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Community care: older than the NHS

Whatever today’s politicians seem to think, community care has been around a lot longer than they have, says Charles Webster

aziness surrounds the origins of community care. The recent launch of Labour’s proposals for reform are merely the latest re-launch of an important policy that has been around since the beginning of the NHS.

A particularly concerted attempt to establish community care followed the Royal Commission on Mental Illness of 1957 and the subsequent Mental Health Act of 1959.

In his sanguine commentary on these events in 1961, Richard Titmuss confessed that he had failed to locate the source of the term ‘community care’, but he realised that it was in use in the early 1950s. This is indeed the case.

The annual reports of the Ministry of Health confirm that the term and concept of community care were in use at the beginning of the health service, and there was no sense that they were regarded as originating at this point. It is possible that the idea of community care was already current before the modern health service was established.

In fact it is possible to discover a precise origin to the phrase ‘community care’. A useful clue is provided by the report on mental health services produced during the Second World War by C.P. Blacker. This was an officially sponsored blueprint for the mental health services of the NHS. In common with later Ministry of Health annual reports, the Blacker Report contains a section on ‘care in the community’, mainly comprising a digest of information from the Wood Report of 1929.

This substantial and important report on what was called ‘mental deficiency’, together with associated documentation, seems to provide the ultimate source for the community care concept and terminology.

The Wood Committee conducted a thorough review of ‘mental handicap’ (now termed learning disability) and concluded that this care group, comprising some 300,000 individuals, could be sub-divided into two halves, those requiring institutional care and those suitable for care in the community.

The latter was the nucleus of the larger ‘social problem group’. Control of this section of the population was regarded as an important national priority. The Wood Committee concluded that if the ‘nation is prepared to make the necessary provision for their education, training and supervision, the mentally defective children and adults could… live harmoniously in the general community; if, on the other hand, this provision is not made, many of them will sooner or later require the more costly provision of an Institution or Colony’.

The Wood Committee was established by the Board of Education and Board of Control, and it reflected the thinking of these bodies. The annual reports of the Board of Control produced during the 1920s indicates that it was increasingly understood that there was no realistic possibility of incarcerating the numbers involved. Accordingly ‘community care’ became adopted as the preferred care for at least half this group.

The Board of Control report for 1928 recommended the relevant authorities make every effort to improve all forms of community care. The 1928 and 1929 reports contained detailed proposals for day centres, which were regarded as the key element in community care. In the 1930 report, there was a subtle but significant shift of emphasis, suggesting that two-thirds of the ‘mentally defective’ should receive their care in the community.

By this stage community care had achieved flagship status in the polices of the Board of Control. Over the course of three years, the board evolved a community care policy that was impressive in its scope and character. By 1930, community care was promoted with enthusiasm and conviction, but it was appreciated that it placed a heavy responsibility on local authorities and voluntary agencies.

In particular the community care of adolescents presented difficulties. This group was likely to display ‘aberrations of conduct, and to self-assertion by way of lying, thieving, sexual irregularities, and sometimes violence’. The Board of Control was fully aware that such problems could not be effectively confronted without substantial investment, especially in training professionals capable of dealing with this group from earliest childhood onwards.

Although these vintage reports seem dated, they display some commendable humanitarian instincts. The Board of Control accepted that ‘mental defectives’ were subjected to an unacceptably impoverished existence, and that the collective efforts of society could lead to a useful and fulfilled standard of life for these people.

Considering the austerity prevailing at the height of the Depression, the board is to be complimented on its expansionist outlook and for appreciating that permanent and substantial investment constituted an essential condition for realising the aspirations of community care.

The board provides something of an object lesson for more recent claimants to the title of inventor of community care.