Policy Papers


A National Social Care Service beyond COVID-19: Lessons from the History of Mental Health Social Work and the Origins of the NHS

Dr Kevin Matthew Jones |

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Executive Summary

  • Growing concern about the state of the social care services has been partly triggered by the COVID-19 outbreak, but also by a recognition that problems have been in development for a long time.
  • Key events in the formulation of the mental health services were brought about during a period of crisis that placed pressure on clinical services.
  • As we emerge from the COVID-19 crisis, new opportunities present themselves for policy makers to reform social services, but these must address long-standing attitudes that have prioritised clinical services since 1948.
  • A proposed solution enjoying considerable support is for a new national care service that uses the NHS-model to introduce a paradigm shifting rights based approach.
  • This article draws upon developments surrounding mental health social work either side of WWII to provide insights into the links between service provision and public attitudes to health that may hinder reform.

Introduction

Between 2007 and 2009, the Labour government held the Big Care Debate, the largest consultation held on the state of social services in the United Kingdom. Over twenty-eight thousand individuals and organisations responded to the call, culminating in a white paper published before the May 2010 general election. ‘Building a National Care Service’ called for reform that would standardise social care across the country, and used a model of a universal and free at the point of need service inspired by the NHS. The authors compared their proposal to the reorganisation of the health and welfare services after the Second World War, and in the wake of the crisis in public funding seen after the financial crisis of 2007 – 2008, held that radical action was needed to avoid the longer-term social burdens of an ageing population. Labour’s subsequent general election defeat meant that these plans would not be realised, and as public attention shifted away from social care first to austerity and then to Brexit, discussion of a standardised social service fell away.

Talk of a long-term solution to social care has recently resurfaced, partly due to weaknesses arising from additional pressures placed upon it during the COVID-19 outbreak. In response, Labour and the Scottish National Party have reintroduced discussion of a standard national care service, and the Conservative party recently came under fire from health groups for not providing a clear vision of the future of social services in their 2021 Queen’s speech. Research that links COVID-19 to long-term psychological and neurological complications is seen by mental health groups and local government to further highlight the need for wholesale reform of social care.

Lack of clarity on what social care exactly describes in these debates is captured neatly in the case of mental health social care, the focus of this discussion. Conceptions of health and wellbeing are especially unclear in the case of mental health social work and go back to their origins in the late-nineteenth century. During the first half of the twentieth century, mental health social services developed ad-hoc as new organisations were established, leading to fractured services. Attempts to standardise them took place around WWII, and helped to formulate the organisation that eventually would become Mind, the mental health charity. These reforms nevertheless left a fragmented mental health social service by the time of the establishment of the NHS, which set the paradigm for mental health social services during the post-war era. In contrast, clinical services were integrated into a universal health service, whose success is currently used as a model by policymakers for a new national social service. The dominant-paradigm of the post-war period has shaped broader cultural and social attitudes to health and social care that may prove an obstacle to long-lasting reform.

Although there is widespread recognition that problems with social care provision are caused by the recent history of social care policy, the failure to consider the longer history of social care risks overlooking key yet subtle factors that have shaped the decisions of policy makers. A degree of historical awareness of the problem is seen in these discussions through calls to model changes to social care upon the health reforms that occurred immediately after the Second World War. The Local Government Association, for example, calls for a ‘1948 moment’ that will enable a move away from a support-model conventionally viewed to provide services only to those who find themselves in severe need, towards heightening wellbeing and enrichment. It also suggests that the support-model of social services partly contributed to a system operating at its limit and unable to cope with unforeseen pressures.

Long-term reform of the social services go beyond changes to policy, and will require a shift in public attitudes. Advocates of a social service appeal to the NHS’s status as a cultural icon, which can in turn help to shift health policy paradigms and wider cultural attitudes. Its brand effectively and clearly communicates to many a universal and standardised service: this was especially demonstrated during the pandemic. The use of a well-established brand will change the ways users seek to access support: instead of being viewed as a last resort in crisis, social services could come to be regarded as a universal service in a similar manner, and raise public health levels by promoting an enriching and rewarding life.  

