1 Introduction
In 1989 I was a very junior psychiatrist at Withington Hospital, Manchester. One morning, the senior consultant old age psychiatrist, Dr David Jolley, came bounding up the back stairs to the offices on the third floor of the old workhouse block which housed the ‘psychogeriatric’ wards. He announced exuberantly: ‘We are a specialty! We are a specialty!’ I wondered what he meant: we were doing the work, weren’t we? I was too embarrassed to ask, but it whetted my appetite to find out. He was celebrating the recognition of psychogeriatrics (‘old age psychiatry’ or mental health services for people over 65 years),Footnote 1 as a specialty by the Department Health and Social Security (DHSS). His exuberance related to the long and convoluted struggle to achieve this, the subject of the present study.
This paper focuses on the tortuous administrative processes, largely involving the ‘psychogeriatricians’, the Royal College of Psychiatrists (RCPsych) and the DHSS, to achieve specialty recognition, rather than the demographic challenges or the development of clinical knowledge which was rooted in earlier decades. However, some understanding of these issues, and of the process of medical specialisation more generally, are important to understand the subsequent events. They are outlined in the introduction. Patients, their families and staff working specifically with older people could see the benefits of the new methods.Footnote 2 Convincing the authorities was more challenging.
This study contributes to the historiography of old age in the twentieth century. Social, financial and economic aspects of old age have been tackled by some historians.Footnote 3 Fewer have explored physical health provision in old age.Footnote 4 The development of mental health services for older people has been almost untouched by historians. Lack of historiography perhaps reflects the tendency of historians of medicine to marginalise older people in their studies,Footnote 5 reflecting a broader, and ongoing, marginalisation of older people which is central to the theme of this paper.
2 Medical Specialisation
Increasing medical knowledge and technological changes, associated with the need for particular clinical skills, stimulate specialisation. The development of new medical specialties is usually medically led, revolving round accurate diagnoses and clinical interventions, the core work of a physician. The medical profession might also have been helped to take a creative lead in service development because it was securely established in society and was male dominated. This contrasted with other professions, such as nursing and social work, which were regarded as lower status and were largely female-dominated. Other factors such as public demand, clinicians’ interest and financial rewards,Footnote 6 and the perceived balance of specialist and generalist skills required by the hospitals also contributed to the process.
In England, eye hospitals, ‘lying-in’ hospitals, ‘asylums’, hospitals for ‘sick children’, and a hospital for ‘Fistula and other Diseases of the Rectum’ developed in the nineteenth century.Footnote 7 Tensions developed between specialists and generalists,Footnote 8 but by the 1920s, the medical profession accepted that specialisation was necessary and inevitable.Footnote 9 Particularly in state-provided health services, a fluctuating economic climate might also affect government commitment to recognise new specialties, especially if they focused on chronic disorders in undervalued sectors of the population and required additional resources.Footnote 10
Psychiatric specialisation emerged alongside that for physical illnesses. The Royal Medico-Psychological Association (RMPA), the professional body of psychiatrists, established ‘Committees’ for psychotherapy and learning disability psychiatry in 1927, for child psychiatry in 1943, and for forensic psychiatry in 1963.Footnote 11 The RMPA became the RCPsych in 1971 and the Committees became ‘Sections’. New clinical interests led to the formation of special interest ‘Groups’, smaller and of lower hierarchical status than the Sections, but indicating increased interest and knowledge, precursors of specialisation.
The emergence and recognition of new clinical specialties is administratively complex. It necessitates various interactions, such as with the government, with university medical schools and teaching hospitals, and with bodies responsible for ensuring high standards of clinical work, including training schemes and professional examinations (in the United Kingdom (UK), the medical Royal Colleges).
3 Older People: The Knowledge Base and Demographic Background
Some medical practitioners in the nineteenth century acknowledged that older people had medical needs for which their doctors required specific knowledge and skills.Footnote 12 Concerns paralleled those about illness in childhood; children and older people had distinct illness presentations and treatment requirements, different from young and middle-aged adults.Footnote 13 Thus the need for modified clinical approaches across the lifespan was recognised well before the period explored in this paper, but for older people, clinically beneficial changes in practice were rare.
