New Developments in Mental Health Policy in the United Kingdom

International Journal of Law and Psychiatry, Vol. 23, No. 3–4, pp. 261–276, 2000Copyright © 2000 Elsevier Science LtdPrinted in the USA. All rights reserved

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261

New Developments in Mental Health Policy in the United Kingdom

Andrew McCulloch,‡ Matt Muijen,* and Heather Harper†

The Country

The United Kingdom consists of a union of four countries each with distinc-tive features of culture and social organization. These countries, which consistof the large island of Great Britain together with associated small islands, andthe northern part of the island of Ireland, are:

• England, which covers the southern part of the Great Britain. It has apopulation of 49.3 m (Office for National Statistics, 1998), of which 5.5%(Raleigh, 1995) are from ethnic minorities, mainly of Asian and AfricanCaribbean origins. Most of the population of England live in towns andcities, but some regions are mainly rural. Health care is provided largelyby the National Health Service (NHS) and social care by local authorities;

• Wales, which is located in the west, with a population of 2.9 m. Welsh iswidely spoken, although almost the entire population are fluent in En-glish. The structure of health and social services is similar to England;

• Scotland, which covers the northern part of Great Britain and has a popu-lation of approximately 5 m, most of whom live in the central industrialbelt. The Scottish care system is globally similar, but it has a different le-gal system and different mental health legislation from England;

• Northern Ireland is separated from the rest of Great Britain by the IrishSea and has a land border with the Republic of Ireland to the south. It hasa population of approximately 1.5 m. Structures are somewhat distinct—in particular health and social services are unified.

In recent years, the United Kingdom has moved from being a Europeanstyle state-controlled economy toward an American free market model

*Senior Policy Advisor, Sainsbury Center for Mental Health, London, UK.

†Director, The Sainsbury Center for Mental Health, London, UK.

‡Service Evaluator, Sainsbury Center for Mental Health, London, UK.

Address correspondence and reprint requests to Matt Muijen, The Sainsbury Center for Mental Health,134/138 Borough High Street, London S1 1L, UK.

262 A. MCCULLOCH, M. MUIJEN, and H. HARPER

(Hampden-Turner & Trompenaars, 1994). Much public sector industry hasbeen privatized. Economic growth since 1980 has been reasonably good, butwith two major recessions in the early 1980s and 1990s. There has been a heavyswitch away from manufacturing industry toward the service sector. The UnitedKingdom has welcomed widening of the European Union to its current 15 mem-ber states, and the new Labour Government is taking a more pro-Europestance, whilst retaining many of the policies adopted during the previous 18years of Conservative administration. The United Kingdom is not, however,joining the single European currency in the first wave.

Health Policy and Structures

Up to the Second World War, health care was organized around charitableinstitutions for the poor and working classes, and private health care for pro-fessionals. The upheavals of the war identified much morbidity and raised ex-pectations. This led to a major package of social reforms introduced by the1945 Labour Government, including the creation of the National Health Ser-vice (NHS) and the welfare state/social security system. Both still exist, al-though the latter has undergone greater erosion than the former (Timmins,1995).

The NHS is funded by taxation, and provides most health-care services freeat the point of use to all citizens, with limited item of service charges. Ap-proaching 100% of the population are registered with a general practitioner(GP) or family doctor, who with the support of other practice employees suchas nurses, provide a complete package of primary health care, and regulate ac-cess to secondary care. GPs are self-employed contractors paid by local healthauthorities. These health authorities also commission secondary and tertiaryhealth care from semi-independent NHS Trusts. The NHS is not, therefore, atruly unitary organization, but a close federation of public agencies with strongdirect management by the Department of Health, but with some local flexibil-ity. Health Authorities are not democratically elected but are run by a boardof local professionals and lay people appointed by the Secretary of State. Theycover populations of between 250,000 and 1 m.

The NHS has undergone a number of reforms over the last 20 years, while re-maining within the same broad model. In the mid-1980s management throughmultidisciplinary teams (referred to as consensus management) was replaced bygeneral management based on single individuals carrying lead responsibilitiesfor services or areas (Department of Health and Social Security, 1983).

Prior to 1991, all secondary health-care services were run by Health Au-thorities, which operated as both commissioners (purchasers) and providers,but with separate commissioning (by Family Health Services Authorities) ofprimary care. The 1991 reform was intended to create an internal marketwithin the NHS, with Health Authorities responsible solely for commissioningservices, including primary care from GPs who remained independent, and theold provider units, which were previously managed by Health Authorities, be-coming semi-autonomous NHS Trusts providing secondary and tertiary care(Department of Health, 1989; Klein, 1995).

