Mental Health Day Services in the United Kingdom from 1946 to 1995: An 'Untidy Set of Services'

Article excerpt

Introduction

Community mental health services have evolved from an initial drive to reduce the use of institutional care, with mental health day services playing an ongoing and critical role as a bridge between hospital and community Essentially, people have used day services to access professional and social mental health care without the inconvenience or disruption of an admission to hospital. Through the provision of medical, nursing, occupational, psychological and social interventions, day services have offered transition from inpatient treatment, crisis management and ongoing contact. As community services have diversified, day services have shifted emphasis and evolved in response. Recently, it has not been clear whether they are primarily regarded as a community resource or as an outpost of institutional and professional intervention. This partly reflects the historical dual provision of services by health and social care organisations. Frequently, these providers have worked in partnership, and the sources reviewed here indicate that the differences between the two were more ideological and organisational than a reflection of different needs arising from mental health problems.

This critical review suggests that the recent modernisation policy, which has refocused services on social inclusion (National Social Inclusion Programme 2008), could be better informed by a sophisticated understanding of the complex role of day services since their beginning in the 1940s. The established collective approach of day services is not easy to reconcile with modernised services based on individualised treatment or care. Increased emphasis on individual adaptation and change has been associated with not only the social inclusion agenda (Cameron 2006) but also recovery (Repper and Perkins 2003). This emphasis has meant that bringing service users together has appeared undesirable. This could be because of long-standing fears about the negative effects of institutional approaches to service provision (Illich 1973), although it could be argued that these institutional approaches are still evident in mental health services, particularly in forensic units (Carpenter 2000). Leighton (2003) challenged the emphasis on individualised approaches, giving details of the varied collective approaches to mental health care and their benefits. The history of day services presented here indicates that the benefits of working with groups of people, in a social context, have been identified by many researchers.

The focus of this review is on how day services have evolved in approach and in relation to other service developments. Clark (2001) claimed that day services do not receive sufficient attention, given their significant role in supporting many people. Published histories of mental health services tend to focus on institutional rather than community care (Bartlett and Wright 1999). There are many reasons for this, including the dominance of medicine, accessibility of hospital records and the focus of policy and legislation on hospital care. Community care has coexisted with hospital care for the majority of mental health service users, based on the informal efforts of the family, neighbourhoods and charities (Jones 1972, Bartlett and Wright 1999, Welshman 1999). There has been consistent recognition that the community is a better place for most people, informing successive reforms such as the modernisation of day services (Boardman 2005). Yet the evolution of day services has not been analysed recently.

This review was conducted to inform a participatory action research project (Bryant et al 2010), which aimed to influence local interpretations of the day services modernisation policy (Office of the Deputy Prime Minister 2004). Service users and staff were involved over 4 years in cycles of action and reflection, creating evidence of their interpretations of the policy. For example, there was a strong view that locating services primarily in designated day services buildings was socially exclusive (Lingwood 2005). …