Among professionals and public, the belief prevailed that poor health in older people was inevitable and irreversible and therefore not worthy of the attention of the medical profession. That shifted slightly in the 1940s, following reports in the prestigious British Medical Journal (BMJ)Footnote 14 and The Lancet Footnote 15 demonstrating that improved outcomes could be achieved through accurate diagnosis, cautious but adequate treatment and rehabilitation, and allowing older people more time to recover from illness. In addition, in old age, unlike in younger people, physical and psychiatric illnesses and frailty commonly coexist, creating different diagnostic and treatment challenges. This was also observed in the 1940s.Footnote 16
A handful of ‘geriatricians’, keen to improve the heath of older people, established the Medical Society for the Care of the Elderly (MSCE, later British Geriatrics Society, BGS) in 1947.Footnote 17 The specialty of geriatric medicine, was officially recognised in 1948 at the inception of the National Health Service (NHS), followed by a gradual increase in consultant appointments and development of services.Footnote 18 Reports of benefit from psychiatric interventions for older people were also published in the mid 1940s. However, these were less robust than for geriatric medicine and appeared in less influential journals.Footnote 19 Also, psychiatrists were ambivalent towards working specifically with older people.Footnote 20 There were no developments parallel to geriatric medicine for older people’s mental health.
From the 1950s onwards, mental health services were changing in Britain and other western countries. New effective medications and more liberal mental health legislation contributed to gradually closing custodial psychiatric hospitals, giving way to community services with psychiatric departments incorporated into general hospitals.Footnote 21 Younger people, thought to be more likely to respond to treatment, were prioritised for the new approaches.Footnote 22 Although there were more older people in the population, the government prioritised the well-being of younger people in order to compensate for the population imbalance, rather than promoting older people’s health and welfare.Footnote 23 Nevertheless, in 1950, the Ministry of Health proposed assessment services and improvements in long-term care for ‘the aged suffering from mental infirmity’.Footnote 24 Little implementation followed; evidence is lacking that the government actively encouraged the psychiatrists or the authorities.
Concern was also prompted by the rising number and proportion of older people in mental hospitals. In 1948, almost 25% of patients in the mental hospitals were over 65,Footnote 25 when 11% of the general population were that age. In 1964, people over 65 occupied over 40% of beds in six regional health administrative areas and over 33% in the other nine areas mainly on long-stay wards (from 12% of the population).Footnote 26 Increased institutional care partly reflected age-related degenerative disorders and the needs of ageing long-stay patients with illnesses dating back many years, but these factors were unlikely to account fully for this trend. Stereotypical pessimism, concerning improving the mental health of older people, in hospitals and in society more broadly, probably contributed to their receiving mainly custodial care. Outpatient treatment was rare; when community psychiatric assessments were undertaken it was frequently with a view to long-term admission.Footnote 27
The first comprehensive mental health service ‘for the aged’ opened in Dumfries, Scotland, in 1958, led by psychiatrist Ronald ‘Sam’ Robinson. It demonstrated benefits of active treatment and influenced provision south of the border.Footnote 28 The service was based on geriatric medicine practice and on research in the 1950s indicating clinical principles for the diagnosis and treatment of older mentally ill people. This knowledge was based mainly on the work of two psychiatrists in England, Dr Felix Post and Professor Sir Martin Roth. Post’s long term follow-up studies of older people with depressive illness and schizophrenia indicated their potential for recovery.Footnote 29 Roth classified mental disorders in old age, identifying five main types.Footnote 30 His findings challenged the widely held assumption that the only psychiatric disorder in older people was inevitably hopeless ‘senile dementia’. The new evidence was regarded scepticallyFootnote 31 and was not implemented in a systematic or widespread way. Introducing changes in clinical practice required a major cultural shift from earlier entrenched ideas,Footnote 32 which was not forthcoming.