Deeply ingrained cultural understandings of the function of social work translate themselves into what the King’s fund describes as a public having ‘very little understanding of how social care operates and even less understanding of how it is funded’. A recent report commissioned by the SNP wrote that:

people feel that the term itself – social care – is often used negatively, to mean services that are for people only when in crisis, that just prevent or delay a deteriorating situation, or are a buffer to absorb pressure that would otherwise fall on the NHS.

Policy changes must be carried out on the basis of an understanding of how these difficult-to-shift attitudes arose. In this paper, I will present an episode from the history of social care that presents relevant considerations to health and social care policy makers. Fundamental questions clarifying social care’s role and what we want its future look like require a return to the very origin of the NHS and local authority social services. This discussion of the first attempts to standardise social services in response to the crisis brought by World War Two will demonstrate how cultural and social attitudes to health have an impact upon formulating policy.

 

Section 1: Wartime Medical Services and the First Attempts to Standardise Mental Health Social Services

The lack of a nationally co-ordinated framework for social work came to prominence during the Second World War, and it was most starkly seen in the mental health services. Despite pushes from psychiatric social services to establish a national organisational framework with guaranteed sources of funding, much of their responsibilities were placed in the hands of local authorities, which were required to find independent sources of funding. Archives show that this had come as a surprise and disappointment to prominent figures in mental health social work, who had lobbied the government during the re-organisation of the health services prior to the introduction of the NHS. Many of the problems that have been outlined in recent debates over social care policy were encountered during the formulation of health and welfare services during and immediately after WWII.

Attempts to nationally standardise social work began shortly before the Second World War. The Feversham committee on the Voluntary Services was established in 1936 to provide a comprehensive review of the voluntary mental health services operating in the United Kingdom. It provided a full audit of the various voluntary local service providers in an attempt to avoid overlap in services and increase efficiency of mental health social care. In its report, the Feversham commission recommended the amalgamation of the voluntary organisations operating in the UK into a centralised national body. These organisations had developed from the late nineteenth century into a complex patchwork of local and national social work agencies, and they included the Mental Aftercare Association, the Child Guidance Council, the National Council for Mental Health and the Central Association for Mental Welfare. They had emerged from parish and religious groups, and from societies affiliated to the eugenics and mental hygiene movement. As Jonathan Toms notes, these organisations principally operated on a conception of mental health as deficiency and defectiveness, a deficit in capacity that needed a cure or support and were therefore little concerned with life enrichment or patient autonomy. The Feversham report emphasised the need for a shift away from ideas of deficit and towards promoting ‘mental health’ as the standard amongst social workers, because it ‘implies the ideal of wholeness of mind and body’. The commission also held that the fractured nature of social services led to appeals for funding being made by these ‘rival associations, with the result that both effort and money were not being employed to the best advantage.’ The commission recommended that the principal psychiatric social work organisations operating in the United Kingdom should formulate a new national committee to oversee local community operations. This national framework would be responsible for upholding national standards of service provision, access, staff training and career progression. The report recommended that the work start immediately, but acknowledged that it might take up to a decade for full amalgamation to take place. 

The war would accelerate this process. The Mental Health Emergency Committee (MHEC) was established just before the outbreak of the Second World War in Spring 1939 to bring together mental health social services into an emergency wartime service. The repurposing of institutions into war hospitals, and the conscription of a great-proportion of doctors and nurses into the military had increased the need for well-organised mental health social services. This move to become an emergency wartime service introduced a first step in the standardisation and professionalisation of mental health social services: the government had not placed psychiatric social work on the list of professions exempt from the first wave of conscription, and this risked leaving the field both under-staffed and at risk of losing trained professionals. The first action of the newly organised MHEC then was to campaign for social services to be included as a reserved profession in the Schedule of Reserves Occupation, drawn up by the government prior to the outbreak of war. The organisation made a case to the Ministry of Labour and the War Office for the importance of preserving these professions, and compiled a Register of Full Time Salaried Social Workers in the Mental Health Field for use by local authorities as well as a Supplementary Register of part-time and Voluntary Workers. This standardised information would make it easier for local authorities across the country to request trained mental health social workers, who gave assistance to families who had seen their relatives discharged from repurposed psychiatric institutions.