NEW DEVELOPMENTS IN MENTAL HEALTH POLICY IN THE UK 263

NHS Trusts were created in a variety of configurations, including all healthcare (“single District Trusts”), all community and nonacute services, mentalhealth only, or mental health and learning disabilities, for example. Trusts hadto act in a similar manner as private sector providers, seeking contracts withhealth authorities and developing new services to respond to the market. Thisdid not however, result in a true market because of the scarcity of meaningfulcompetition coupled with a large degree of “provider capture.” In addition,some GPs became purchasers (“GP fundholders”), which tended to destabi-lize the system and create inequity, although it also made providers sharplyaware of the primary care perspective (Audit Commission, 1996).

These reforms have now been partly reversed, and partly built on, by theLabour administration which came to power in 1997. The market has beenabolished with the aim of moving toward long-term agreements betweenTrusts and Health Authorities. Commissioning by GPs is being rationalized.GPs (both fundholders and non-fundholders) are grouped on a locality basisinto Primary Care Groups (PCGs), with a population size of around 100,000,from the 1st of April 1999. Fundholding will be abolished. PCGs will commis-sion some services within a framework called the Health Improvement Plan(HImP) set by the Health Authority. Some PCGs may evolve into PrimaryCare Trusts from April 2000, providing a range of community and primarycare services whilst commissioning other secondary care elsewhere. Mentalhealth services will be provided by mental health and other Trusts, althoughpossibly some mental health services may eventually be provided by the newPrimary Care Trusts (Department of Health, 1997).

The Organization of Mental Health Services

As already stated, secondary health care for mentally ill people is providedby NHS Trusts and commissioned by Health Authorities, with growing degreeof delegation to PCGs. There is also a small but not insignificant private sectorin psychiatry, about 50% of which is purchased by health authorities to relievebed pressures in the NHS. The other 50% mainly provides services to peoplewho have health insurance (often provided by non-profit-making providentand friendly societies or as part of employment packages).

Many of the other services required by mentally ill people are provided bylocal government, which in the United Kingdom consists of a network ofelected local authorities. Local authorities have differing structures, depend-ing on the country concerned or whether they are urban or rural, for example.They are not necessarily co-terminous with health authorities. These servicesare organized as follows:

• Social care is commissioned and partly provided by the Social ServicesDepartments of local authorities. Most residential care is provided by theindependent (voluntary and private) sector;

• Housing is commissioned by Housing Departments of local authoritiesand also by national agencies, and provided mainly by independent hous-ing associations.


In addition, welfare benefits are provided primarily by the Benefits Agency,which has a network of local benefits offices, and is linked to the Departmentfor Social Security. Employment services are provided by a range of agencies,including a national public employment service.

The system is not well-integrated, with severely mentally ill people often re-ceiving services from a wide range of agencies: public, voluntary, and private.There have been many examples of care planning and integration breakingdown. Attempts have been made to establish systems of key workers and careplanning—led by health or social services. A number of areas have been ableto establish services that are integrated across health and social care andclosely linked with housing. In doing so they have had to overcome a range ofbureaucratic obstacles (Parker & Gordon, 1998). The split between centrallyand locally run services with the perverse incentives it creates has been ad-dressed by a consultation document, proposing the creation of joint commis-sioning or the pooling of budgets (Department of Health, 1998c). The inten-tion to proceed with these reforms has now been confirmed.

Models of Care for Severe Mental Illness: Inpatient Care

Up until the 1960s/1970s, mental health care was organized around largeasylums, which were built mainly in the period 1840–1920. At this time, theasylums started significantly to decline because of the introduction of newmedication and changes in care and philosophy. This process was recognizedby government and it became official policy to close the old institutions (Min-istry of Health, 1962; Ramon, 1992). The policy is now in the final stages of im-plementation, and most of the old long-stay beds are now closed.