Despite benefit from clinical interventions, geriatric methods were rarely taught in medical schools and rarely inspired psychiatrists. The latter was perhaps associated with the slow rate of change in mental hospitals, perceived challenge to established psychiatric practice by clinical innovations,Footnote 33 and the marginalisation of older people. Fixed retirement ages, financial constraints of living on a pension and a focus on youth culture reinforced marginalisation. Raised awareness of this marginalisation was highlighted with the terms ‘gerontophobia’ and ‘ageism’, coined in the late 1960s.Footnote 34 Ageism is difficult to understand, since, unlike many other sorts of discrimination, for example, concerning gender, sexual orientation, race and religion, it relates to our own lives in the future. However, ageism remained prevalent among clinicians and in the public perception. When people become old they may adopt the stereotypes, attitudes and expectations themselves.Footnote 35
Pat Thane has noted that public concern about older people focused more on poverty, pensions and employment rights, and much less on inequalities in health and social care.Footnote 36 Dedicated geriatric and psychogeriatric services aimed to alleviate existing health inequalities by providing clinical interventions to older people, delivered by enthusiastic staff who took an interest in them and who expected to achieve therapeutic benefit. Their low-tech clinical practices had to compete for NHS resources against more highly regarded, often high-tech, interventions, usually for acute conditions. High-tech interventions, such as in cardiology or replacing a hip joint, often produce dramatic and easily measurable improvements,Footnote 37 and were prioritised over low-tech for funding.Footnote 38 Low-tech, such as medico-psycho-social approaches which restored an older person with depression to good health or enabled a person with dementia to live contentedly at home, received less. All were miraculous clinical interventions devised in the mid-twentieth century, but the latter two were under-valued compared to the first two. In part that can be explained by high-tech innovations being anticipated by Western society and being readily adopted and funded compared to low-tech innovations, which often require a psychological mind-shift of professionals and public, and often take years.Footnote 39
Arguably, government policy-makers should have ensured adequate services for older people in the light of evidence of their increasing numbers and needs, and the demonstrable benefits of clinical interventions.Footnote 40 When effective schemes, reducing hospital bed use and supporting people at home, were reported in the 1960s,Footnote 41 Ministry spokesmen were unenthusiastic, stating that those successes would not be reproducible elsewhere.Footnote 42 When services for children and older people competed for the same pot of money, older people lost.Footnote 43
Rhetoric was full of good intentions,Footnote 44 but that did not align with availability of resources to support dedicated health care for older people. For example, in 1977/8 the Cabinet acknowledged that, for older people, ‘Important needs are going unmet’.Footnote 45 Deep-rooted negative stereotypes probably contributed to under-provision. Negative perceptions of inevitably declining health in old age were common in professional and lay circlesFootnote 46 with little evidence of shift during the period under study.Footnote 47 Stereotypical beliefs that active treatment was ineffective and stigmatising language, such as labelling older unwell people as hospital ‘bed blockers’,Footnote 48 could be associated with reduced staff interest in treating older people and prevent improvements in well-being. Although some negative expectations of health in old age are accurate, relentless decline into dependency is not. A joint geriatric, psychiatric and nursing report in 1987 commented: ‘the low worth of old people and their therapeutic potential still persist despite the dramatic evidence to the contrary’.Footnote 49 ‘Stigma by association’, the phenomenon of attaching negative characteristics of the disadvantaged group to those supporting them,Footnote 50 might have undermined provision and discouraged staff from working with older people. In the 1980s at the Bethlem–Maudsley Hospital, for example, nurses on the psychogeriatric ward were known as ‘shit shovellers’ by their colleagues.Footnote 51 In 1985, Thomas Bewley, president of the RCPsych, highlighted the stigma associated with the work:
it was quite difficult to discover what percentage of a psychiatrist’s sessions were spent on caring for old people, part of the problem being that the general psychiatrist might have fears about being labelled as a psychogeriatrician.Footnote 52
4 Leading Service Development from c.1970 and into the 1980s
A pattern established during the 1950s and 1960s of the government intermittently appearing to encourage psychogeriatric clinical work,Footnote 53 while failing to recognise the specialty or provide necessary resources, continued into the 1970s.Footnote 54 High profile scandals of NHS hospital care in the 1960s highlighted that older people frequently received inaccurate diagnoses, inadequate treatment and poor quality care.Footnote 55 The World Health Organisation’s report, Psychogeriatrics, in 1972, emphasised the need for widespread and adequate services for older people based on the ‘epidemiology, origin, prevention, development and treatment’ of psychiatric disorders in old age.Footnote 56 It also expressed disappointment at the generally inadequate implementation internationally of their earlier recommendations.Footnote 57 No evidence has been found at the National Archives or in other sources that the UK government paid serious attention to either set of recommendations. By 1969, there were still fewer than ten dedicated old age mental health services nationally.Footnote 58
In the late 1960s, a handful of new psychogeriatricians began to organise clinical services in their own localities. In the early 1970s, psychogeriatrics underwent a transition, from individuals, working in relative isolation in their own localities, to creating a clinical network. The psychogeriatricians established a ‘coffee house’ group to exchange views, offer mutual support and consider ways to improve their services,Footnote 59 since, despite growing clinical expertise, how to organise and deliver widespread effective psychogeriatric services was not a given. Members of the group included: Brice Pitt (London Hospital, Mile End); Loic Hemsi and James Cockburn (Long Grove, Epsom); Carrick McDonald (Warlingham Park, Surrey); Klaus Bergmann and Garry Blessed (Newcastle upon Tyne); Anthony (Tony) Whitehead (Brighton); and Tom Arie (Goodmayes, Ilford).Footnote 60
The group had similar objectives to the BGS. Considering that potential benefits of treatment in both physical and psychiatric illness in old age were identified twenty-five years earlier, it is surprising that psychogeriatrics took so much longer than its physical illness counterpart to reach the stage of forming a nucleus of interested consultants. The almost religious enthusiasm of the early BGS, ‘engaged upon a crusade on behalf of our forgotten but deserving patients’,Footnote 61 resembled the fervour of the new psychogeriatricians: ‘a happy band of pilgrims’.Footnote 62 Enthusiasm was intense and unpredicted.Footnote 63 It expressed an important sentiment: treating mentally ill older people could be a rewarding career. Enthusiastic psychiatrists joined geriatricians to set out ideas for widespread, comprehensive psychogeriatric services.Footnote 64
In 1972, the coffee house group ‘heavily influenced’Footnote 65 the development of the DHSS memorandum Services for Mental Illness Related to Old Age (HM(72)71),Footnote 66 a blueprint for future services. Typically, this followed a year behind a DHSS circular which mainly concerned younger mentally ill people.Footnote 67 The coffee house group also realised that, if they were to make a significant impact, they would have to increase their numbers and acquire a body through which they could find a voice. The required quorum for an official RCPsych Group was achieved and the Group for the Psychiatry of Old Age (GPOA) was inaugurated on 9th February 1973.Footnote 68 Its purpose (although not explicitly stated during the early meetings) was to promote good practice by sharing experiences, developing services, fostering education, encouraging research, exerting pressure on government and other bodies, and commenting on all matters relating to mental health in old age.Footnote 69 The Group worked within the RCPsych, including aiming to establish training programmes for the specialty, and forged outside links with people, including policymakers, geriatricians, nurses and social workers, to develop age-appropriate services. The GPOA was the only national body campaigning for better services for older mentally ill people. Other organisations, for example, the Alzheimer’s Disease SocietyFootnote 70 was founded in 1979,Footnote 71 while Age Concern and Help the Aged (now Age UK) had no specific mental illness focus. Special interest group status within the RCPsych did not confer any authority or standing as a specialty.