In their first annual report from 1940, MHEC described how it acted as the national reference point for information on the mental health service operations. It co-ordinated the efforts of mental health workers across the country to provide home visits to ex-servicemen and civilians. It treated and supported specific mental health problems that had arisen as a result of the conflict and provided support in the absence of clinical services. It co-ordinated the deployment of Mental Health Social Workers that could assist in the treatment of air raid victims who suffered trauma, especially in the heavily bombed cities of Coventry, Bristol, Southampton, Portsmouth and Plymouth. Regional information centres were established to provide assistance on mental health matters including those related to billeting children and air raids, with literature published to assist schools and medical services. MHEC helped to maintain evacuee hostels and co-ordinated the services of educational psychologists for Local Education Authorities. MHEC maintained a Register of Mental Health Workers and Hostel workers, and managed their availability on a local and national level. The MHEC also developed standardised training for clinical staff such as lectures on child psychology to hospital nurses and teachers. As the Commonwealth fund of America withdrew their funding for the Mental Health Course at the London School of Economics towards the end of the war, the organisation stepped in to save it, thereby preserving the first and most prestigious training scheme for psychiatric social workers in the United Kingdom.

 Despite performing valuable public services during wartime and to some extent raising awareness of mental health social work amongst the community, MHEC did not gain full state support and was required to attract other sources of funding to maintain its activities. Along with philanthropic donations, profits from teaching and training courses made up a great deal of its private revenue. In all, MHEC conducted ninety-one lectures for civil defence workers, with an estimate of between twelve thousand firefighters and medical staff having attended up until 1941, but this was not enough for it to break even as charitable sources dried up during the war. The issue of funding for MHEC was brought up in parliament on 25th June 1941 by Francis Freemantle, a former doctor and Conservative MP for St Albans who was a leading authority on state medicine and considered ‘the Doctor in Parliament’ by contemporaries. Freemantle asked the then Minister of Health Ernest Brown whether MHEC was receiving state support for its work with evacuated children, and whether the Ministry valued its wartime activities. The parliamentary secretary for the Ministry responded by confirming that a grant was awarded for the financial year ending March 1941, and that MHEC’s application for a subsequent grant was under consideration. According to accounts published in MHEC’s second report, the Ministry accepted this application and awarded the organisation £8,500, which would continue until 1944, when the grant would increase to £10,000. In 1943, the bulk of this grant was directed towards paying for regional representatives and for child guidance workers distributed in rural areas to assist billeted children. Towards the end of the war, MHEC had realised to some extent the goals of the Feversham report to bring greater alignment to the activities of local and national social work. They had secured professional recognition, government funding, and had made progress in co-ordinating social work across the country. The organisation had taken steps to develop a model of mental health social work within the emergency wartime services and their work had to some extent raised the profession’s awareness amongst the community. Increased demands were placed upon their services as veterans from the war began to return home as the war drew to a close in Europe, and although optimistic about the future following this greater recognition, the MHEC was beginning to sound cautious tones about the need for additional resources to cope with the existing pressures and make progress in mental health social care.

 

Section 2: The Establishment of the National Health Service and An Unrealised National Social Care Service

Despite the pressures incurred by war, MHEC was hopeful of being able to expand their work under the proposed health services. Under their new moniker, the National Association for Mental Health (NAMH) formulated longer-term plans from 1942 onwards. These included seeking to awaken amongst the community a new conception of mental health that went beyond the curative and clinical model that informed a great deal of psychiatric care of the time. They sought to further progress in the quality and standardisation of training to address the shortage of psychiatric social workers revealed by the war. They hoped to secure state resources that would allow for wages to be raised, thereby making the field a more attractive career-option, and to assist in the establishment of apprenticeships. NAHM also proposed an ambitious awareness programme that would give lectures to the general public on mental well-being and developmental psychology. As well as working with general practitioners and nurses, the NAMH representatives would provide consultation services to teachers, local authorities and remand services, to raise awareness of mental wellbeing and to realise a holistic conception of health that would have broader social and cultural impacts.

