Academic journal article Hong Kong Journal of Psychiatry

Development of Health Service Policy for People with Learning Disability in the United Kingdom

Academic journal article Hong Kong Journal of Psychiatry

Development of Health Service Policy for People with Learning Disability in the United Kingdom

Article excerpt


The evolution of health services for people with learning disability in the UK is reviewed in the context of health policy, with an emphasis on developments since the formation of the National Health Service in 1948.

Key words: Clinical Governance; Community Care; Learning Disability; Mental Handicap; Mental Retardation; National Health Service; Services


In pre-industrial Britain, people with severe learning disability (severe mental retardation) were looked after by their families, although institutions began to appear from the late 13th century. Those with milder degrees of retardation usually found some suitable work in what was largely an agricultural economy heavily dependent on manual labour. However, following the industrial revolution in the 18th century, there was a large shift of populations into the developing towns and cities. The complexities of urban industrial life soon exposed vulnerable groups of people, particularly the mentally ill and those with learning disabilities. These people were suddenly 'visible' and became a political embarrassment as they gravitated to prisons and workhouses.

Initially, legislation and care provision did not distinguish between the mentally ill and learning disabled. However, by the late 19th century, the onset of compulsory education identified people who could not cope with mainstream educational services (Elementary Education [Defective and Epileptic Children] Act, 1899) and institutions for the training and education of 'defectives' began to appear.

The initial aim of these special services was to return people to the community after a period of training but, by the early part of the 20th century, fears about the high birth rate amongst the 'feeble-minded' and ideas, perpetrated by the eugenics movement, about their high birth rates diluting the quality of the gene pool in the general population, prompted a trend towards longer term care.

The Mental Deficiency Act of 1913 differentiated between 'idiots' (severe learning disabilities), 'imbeciles' (moderate learning disabilities), 'feeble minded' (mild learning disabilities) and 'moral defectives'. Provision was made for statutory institutional care or community care under licence or guardianship for people who could not be cared for in society. Institutions were also established for 'defectives' with violent propensities. Local Mental Deficiency Committees, run by local government, acted as gatekeepers, providers, and inspectors of institutions. Local Authorities were also responsible for training and daytime occupation.


1948 TO 1969

Until the onset of the National Health Service (NHS) in 1948, all services for people with learning disabilities were in effect provided by local government in a variety of settings including institutions, residential colonies, and day care settings. The majority of the staff in the institutions were unqualified 'attendants', although some of the larger institutions had part-time medical staff or a medical superintendent.

When the National Health Service was formed, these institutions, housing some 50,000 inmates and varying in size from 20 beds to 2000 beds, were re-designated as 'hospitals' whilst day care services remained under the local government authorities as before.

By the 1960s, the hospital population had peaked at 64,000 patients. Recruitment of specialist staff was increasingly successful and a wide range of medical, nursing psychology, and allied professionals entered the service. Diagnosis, treatment, teaching, and research achieved greater prominence in the activities of institutions. State enrolment of specialist learning disability nurses was initiated in 1964.

The first glimmerings of a shift back towards community care came in 1965 with the publication of a government document Improving the Effectiveness of Services for the Mentally Subnormal, which advocated returning people to supported life in the community. …

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