In 1978, approximately 20,000 beds (25% of total) were occupied by people over 75 yearsFootnote 72 (drawn from 5.3% of the general population),Footnote 73 an upwards trend which was expected to continue.Footnote 74 Some factors which seemed to contribute were hard to justify. For example, the tendency for hospitals to prioritise younger people for community and rehabilitation servicesFootnote 75 was perhaps related to stereotypical views of the impossibility of recovery in older people and to younger people’s perceived future economic potential, if they achieved sufficient recovery to enable them to (re)-enter paid employment, a yardstick of success in Western society and an outcome unlikely for pensioners. Other explanations for more older in-patients include: clinically unnecessary admissions; patients remaining in hospital when they no longer required treatment and could have been supported better elsewhere; limited provision of community residential care and domiciliary services; unsupported families being unable to cope with their care;Footnote 76 treatable conditions such as depressive illness remaining undiagnosed.Footnote 77 In localities where psychogeriatricians established teams, psychiatric hospital bed occupancy was a useful measure of clinical success. Their interventions dramatically reduced long-stay admissions, above the rate suggested by the illness epidemiology, thus supporting the view that factors other than the illness affected bed use. This justified the psychogeriatricians clinical approach and reinforced their enthusiasm.Footnote 78 Psychogeriatricians had positive expectations of treating older people, accurately distinguishing and treating the various and multiple disorders which occur, and devising medico-psycho-social interventions tailored to their needs in the community. These hallmarks of their specialty emerged through empirical observation, service evaluations, publications and discussion with colleagues. They were supporting older people to be as independent as possible in the community instead of living in institutions. Arie commented on the interest of general psychiatrists who were unable, or unwilling,Footnote 79 to do this; they: ‘cannot formulate a “psychogeriatric” problem in any other terms but as the need to get it instantly off their hands’.Footnote 80
Thus a distinct body of clinical knowledge and practice began to emerge, core features of a new specialty. More clinical teams were established. Pitt commented in 1974: ‘colleagues who argue that it [psychogeriatrics] should not exist are in no stronger a position than Canute holding back the waves’.Footnote 81
Even with HM(72)71, consistent government support for steady psychogeriatric service development was not forthcoming although it gave the clinician-campaigners a basis for persisting with negotiations, centrally and locally. With little government support by 1974, the GPOA queried: ‘Is the DHSS aware of, and prepared to condone the inadequacy of services?’ They requested a meeting with the DHSS.Footnote 82 An informal meetingFootnote 83 concluded:
The Department thanked the Group for joining in the interesting discussion. They would welcome further proposals from the College on the holding of a joint Conference on the psychiatric services for old people after the publication of the White Paper.Footnote 84
Merely having an ‘interesting discussion’ gave the impression that the DHSS was condescending towards the psychogeriatricians and their objectives. An official conference was postponed until after the publication of ‘the White Paper’ in 1975, which was mainly concerned with mental illness in younger adults.Footnote 85 Their services were also slow to improve, but planning for older people lagged behind younger, again. Jolley commented that the DHSS listened to the Group,Footnote 86 but at times it did ‘not quite’ understand its concerns.Footnote 87 A senior DHSS representative usually attended their meetings,Footnote 88 so overt criticism may have risked harming that relationship.Footnote 89
Throughout the 1970s and ‘80s, using funding redirected from existing resources, more consultant psychogeriatrician posts were advertised by local health authorities,Footnote 90 suggesting acknowledgment that benefits accrued from the services they provided. Official data on numbers of psychogeriatricians leading teams were not available to support these observations: they were subsumed under the label ‘general psychiatrists’. Psychogeriatricians carried out their own studies to ascertain for themselves staff numbers, types and extent of services provided and in which localities.Footnote 91 At the end of 1986, about 70% of the population of the UK had a specialist psychogeriatric service available to them. Most full-time consultants were supported by junior medical staff, and had a mean of twenty-one assessment and seventy-four long-stay beds, plus twenty-five ‘day places’.Footnote 92 From twelve consultant psychogeriatricians in 1970, there were 120 in 1980 and 280 in 1989.Footnote 93
The UK was ahead of other countries including those in Western Europe and North America.Footnote 94 The UK model of psychogeriatrics (and of geriatrics), linking primary care, acute hospital treatment, community and long-term care, based on research and facilitated by the structure of the welfare state, was internationally regarded as effective and appropriate for treating and supporting older people.Footnote 95 Alongside NHS services, the presence of psychogeriatricians in UK universities had the potential to influence recognition; ensuring dedicated time and expertise for research and teaching gave academic credibility to the discipline. Arie was appointed Professor of Health Care of the Elderly in 1977, in Nottingham,Footnote 96 and took a lead role in subsequent negotiations concerning recognition of the specialty. Several chairs of psychogeriatrics were established in the 1980s. The first academic journal in the subject, the International Journal of Geriatric Psychiatry, originated in the UK in 1986, edited by Elaine Murphy, Professor of Psychogeriatrics at Guy’s Hospital, London.Footnote 97 There is no evidence to indicate that international and academic standing directly influenced DHSS recognition. However, the confidence it gave to the psychogeriatricians perhaps bolstered their determination to achieve it.