These hopes were quickly dashed as the NAMH was side-lined during the planning of the social and health services. This is due to a complex set of cultural and social biases towards clinical services that prioritised a curative model of health in decisions about the distribution of resources. The 1944 white paper on the NHS, regarded by historian Charles Webster as the foundational document for a comprehensive, free and universal service, had placed its emphasis on aligning clinical services; but there was little mention of social services, especially those related to mental health. None of the recommendations proposed by the NAMH were taken up by the report, and social services were placed in the hands of local authorities. Fearing that the progress of the wartime years would be undone by proposals that risked pulling mental health social services between the pillars of a centralised hospital service and local health authorities, the board of NAMH wrote to the Minister of Health Henry Willink, who before his time as minister had contributed to the Beveridge Report. The NAMH’s director Otto Niemeyer, at the time also acting as head of the Bank of England, suggested that a department for mental health be set up in Whitehall with its own secretary: this would provide longer term guarantees for public funds that were less dependent upon political will and may provide safeguards for a standard national framework of psychiatric social care. The letter called attention to the existing inequalities between local authorities, with some areas being able to provide full funding for psychiatric social workers and others relying upon a voluntary workforce of unpaid staff.

In response, a letter dated 6th July 1944 was sent by Willink’s office to Niemeyer that expressed formal gratitude for the memo but made no commitments to include the NAMH in the planning of the health services. Months later, after receiving no further reply, the NAMH sent another request to Willink in October 1944 to discuss the organisation of social care under the new health and welfare services with the Health Minister. The reply from the minister’s office was curt, and deflated any hope that the mental health social services would be in direct dialogue with the Ministry of Health: the letter directed the NAMH to the Board of Control to discuss further plans, a move tantamount to placing mental health social services underneath a curative model that informed the clinic: the Board of Control was the agency in charge of managing psychiatric hospitals at the time, and had developed from asylum administration in the late-nineteenth century This interpretation is reinforced when as the letter makes it clear that consultation would first be carried out with psychiatrists, local authorities and the British Medical Association when discussing the reorganisation of services. NAHM, then, found themselves cut off from direct contact with the Ministry of Health in the planning of future health services, subordinate to clinical services and a curative model of mental health. These attitudes came to fruition in a British Medical Journal memorandum on the 1944 NHS White Paper that described the role of social work in the future health service as providing supplementary and ancillary support to clinical services: reform of the social services was an afterthought.

Three days after the passing of the NHS act in July 1948, the Labour government of Clement Attlee established the Mackintosh committee to report on the state of mental health social services. Led by J.M. Mackintosh, a professor of public health who had been involved in the drafting of the Feversham Report, the committee’s report was eagerly awaited by the NAMH and the Association for Psychiatric Social Workers. It was published in 1951, and again came as somewhat of a disappointment to those hoping that social work would gain greater autonomy from clinical services. It recommended that training for psychiatric social work should be based in psychiatry departments of universities, and that more time be spent on teaching the physiological causes of abnormal psychology to mental health social workers. This defining moment for mental health social work finalised the paradigm for post-war services to continue to act as an ancillary service to the clinic.

The circumstances that surrounded the formulation of the welfare state and universal health services shaped long-standing cultural attitudes on health that have marginalised social work as an ancillary service. This has had a lasting impact on the funding and structuring of mental health social services as a clinical model of mental disorder has informed the practice of mental health social work since. Vicky Long uses a longitudinal analysis of the Journal of Psychiatric Social Work to demonstrate the professional turf wars over social work that subsequently took place during the post-war period. She argues that the growing influence of the psychiatric profession continued to stand in the way of holistic models of treatment that were promoted by psychiatric social work. Apparent breakthroughs in physical treatments such as electro-convulsive therapy and the growth of psychopharmaceutics made curative models of the clinic more attractive to policy makers. These were heightened by the invention of treatments during the 1950s which appeared to give the edge to biological curative approaches to mental health and further bolstered the already dominant psychiatric profession in the structuring of services and the allocation of resources. Psychosocial models that informed psychiatric social work were viewed as an auxiliary to the biomedical model, despite attraction towards social psychiatry increasing during the 1970s in response to the anti-psychiatry movement. Long states that ‘the growing appeal of social psychiatry and the shift in government policy was not matched by a commensurate investment in training specialised personnel or providing community-based services.’ Long describes how psychiatric social work had contested the dominant ‘paradigm of psychiatric practice keen to emphasis the curability of mental illness’ by offering treatments that blended distinctions between social and physical causes. Organisational factors established soon after the war overlooked holistic conceptions of health in favour of the curative models that dominated clinical services, and new physical treatments such as psychopharmaceutics were viewed as more economical than social work by many health policy makers.