As the number of inpatient beds has declined, from a peak of about 140,000in the early 1950s to about 36,000 now, the utilization of acute beds has be-come much more intensive with much higher throughput and occupancy. Overthe 10-year period 1984 to 1994/95 the number of available beds in Englanddeclined from 79,000 to 42,000, whereas the yearly bed turnover increasedfrom 2.6 to 5.7 (National Association of Health Authorities and Trusts andThe Sainsbury Centre for Mental Health, 1997). This increase in the intensityof the use of inpatient facilities has been fueled not only by bed reductions, butalso by significant increases in demand. Between 1984 and 1994/95, the annualnumber of informal (voluntary) admissions to inpatient care increased from192,258 to 216,270 and the number of formal (involuntary) admissions from16,044 to 23,410 (Department of Health, 1998b). On average, 30% of inpa-tients in NHS acute adult psychiatric units in England and Wales are detainedinvoluntarily (Ford et al., 1998), and as many as 57% of patients in Inner Lon-don (Ward et al., 1998).

Models of Care for Severely Mentally Ill People: Community Services

The number of community services has steadily increased over the last 30years, and these are also heavily pressured. The position has, therefore,changed from an entirely bed-based system, to a system where acute psychiat-ric inpatient provision deals only with the most disturbed individuals, and


where community teams and primary care absorb other pressures. Most com-munity teams are far too heavily loaded to deliver comprehensive and inten-sive care packages (The Sainsbury Centre for Mental Health, 1998a). In 1996/97 there were thought to be 803 Community Mental Health Teams in En-gland, an average of about one team for a population of 60,000, but subject towide geographical variation (NHS Executive, 1996). Many teams do not con-tain the full range of professionals, and most do not open outside office hoursor provide continuity of care across hospital and the community settings (TheSainsbury Centre for Mental Health, 1998b; Minghella et al., 1998; Onyett etal., 1995).

More specialized community services for severely mentally ill people havebeen slow to develop in the United Kingdom. In 1996, only 11% of servicesparticipating in a research project had a specialized community team offeringassertive outreach or intensive support (The Sainsbury Centre for MentalHealth, 1996). The same study also found that again, only 11% of services of-fered a crisis team to deal with crises arising in the community. Sixty percentrelied purely on accessing on-call medical staff from a generic accident andemergency department (emergency room) in a district general hospital. Widercommunity services are also in limited supply:

• While there were some 300 work or employment rehabilitation schemesfor mentally ill people in Britain in 1996, few provided much opportunityfor users to exercise choice or get involved in complex and demandingtypes of work (Nehring & Poole, 1993; Schneider & Hallam, 1996);

• Official statistics show that during the period 1983 to 1993 there was a29% reduction in the number of residential places available for mentallyill people in England from 75,130 to 53,500 (excludes hospital care)(Health Select Committee, 1994).

Quality And Distribution of Care

The distribution of mental health-care resources in the United Kingdom isuneven, and not necessarily linked to demand, although there is probablysome correlation between higher spending and higher need. A 1996 studyfound, for example, that:

• Hospital bed provision per 100,000 population varied from 30.8 to 85.6;• The proportion of provision that was hospital-based, as opposed to com-

munity-based, varied from 19% to 45%;• There was threefold variation across health authorities in the total num-

ber of residential places available for mentally ill people (Lelliott et al.,1996).

These variations in levels of service provision are undoubtedly coupled withvariations in quality, although these are hard to quantify. Issues such as poorcare coordination and lack of community resources are thought to be wide-spread. Many community psychiatric nurses have caseloads of 30–40 clients(National Association of Health Authorities and Trusts and The Sainsbury


Centre for Mental Health, 1997), which rules out any intensive or one or onetherapeutic work with clients.

As far as inpatient care is concerned, there is clear evidence of a major gapin quality. A recent study of the care received by 215 patients on a representa-tive sample of wards found that:

• Underlying social needs were not met;• Patients only received limited therapeutic input;• There was little to do, and few organized social activities;• Wards were unpleasant or even threatening for patients (The Sainsbury

Centre for Mental Health, 1998b).

Another concern is the poor structure and design of many inpatient units, notallowing optimum quality supervision and care. Recently, the recommenda-tions have been made about size and staffing, although the cost implicationsare likely to be prohibitive (Royal College of Psychiatrists, 1998).