5 Recognition until 1980: Mainly Establishing a Psychogeriatric Foothold within the Royal College of Psychiatrists
It was not inevitable in the early 1970s that the discipline would become a separate specialty. At the first meeting of the GPOA, the need for separate specialty status was discussed. The question was asked, but not answered, whether old age was a separate specialty like child psychiatry, or the work of a general psychiatrist with a particular interest in old age.Footnote 98
Over the next few years, psychogeriatricians held various opinions on the need for official specialty status, although this did not split an otherwise unified group of clinicians intent on providing adequate clinical services. Post held the opinion, that clinically, there was no need for a separate specialty: illnesses in old age might present differently but this was part of a continuum and there was no clear dividing line between middle and old age. Psychogeriatrics lay within general psychiatry, he stated, and the only reason for separate recognition was to ensure adequate training and facilities, a political need. Blessed was concerned that separate status would result in professional isolation ‘from the general body of unwilling psychiatrists who wish to reject the elderly’ but he acknowledged that recognition might help in demarcating areas of responsibility. Pitt commented that the specialty already existed de facto and the College should inform the DHSS of that.Footnote 99
The GPOA struggled to get the ‘voice’ of psychogeriatrics heard within the RCPsych by influential senior colleagues, and by the DHSS.Footnote 100 Standards of psychiatric practice for all age groups were ‘abysmally low’, according to the RCPsych in 1974.Footnote 101 In the light of new ideas and dynamism about psychogeriatrics it is surprising that psychogeriatrics was not rapidly encouraged in order to improve standards in that area. On the other hand, older people were only one of the RCPsych’s concerns. With an increasing membership, in 1978 the Group became a Section (SPOA). This gave it greater authority within the RCPsych, including automatic representation on the College Council, but did not noticeably improve interest among psychiatrists at the top of the College hierarchy.
The DHSS overlooked the adequate resourcing of services for older mentally ill people, despite their own recommendations. The department stated in 1975 that ‘in some districts a psychiatrist with a special responsibility for the elderly has been appointed and there may be advantages in this arrangement’,Footnote 102 and in 1976 discussions between the DHSS and RCPsych concluded that ‘at least one consultant in each district should …[act] as a focal point for advice and for developing the district’s psychiatric services for the elderly’.Footnote 103 However, in 1977, the RCPsych and the DHSS proposed a national increase in the number of consultants in general psychiatry without a mentioning a proportional increase for psychogeriatrics.Footnote 104 This was amended, under pressure from the GPOA.Footnote 105 A DHSS paper (1978) on medical manpower also omitted psychogeriatrics, stating that there should be five consultants in ‘adult’ psychiatry and one in child psychiatry for a district of 200,000 people.Footnote 106 Proposals may have included some clinical sessions for older people, but made no reference to earlier recommendations.
