The following article is an abbreviated edition of 'The Portsmouth Mental Service, 1926-1952,' the original of which appeared in 'The Medical Officer' in March 1962; the author being Dr. Hugh Freeman, Consultant Psychiatrist at Springfield Hospital, Manchester. It was reprinted in the St. James Hospital Journal in Autumn 1962
At the present time when there is great emphasis on the development of community services in mental health, the examples which are given often contain mention of Portsmouth. One is struck by the absence of any systematic account of how this service began, or of its subsequent development - surprising, in view of its uniqueness at the time, Although a number of authorities made arrangements of administrative convenience (e.g. joint organization of a mental hospital for neighbouring areas), Portsmouth had the only known instance, before the National Health Service, of a comprehensive mental health service, providing continuity of care. The experiment was, substantially, the creation of one man - Dr. Thomas Beaton.
In 1919, a branch of the Voluntary Association for Mental Welfare was founded in Portsmouth, under the leadership of Miss Ida M. Brayn, daughter of a former Superintendent at Broadmoor. The Association was later subsidised by the local authority to carry out its statutory work under the 1913 Act for the care of mental defectives. Miss Brayn also became the first social worker to the new psychiatric out-patient department when it was established.
Dr. Beaton was appointed Medical Superintendent of the 'Portsmouth Lunatic Asylum' in 1926 and also adviser to the Committee for the Care of the Mentally Defective. In the previous year, the Committee of Visitors of the Asylum (required by the Lunacy Act, 1890) had been made a standing committee of the County Borough Council and renamed the Mental Treatment Committee.
Like so many asylums of its time, the mental hospital for the City of Portsmouth was built in an entirely rural area, on an extreme corner of Portsca Island. However, in subsequent years the built-up area grew out to engulf it, although it still remained difficult to access by public transport. Nevertheless, it was fortunate for further developments that the hospital was reasonably close to the main area of population.
Roberts writes - 'In 1926, Portsmouth's mental hospital had a thousand patients, all certified and pauperized . . . . a discharge rate that was approximately nil, locked gates, (let alone locked doors) and property stamped `PBLA' for Portsmouth Borough Lunatic Asylum'. The average weekly cost per patient was 14s. 6d. Since this was before the reforms of 1929-30, a patient legally required to be both certified and a pauper, before being admitted to a public mental hospital. The 'pauper' status, though, was often nominal, since most patients paid a contribution on a sliding scale, as in general hospitals, and many paid full maintenance charges.
In one sense, the need for certification was a spur to develop out-patients services, in order to treat those patients who were not certifiable. On the other hand, it also limited the effective work of such clinics, since they could not recommend admission without involving the indignity of certification. Even more important, until the 1930 Mental Treatment Act local authorities had no legal power to pay for outpatient clinics as such, so that any work of this sort depended on voluntary facilities.
The first step in the development of new services was the opening by Dr. Beaton of a weekly out-patient clinic at the Royal Portsmouth Hospital. The number of cases referred here grew steadily, and there was a further expansion after the 1930 Act came into force, when voluntary admission became possible. Until about 1933, all cases were seen by Dr. Beaton alone, but other members of the medical staff later took part, and out-patients began to be seen at the mental hospital also.
The Board of Control commented favourably on these clinics in their reports, for 1934 and 1935, and it was recorded that about a quarter of the new patients were admitted voluntarily to the mental hospital, while the rest were managed on an outpatient basis. The co-operation of local general practitioners was said to have played a big part in the success of this service, which resulted in an unusually high proportion of voluntary admissions. The number of children referred to the clinics increased rapidly and eventually resulted in a separate service being established.
To achieve a better degree of coordination, the voluntary services were taken over by the local authority in 1934, and absorbed into a new Mental Treatment Department. The Committee for the Care of the Mentally Defective became a subcommittee of the Mental Treatment Committee and the whole service was unified, with Dr. Beaton as chief administrative officer. It resulted in an integration of hospital and community services which was an entirely new concept.
A psychiatric social service was then built up, operating from a central bureau, where a record of every case was kept, and the legal work of the Mental Deficiency Acts was carried out.
The 'Relieving Officers', however, remained administratively separate from the Mental Treatment Department, though they were encouraged to seek psychiatric help in their work. The 'Imbecile Wards' of the Public Assistance Institution (now St. Mary's Hospital) also remained separate, but were visited daily by Dr. Beaton and his staff. The population of these wards consisted mostly of long-stay mental defectives, who had been admitted prior to the present service being established, but cases thought to require psychiatric treatment were generally transferred to the mental hospital.