National Policy

These changes on the ground have been reflected by the development ofthe national strategy or vision for services. In the 1970s the replacement modelfor the old asylums was seen to consist of acute psychiatric care in district gen-eral hospitals, coupled with multidisciplinary community mental health teams(Department of Health and Social Security, 1975). This vision has since beenbroadened and elaborated to describe a system of care including in-patientcare, crisis care, assertive outreach, community teams, 24-hour nursed care,residential care, supported housing, daytime activities, and social support (De-partment of Health, 1998a). A National Service Framework detailing the na-tional service model is shortly to be published for England. The new Frame-work will build on previous policy, but will emphasize the need for sufficientbeds, coupled with assertive and intensive community services for severelymentally ill people. Protection for the public has become a major part of thisagenda. Realistically, the Framework will only be deliverable with heavy in-vestment in both services and staff, and over a number of years. This is de-tailed in the government’s policy statement “Modernizing Mental Health Ser-vices: Safe, Sound and Supportive” (Department of Health, 1998a).

Inspection and Control

The NHS in England is strongly centrally regulated by the Department ofHealth, although this does not currently include systematic arrangements forregular inspection. The Department has hitherto relied on a combination ofperformance management to targets and professional self-regulation. This sys-tem is not now seen as fully effective and a national inspection agency, TheCommission for Health Improvement, is to be established (Department ofHealth, 1998b).

In mental health, The Mental Health Act Commission (and its Scottishequivalent) already has a role in relation to the rights and care of patients de-


tained under mental health legislation. In addition, there are a few indepen-dent agencies that can carry out inspections/evaluations on request. In socialcare, all statutory services are inspected from time to time by the Social Ser-vices Inspectorate, which is part of the Department of Health. This will be re-placed by regional inspection units covering all social care.

Incentives and Disincentives

There are a number of perverse incentives operating within the system.Generally speaking, it is in an agency’s interests for a patient, particularly onewith complex needs, to be referred to another agency and receive care there,thereby shifting costs (Muijen & Ford, 1996). This is apparent in the acute sec-tor where a significant proportion of beds are blocked by patients who couldbe discharged if community or social care, or appropriate housing, were avail-able. One recent study showed that 30% of a sample of short stay patientsblocking beds could not be discharged due to a lack of suitable accommoda-tion, and 19% because there was no domiciliary support available. In a similargroup of long-stay patients 33% blocked beds due to a lack of move-on accom-modation and 41% due to a lack of rehabilitation facilities (Shepherd,Beadsmore, Moore, & Muijen, 1997). The government is aiming to tackle thisissue by reducing the number of boundaries between agencies, for example, byallowing budget pooling across health and social care (Department of Health,1998d). However, much of the problem is probably due to limitations on thetotal quantum of resources available and other structural problems as much asa lack of good will between agencies.

Relationships Between Primary, Secondary, and Tertiary Care

Boundaries within the NHS itself also cause difficulties. GPs and primary carestaff often feel that they are left to deal with a huge volume of morbidity withoutsupport, and that they cannot get adequate secondary services when they needthem. Mental health trusts feel that they must sustain their focus on severemental health problems as they are required to do by government. The interfacewith tertiary care is less difficult since they are mostly part of the same providersthat offer secondary care. However, forensic services in particular are oftenseen as inadequate, and large number of quite difficult offenders have to bedealt with within secondary care. With the growth of GP-led commissioning—whether by GP fundholders or primary care groups—mental health trusts andother secondary care providers have felt pulled in two directions, with primarycare demanding better support for people with milder disorders, but governmentdemanding better services for severely mentally ill people.

Rehabilitation

During the last few decades rehabilitation has been dominated by the re-provision agenda of long-stay patients leaving the asylums, often after verylong stays. The benefits to patients of living in residential facilities have been


demonstrated by a carefully designed study, following up patients dischargedfrom two mental hospitals in North London (Leff, 1993). All 278 service usersand their matches were followed. The quality of care became less restrictive,but symptomatology did not show much change. Social interactions increasedsomewhat, however. Satisfaction with the living in the new residential settingswas high. Seven patients (1%) were lost to follow-up, possibly becominghomeless (Leff, Trieman, & Gooch, 1996). This undermines the popular beliefthat homelessness on the part of mentally ill people in inner cities was due tothe process of deinstitutionalization.

Of note are the secondary implications of mental hospital closures on theacute beds available. Eventually 6% of the resettled patients became difficultto discharge following readmission (Dayson et al., 1992). During a 5-year fol-low-up period, 27% required readmission at some point, with 9% of this grouprequiring a hospital stay of over a year (Thornicroft, Gooch, & Dayson, 1992).Much of the bed pressure in the United Kingdom might be explained by thisgrowing burden, especially if it is considered that a proportion of people ad-mitted to acute care would in the past would have relied on places in institu-tions.