In 1977, leaders of the discipline realised that official recognition would be essential to create the means to collect data to identify gaps in services, obtain information on the implementation of government guidance, advocate for resources, and to ensure high quality training posts for doctors wanting to specialise in the field.Footnote 107 Existing official data did not show how many people and in which professions provided psychiatric services for older people nor the availability of rehabilitation, domiciliary, district general hospital, day hospital or community services, even after the DHSS had recommended them.Footnote 108 Relevant information often had to be extracted or estimated and was difficult to interpret.Footnote 109 In official documents, potentially useful data were at times subsumed under the title, ‘For the elderly (including the elderly mentally infirm)’,Footnote 110 giving imprecise indications of requirements and provision for psychogeriatric disorders. The lack of specific data was acknowledged by Roland Moyle, Minister of State for Health, but without suggestions to remedy the deficit.Footnote 111 The GPOA discussed whether to draw the lack of specialty status to the attention of the Royal Commission on the NHS in 1977. However, the Commission’s focus was largely clinical service provision, which in psychogeriatrics was increasing, and it was decided to tackle the status issue through the College.Footnote 112
Among the leadership of the RCPsych, there were undertones of opposition to specialty status for psychogeriatrics and incredulity that colleagues should choose to work in the field. The Manpower Committee minuted disparaging comments that psychogeriatrics might create ‘a vacuum for unsuitably qualified people’ and ‘It was necessary to preserve standards and maintain some unity’.Footnote 113 The main implication of such comments was, in psychogeriatrician Michael White’s words, their erroneous belief: ‘that psychogeriatrics is a dead-end job for which no psychiatrist in his right mind applies’.Footnote 114 It has been difficult to identify statements made by the RCPsych or DHSS at this time which suggest they held alternative, more positive perceptions. These gaps might reflect the systematic ‘weeding’ of RCPsych archives, which, for example, discarded papers and correspondence attached to minutes.Footnote 115
An illustration of lack of understanding of psychogeriatric enthusiasm and leadership is suggested by the blunder of the Royal College of Physicians of London (RCP) when planning a meeting about psychogeriatrics in 1979. The date coincided with a committee meeting of the SPOA, an arrangement with which the SPOA would never have agreed.Footnote 116 The meeting had been arranged with the RCPsych leadership, rather than directly with the SPOA, making the SPOA angry.Footnote 117 The ignoring of old age specialists was a recurrent problem. It had happened previously, at the Bethlem–Maudsley Hospital, when a report on psychogeriatric services excluded the opinions of Post, the only psychiatrist working there with older people.Footnote 118 It also recalled the position of geriatricians among their physician peers in the early years of geriatric medicine.Footnote 119 These recurrent faux pas suggest that generalists saw themselves as the profession’s decision-makers, to the exclusion of old age specialists, who had the hands-on expertise.
The influence of general psychiatrists, well represented in higher tiers of the RCPsych, combined with the DHSS’s habit of planning and providing for younger before older people,Footnote 120 perpetuated the neglect of services for older people. However, it is uncertain whether the journey towards recognising psychogeriatrics was any slower than for other under-valued new psychiatric disciplines at this time. This can be illustrated by comparison with substance misuse (drug and alcohol) psychiatry, which became a special interest Group in 1978.Footnote 121 This too had had a slow gestation from the first suggestion for specialist clinics in 1943.Footnote 122 Despite proving its worth clinically and providing services, it encountered similar problems within the RCPsych.Footnote 123 As with psychogeriatrics, the Manpower Committee did not envisage consultants specialising in substance misuse full timeFootnote 124 and slow development probably reflected sluggish changes in attitudes among professionals, and more widely, towards stereotyped and stigmatised people. Committees consisting largely of senior clinicians in established specialties seemed to project their own clinical dislikes and stereotypes onto emerging disciplines. They perhaps also regarded emerging specialties as a criticism of their own expertise, a challenge faced by clinicians with new interests.Footnote 125
6 Training the Psychogeriatricians and Specialty Recognition
Providing specialist training to ensure high quality psychogeriatric clinical leadership was an objective of the GPOA/SPOA. Theoretically, training could progress without specialty recognition, but, in practice, allocation of training posts was inseparable from it. Training issues thus help to illustrate the reasons for the psychogeriatricians’ desire for recognition. For example, a discussion about part-time training at senior registrar (SR) level, the specialist training grade prior to consultant appointment, noted a proposed cap on general psychiatry training posts because of a ‘national surplus’ of trainees in that specialty. Since psychogeriatrics was included under that umbrella, psychogeriatric training would also be reducedFootnote 126 despite a shortage of psychogeriatricians. In essence, training for consultant leadership for a specialty was intimately linked to the recognition of that specialty.