These administrative arrangements were also praised by the Board of Control, in their report for 1937....
'There is in full and successful operation a well-organised and comprehensive scheme . . . . covering every aspect of a difficult and complex problem . . . There is the fullest cooperation between the Mental Treatment Department, the Education Department, the Public Health Department, the Chief Constable and the Justices, as well as with the Public Assistance Department. In the result, Portsmouth has a mental treatment service which is, if not unique, at least extremely exceptional'.
When the first qualified Psychiatric Social Worker was appointed in 1937, her services were available (through the unified service) for all types of cases, e.g. mental defectives, children, psychiatric admissions, and problems in the community. Her work was supplemented by members of the Mental Treatment Department Staff, who had been trained on an ad hoc basis.
From about 1928, changes began to be made in the mental hospital. Its name was altered, first to 'The City Mental Hospital' and later to 'St. James' Hospital'. 'Asylum Road', which led to the hospital, was also renamed, although it came to be known unofficially as 'The Beaton Track'!
The gates were removed, the front door unlocked and some wards opened. The Board of Control reported (1936) that 'Two villas on the male side and four on the female are administered on the open-door principle, being open to the grounds'. The allocation of money was greatly increased, staff was improved, and the newer physical treatments were introduced when they became available.
Following the Mental Treatment Act, the number of patients admitted voluntarily began to rise rapidly and, by 1936, 195 voluntary and 29 temporary patients had been admitted in the year, compared with 77 under certificates. These proportions were greatly in advance of the country generally and were attributed by the Board of Control (1934) to the work of the out - patient clinic, the examination of patients at the Public Assistance Institution and the attention paid to patients' home conditions. By 1948, nearly 90 per cent of admissions were as voluntary patients.
However, allocation of patients to wards was always based on their clinical condition, and not on legal status. At this time the Board of Control was urging the development of special units for acute cases who were being admitted as voluntary patients. This view was disputed by Dr. Beaton, amongst others, who felt that such special accommodation would be at the expense of the certified patients. In this way, the stigma of certification would be increased and there would be a tendency for the new units to be developed as 'show places', to the neglect of the rest of the hospital. At St. James', the whole hospital was regarded as an admission unit. Neither was there any attempt to introduce psychiatric beds into local general hospitals which, it was felt, would be merely conceding to prejudice against the mental hospital. Instead special care was devoted to public relations, in an attempt to combat this prejudice.
A more enlightened attitude towards mental illness, both by doctors and the general public, was regarded as an essential basis of the new service, and a determined educational programme was carried out. Dr. Beaton maintained close contact with the local division of the B.M.A., so that doctors were made aware of the services available to them, and of advances in treatment. General practitioners were invited to visit their patients in hospital, and clinical demonstrations were held there.
Lectures on mental illness were given to many community groups, by psychiatrists and social workers. It was emphasized (and this was of great significance in pre-NHS days) that the services of the out-patient clinic and the hospital were available to those of any station in life who required them.
'If the inhabitants of England and Wales as a whole were as advanced in their ideas as are the general practitioners and population of Portsmouth, there would be little need to establish psychiatric units outside the mental hospital', wrote C. P. Blacker in 1946.
'On reflection, it is hard to say whether Portsmouth represents a glorious or a depressing episode in the history of mental health in this country. The achievement is splendid, but it seems a sad example of the light shining in darkness and the darkness comprehending it not', wrote Nesta Roberts. Bearing in mind the difficulties caused by old legislation, shortage of trained staff, economic depression and unsympathetic attitudes, the degree of integration achieved at this early stage seems remarkable. The administrative accident of a compact urban area, with the mental hospital contained within it, was certainly fortunate. This, however, would not have led to much progress in itself without Dr. Beaton's personal conviction of the value of preventive work, which he pursued even before outpatient clinics received official sanction. Another outstanding personality was Miss LeMesurier, Senior Psychiatric Social Worker from 1946 to 1952. Her identity of view with Dr. Beaton and close co-operation with him, were invaluable in the functioning of the integrated service.
What seems particularly surprising is the virtual absence of any reference to this outstanding experiment in the medical and psychiatric literature of the time. It was commended repeatedly in the Board of Control reports, but this does not seem to have acted as much of an example to others. One would not imagine that the same would happen today.
It may be regretted that the unified service did not remain in being, but it was to some extent a casualty of the tripartite organisation introduced by the National Health Service. This structure remains to-day, not only as a challenge to coordinated action, but also as an opportunity for each part of the service to make its own individual contribution.