An important aspect of rehabilitation and mental health care in general isevidence- based medicine. Of particular interest are developments in Cogni-tive Behavioural Therapy (CBT) (Fowler et al., 1995) and family interventions(Dixon & Lehman, 1996). The challenge is to create the training capacity todistribute the required skill throughout the workforce. Finally, the growing de-mand for newer antipsychotics is raising concern about cost-implications, andadditional resources allocated are unable to meet the rise in the drug budget(Department of Health, 1998a).

Special Groups

Services for special groups within mental health have generally developed inan ad hoc way, with the exception of children and adolescents and elderly peoplewho invariably have separate services of some sort. Child and adolescent psychi-atry is, however, particularly poorly resourced. The other exception is forensicpsychiatry, which has a range of inpatient facilities ranging through

• Three special hospitals for the most dangerous patients in England pro-viding about 1,500 beds;

• A network of medium secure units providing a regional or subregionalservice, offering about 1,000 places; and

• Low secure units located in many psychiatric hospitals.

Other groups that have received some attention include:

• Homeless mentally ill people have been addressed through coordinatedprograms in some big cities. In London, the Homeless Mentally Ill Initia-tive provides a mixture of assertive outreach, staffed hostels, and ordi-nary move-on accommodation (Craig, Bayliss, Klein, Manning, andReader, 1995); and


• People with a dual diagnosis of substance misuse and mental illness are agrowing problem, with about a third of people with psychosis falling inthis category (Menezes et al., 1996). There tend to be strong boundariesbetween substance misuse and mental illness services. Some areas arenow setting up specialist dual-diagnosis teams to tackle this problem.

Funding

Health and social care for mentally ill people in England costs about £3bnper annum, 85% coming from the NHS and about 15% from local authorities.The proportionate spend in the other countries is between 10 and 30% higher(Health Select Committee, 1998).

NHS services are funded mainly through general taxation. Monies are dis-tributed to health authorities via a funding formula that reflects morbidity andmortality, including psychiatric morbidity. However, health authorities arefree to purchase as much or as little psychiatric care as they wish. The varia-tion is in the range of 7–20% of their budget, higher spending being associatedto some extent with deprivation (McCulloch, 1997a). This means that the ef-fect of the funding formula is limited in terms of achieving an equitable or ra-tional distribution of resources.

Local authorities are also resourced via needs-based national formulae, butthey have to supplement their national grants through local taxation. Again,local expenditure varies as much according to politics and history as to need.Social care and other local authority services are chargeable, but many se-verely mentally ill people are exempt from charges due to low income. Thereare some special grants from central government targeted toward mentalhealth service development, but the vast proportion of the cost comes fromthe mainstream financial allocations. The charitable sector and health insur-ance companies also contribute a small but not insignificant proportion of thecosts of mental health services.

The other countries in the United Kingdom have heavier investment inhealth care, generally, than England. Scotland is most heavily resourced andstill has a strongly bed-based system for mental health, with higher numbers ofbeds per capita. Northern Ireland is also quite well-resourced and enjoys inte-grated health and social care provision. Although somewhat better resourced,Wales is nearer to the English model.

Personnel

Table 1 sets out the number of staff (for psychiatrists this includes specialists;for mental health nurses this includes qualified and unqualified nursing staff).

Generally speaking, the less-numerous, more-specialized professions inmental health have shown steady, but sometimes unremarkable, increases innumbers in recent decades. The number of psychiatrists who were either con-sultants or in the former senior training grade of senior registrar, for example,increased by 28% between 1984 and 1994/95, whereas the number of mentalhealth nurses increased by only 2%.


TABLE 1Numbers of Mental Health Staff in England, by Profession

General

staff group Number of posts Source and notes

Psychiatrists in services for adults with mental health problems 2654

Source: Royal College of Psychiatrists (1997)

Of which in General adult 1321Children and adolescents 461Forensic services 149Older adults 425Psychotherapy services 128

Clinical psychologists 4333F.T.E.

Source: Department of HealthNon-Medical WorkforceCensus for England (1997)

Social workers in specialist mental health teams

5878.9 Source: Local AuthorityStaffing of Social ServicesDepartments as ofSeptember 1997.

Social workers in services for adults 10062.3 Source: Local AuthorityStaffing of Social ServicesDepartments as ofSeptember 1997.