The curative model of health influenced the development of mental health services during the first years of the NHS and therefore social care came to be viewed as supporting clinical services and was only peripherally involved in the planning of health services. Clinical services had their ‘1948 moment’, but social work did not, experiencing only gradual and piecemeal reform. As Chris Renwick discusses in Bread For All, the ‘creation’ of the welfare state that occurred after the war was actually the rationalisation of existing public, private and charitable organisations, an endevour that as we have seen was conducted by the MHEC and the NAMH in response to the Feversham report. The realisation of a ‘1948 moment’ for social care would require us to learn from the lost opportunity that followed the Second World War and bring together existing services that have conducted important activities during the COVID-19 outbreak into a unified national social care service modelled upon universal and free at the point of need NHS clinical treatment. Such an approach to social care is by no means a simple solution: it must consider the uneasy position mental health social work continues to occupy between health, social care and welfare policy. Many of the new proposals for reform indeed follow these lasting divisions: for example, Labour and the SNP place mental health social work into different parts of their manifestos, making separate provisions for mental health community work. Although recognising mental health by placing it into a distinct category is commendable in some ways, in a cure-oriented policy climate that overvalues direct and short-term return on investment, this categorisation risks continuing to extend the problems of the twentieth century. As British psychiatrist Simon Wessley and historian of mental health Chris Millard comment on parity of esteem between psychological and physical care, expectations of policy makers and public health administration in mental health need to shift towards accepting short-term investment for longer term returns.

This call chimes with remarks from the recent SNP-commissioned Feeley report which argues that problems in service provision are partly based on a conceptual foundation of eligibility assessment as a ‘medical model focused on deficits’. One social care worker compared strict eligibility tests in social work to ‘the equivalent of NHS staff having to make a case for funding every time someone needs a blood test’. Regional variances in eligibility and levels of available support were identified as leading to undesirable outcomes for service users such as unclear criteria for eligibility and different levels of support amongst local authorities which can lead to real-world dilemmas such as whether to move house for fear of not receiving the same levels of support, or delays incurred due to lengthy application procedures. The same report called for a greater standardisation of the bureaucracy surrounding social care provision to alleviate the pressure placed upon service users and social care workers during the pandemic: one described the difficulties they faced accessing fractured and decentralised social care services. Another interviewee described how the piecemeal and means-tested approach to social care led to gaps in necessary services which prevented them from independent living and affected their general well-being. Advocates of a social service modelled on the NHS hold that replanning will solve the fractured nature of social services, but it is also important to bear in mind the broader changes needed in conceptions of support and of health that inform policy and are needed to ensure lasting changes to the provision of social services.

 

Conclusion

The current fractured state of social care services is linked to their origins. Introducing a social service modelled on the NHS is an appealing solution to problems with social work that date back to the establishment of the welfare state. As the example of mental health social work demonstrates, this must be done with caution and with sensitivity to conceptions of health that have contributed to the fragmented structure of services. Cultural and social attitudes towards health and wellbeing are a particular challenge for policy makers, as are moves towards social support being a right rather than a last resort. To properly enact this shift in attitude, a holistic view of physical and psychological wellbeing must be incorporated into social care policy. This will help to facilitate a shift away from a stubborn and lasting perception of a deficit model of health that has structured the curative services of the clinic, and has been applied to social care. It may shift cultural attitudes towards health that dictate the ways users regard and access services. This holds the potential to enact significant improvements of public health standards, as individuals increasingly view health and social care as services that can improve not only basic levels of health, but also promote well-being and enrichment throughout our lives.


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Further Reading


Chris Renwick, Bread For All, Penguin, 2017.

Vicky Long, ‘‘‘Often there is a Good Deal to be Done, But Socially Rather Than Medically’: The Psychiatric Social Worker as Social Therapist, 1945–70’ in Medical History, 2011, vol.55, No.2, pp.223 – 239.

Sarah Henning, Psychiatric Social Work Training: Justifying a Profession in Practice, May 2018, vol.30, no.4, pp.239 – 256.

Andrew Sackville, ‘Professional Associations and Social Work: Working Paper 7 – APSW From Feversham to Mackinstosh, 1939 – 1951’, unpublished paper.

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