention to scan the book of the past as a possible guide to the future. Certain themes persist and since change is slow, it seems possible that one can predict what may be happening at the beginning of the 21st century.

Let me begin at the end of the First World War when there was public unease about the ways in which the mentally ill were detained: a general fear that the whole system of lunacy administration was wrong and that widespread cruelty existed in public mental hospitals. A Royal Commission on Lunacy and Mental Disorder was appointed and reported in 1926 when it spelled out ideas which have guided change in public mental hospital psychiatry since that time (Home Office, 1926). The Commission's report stressed the close relationship of psychiatry to general medicine, the need to reduce legal intervention in the detention of the mentally ill and the need to secure care for the discharged patient. It recommended that local authorities could spend more to establish outpatient services and that the connection between psychiatry and the Poor Law should end. This seemed to mark the beginning of the end of the isolation of psychiatry from medicine and of the mental hospital from the wider community. Psychiatry could develop as a medical ‘scientific’ subject and play a part in medical education.

Psychiatrists at that time hoped that early treatment both inside and outside the mental hospitals would diminish patient chronicity. The Mental Treatment Act 1930 followed the Commission's report and made voluntary treatment available for many patients. But the Poor Law was not finally abolished until 1948.

At the end of the Second World War the National Health Service came into being.