Social workers in services for children

17000 Source: Local AuthorityStaffing of Social ServicesDepartments as ofSeptember 1997.

Nursing staff working in the community

10529 Source: Department of HealthNon-Medical WorkforceCensus for England (1997)

Other psychiatric nursing staff 41365 Source: Department of HealthNon-Medical WorkforceCensus for England (1997)

Occupational therapists 9312 Source: Department of HealthNon-Medical WorkforceCensus for England (1997)

Staff working in day centers for adults with mental health problems

1199.6 Source: Local AuthorityStaffing of Social ServicesDepartments as ofSeptember 1997.

F.T.E.

5

full-time equivalent.

The Training and Education of Staff

There is a significant body of argument and evidence to demonstrate thatthe training and education of staff is not geared to the needs of modern ser-vices and their users.

Training and education mechanisms have failed to keep pace with changingservice models and needs (The Sainsbury Centre, 1997). The delivery andmonitoring of basic and continuing education and training is fragmented in


terms of its organization, and patchy in terms of coverage and accessibility.There are a number of concerns about the relevance of current training andthe fitness to practice of staff. Many staff lack clarity about their roles in a mul-tidisciplinary team, and there is a lack of robust mechanisms for ensuring con-tinuing competent performance after qualifying.

The major staff groups have some common training needs. Many needtraining in team-working, multidisciplinary working, new ways of workingwith people with serious and complex needs (e.g., psychosocial interventions,outreach work, working with substance use) and care planning.

Staff Recruitment and Retention

A key issue of concern to services and policy-makers, at least in relation tomental health services in England, is the emergence of major difficulties in re-cruiting and retaining staff to work in mental health services. These difficultiesare concentrated in deprived inner-city areas, or in areas of the country thatare perceived as less attractive to live in, but are widespread.

These problems arise in all the main professions:

• Royal College of Psychiatrists (1997) found an average of 13% of avail-able posts to be vacant;

• Many trusts report major problems in recruiting mental health nurses;85% of NHS trusts reported difficulties in recruiting nurses in any spe-cialty, but problems were more severe in mental health (National Associ-ation of Health Authorities and Trusts, 1996);

• There are also major shortages of clinical psychologists and occupationaltherapists. Data on social work are scarce.

The genesis of recruitment problems in mental health is complex and prob-ably reflects an interaction between demographic change, the perceived unat-tractiveness of mental health, low morale and high burnout, and the failure tocreate a wide enough entry gate to some of the professions. The SainsburyCentre has launched a major review to elucidate the causes of this problemand come forward with practical solutions. A failure to develop sufficientnumbers and quality of staff could jeopardize current policy aspirations.

User and Carer Perspectives

Both users and carers are deeply unsatisfied with the system of care thatthey consider to be of generally poor quality, uncoordinated, and unrespon-sive to need. The user and carer movements have both grown in a very signifi-cant way over the past two decades and have strong national voices.

Many users feel that services:

• Are not designed around their needs and are wholly inadequate in termsof scope and access;

• Do not address basic needs, such as housing, employment, and welfare;• Are insensitive to issues such as race, sexuality, and gender;


• Offer containment or control rather than care; • Set the targets rather than the user (Beeforth, Conlan, & Graley, 1994;

The Sainsbury Centre for Mental Health, 1998b).

Carers broadly agree, but feel that their perspective is ignored, that they areexcluded from the care process and that they should be offered separate andappropriate support, which is usually lacking.

Public Opinion

Public opinion has played a major role in the development of mental healthpolicy in the United Kingdom, particularly in England. The public, fed by themedia, have tended to view the move away from the asylums as a cost cuttingmeasure, although they generally support more modern models of care. Fromthe late 1980s onward, a series of incidents involving homicides by mentally illpeople, many of whom have received poor community care, have gained ex-tensive and adverse media coverage. As a result, the public now feels seriouslyat risk and this has driven a strong government emphasis on safety in mentalhealth services. In fact, the United Kingdom has a low homicide rate interna-tionally, of which homicides by mentally ill people forms a static or even de-clining proportion (Taylor & Gunn, 1999).

Public attitudes are more complex than simple fear of severely mentally illpeople (McCulloch, 1997b). While such fear exists, there is a tendency toblame government and services for not providing proper care. Simultaneously,there is also an increasing recognition and acceptance of mild to moderate dis-orders that has made it easier for people to acknowledge and present withsuch disorders.

