Background briefings from

The origins of
community care

History of mental
health legislation



FULBOURN, 1858-1983

by David H. Clark

Demand for mental health services has increased dramatically in the twentieth century. Treatment has become more accessible and not just available to those who are detained.

The Lunatic Asylums Act 1845 made it mandatory for each borough and county to provide adequate asylum accommodation at public expense for its pauper lunatic population. This led to a rapid asylum building programme. The asylums quickly became overcrowded institutions.

Critics of the asylum argued for trying to make them more therapeutic and less custodial, by allowing admission without cerification, early intervention, and the boarding-out of the more chronic cases, but they lost the argument in the 1890 Lunacy Act. The Mental Treatment Act 1930 introduced voluntary admission by written application to the person in charge of the hospital and authorised local authorities to set up psychiatric out-patient clinics in general and mental hospitals. The Mental Health Act 1959 made informal admission the usual method of admission to hospital and no longer required the positive statement of willingness on the part of the patient.

In the 1950s, the locked doors of the psychiatric hospitals started to be opened. The traditional asylum became increasingly irrelevant to the bulk of mental health problems. When the doors were opened the traditional hospitals went into decline and alternative services were developed, including psychiatric units in general hospitals, residential homes and day centres. Many old long-stay patients grew old and died in hospital, and the number of new long-stay patients to replace them has been much less.

Despite a two-thirds reduction in bed space between 1950 and 1989 (see chart for recent trends in available beds), there was more than a three-fold increase in admission rate to psychiatric hospital. There have been reductions in the average length of stay, although a significant minority still experience protracted hospital admissions.

Over recent years there has been an increase in secure unit beds (see chart) and in the use of detention under the Mental Health Act until 1999 (see BMJ article). Civil detention has continued to increase over recent years, although this has been offset by a reduction in the number of informal patients detained after admission to hospital (MHAC report).