There is a serious danger that fear of violence, as reflected in governmentpolicy, will lead services not only to focus on severely mentally ill people, butalso to adopt conservative and safety-oriented care practices. This may havethe paradoxical effect that services, such as assertive outreach, become unac-ceptable to, and unable to engage with, users. If opportunities for engagementwith users who pose a risk to themselves or others are missed, improved safetywill not be achieved. An additional problem for services is that increasedstigma makes it difficult to develop community services and for users to be tol-erated by the community.

Legislation

Mental health legislation in the United Kingdom last underwent major revi-sion in the early 1980s. One piece of legislation covers England and Wales, an-other Scotland, and a third Northern Ireland. Mental health legislation inScotland historically evolved somewhat separately and reflects differences inthe Scottish legal system. However, the fundamental principles are the sameacross the United Kingdom.

The main features of the system are:


• Provision of various terms of compulsory hospitalization for assessmentor treatment, including special provision for forensic cases. This requiressocial care and carer involvement as well as the involvement of two doc-tors one not associated with the inpatient unit;

• An independent review of detention by Mental Health Review Tribunals;• Independent inspection by the Mental Health Act Commission;• Arrangements for second opinion in cases of compulsory treatment; • Limited arrangements for aftercare and guardianship, which are not

well used.

While sound in principle in terms of human rights and hospital care, the legis-lation is no longer considered by many to be appropriate to community-basedservices. In response the Government has announced a review of the MentalHealth Act, which will include the introduction of some sort of CommunityTreatment Order. This is highly controversial within the United Kingdom.Many user, staff, and mental health groups are deeply opposed to such Orders,especially in the context of often poorly developed services. They feel thatthey could be used to substitute for proper care and engagement and mightdrive users underground. This debate will continue for some time (Szmukler& Holloway, 1998).

Future Trends

The next 5 years will continue to see major change, and these are likely tobe characterized by the following features:

1. Intensive service development to build up comprehensive services, sup-ported by targeted new monies from central government. The emphasisneeds to shift from policy initiatives toward implementation, and a firststep has been made by announcing the allocation of £700 million over 3years. Regional activities will be set up to support development of arange of specified services in both the NHS and social services (Depart-ment of Health, 1999).

2. The development of more modern staff training programs to fit staff towork in the new services. The lack of suitable training is recognized, al-though it is unclear whether the capacity for a large retraining exercise isin place at universities or other training providers. This is even more ur-gent, since 15–30% of the announced grant to social services is expectedto be spent on training (Department of Health, 1999).

3. Continued tension between the safety agenda and the requirement to en-gage users with sensitive services. The government position inherent inthe new policy document (Department of Health, 1998a) is that “com-munity care has failed,” and the announcement of a review of the MentalHealth Act, putting Community Treatment Orders squarely on theagenda, has created anxiety among users. This has become a distractionfrom the move toward service development, and has hindered a con-structive dialogue between the parties. The emphasis on safety has alsodistorted the potential use of assertive outreach teams to engage users on


their terms toward a system of control (Sainsbury Centre for MentalHealth, 1998a).

4. Increased experimentation with interagency and new provider models.Many exciting models are emerging around the country, although none isstandardized. The position of government is facilitative, rather than pre-scriptive, and it is to be hoped that the forthcoming National ServiceFramework will continue this trend.

5. Scope for expansion of primary care. As much as 95% of all people withmental health problems are treated in primary care only, even thoughthe problems of a high proportion of people with mental health problemsare not diagnosed (Goldberg & Huxley, 1992). This suggests great poten-tial to develop primary care linked secondary care. The newly launchedprimary care groups have a crucial role in developing mental health care,hopefully without the tensions and inefficiencies that emerged as a con-sequence of the past fundholding system Audit Commission, 1996). Thesimilarities between primary care groups and health maintenance organi-zations in the United States are striking, although primary care groupscannot select the population they serve. This might create incentives to-ward control mechanisms, such as managed care, so far alien to the U.K.system, and this demands close scrutiny.

There is now a strong consensus about the need to develop a balanced andcomprehensive mental health system in the United Kingdom, and there is thepolitical will to develop such a system. However, there is also a risk that thesafety issue could jeopardize progress and that overload, burnout, and recruit-ment problems could cause some services to collapse. At present, the positionis finely balanced. The next 5 years will determine the future shape of servicesfor many decades to come.

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New Developments in Mental Health Policy in the United Kingdom

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