Senior registrar training for psychogeriatrics consisted of one year in psychogeriatrics plus two years in general psychiatry. These posts could be filled by future psychogeriatricians or general psychiatrists. In 1980 the SPOA noted that 250 new consultant psychogeriatricians would be required to fulfil health service workforce targets of one full-time psychiatrist dedicated to older people in each district.Footnote 127 This seemed unrealistic within a reasonable timeframe. With only six or sevenFootnote 128 existing SR training posts nationally, even if all posts were full and all SRs holding them finally opted for full-time psychogeriatric careers, there would be only twenty-one more consultants in three years. Sometimes, unrealistic training ideas were put forward by the RCPsych, for example, SRs should be allocated to the most understaffed areas.Footnote 129 That was inappropriate: understaffed areas had few, if any, consultants to provide training, reinforcing the impression that the specialist nature of psychogeriatrics was under-valued or perhaps poorly understood. In 1980, the College Council constructively recommended that all psychiatric trainees should ‘spend a significant amount of their time’ working in specialist psychogeriatric units,Footnote 130 which was probably realistic, since about half of all localities across the country then had a consultant psychogeriatrician.Footnote 131 The SPOA welcomed that and proposed that ‘significant’ should be interpreted as ‘a minimum of six months at both registrar and senior registrar level’. It is unclear whether the Council accepted their proposal.Footnote 132
For psychogeriatrics, a further seven temporary, un-funded SR posts each for up to four years, for which Regional Health Authorities would have to bid, were agreed in 1980.Footnote 133 They might provide an extra twenty-eight trained psychogeriatricians at the end of the four-year period.Footnote 134 These seven additional posts would be re-designated from general psychiatry.Footnote 135 Psychogeriatricians thus had no option but to compete against their general psychiatry colleagues for training resources, which was unlikely to ensure mutually helpful working relationships. The situation might have fuelled the general psychiatrists’ ambivalence towards the new specialty: they might not want to work with old people but nor did they want their own workforce reduced.
In 1984, the additional temporary posts were judged by the College Manpower Committee to have been ‘very effective’,Footnote 136 suggesting interest in them by trainees and a willingness by Regional Health Authorities to fund them. DHSS arguments about inevitable recruitment difficulties for the emerging specialtyFootnote 137 appeared less strong. Meanwhile, the RCPsych proposed that, to achieve consultant targets in all specialties, SR numbers should be approximately one-fifth of the total required for the consultant grade;Footnote 138 thirteen psychogeriatric training posts was still too low. Eventually, in 1986, the Manpower Committee seemed to recognise some advantages of dedicated SR psychogeriatric training and proposed that general psychiatry might relinquish some of their posts to psychogeriatrics.Footnote 139 There seemed to be a cautious shift in opinion towards psychogeriatrics by this committee, whose members also sat on other influential College committees.
7 Influences on Recognition: The Geriatric-Psychogeriatric Interface
Understanding the organisation of geriatric medicine services might shed light on how psychogeriatrics became a separate specialty. Generally there was a mutually supportive working relationship between geriatricians and psychogeriatricians. However, the two specialties did not directly mirror each other in terms of their hospital organisation, so lessons learnt by the DHSS from one might not apply to the other. For example, whereas some physically unwell older patients required referral to specialists other than geriatricians, such as cardiologists, gastroenterologists or surgeons, psychogeriatricians aimed to accept all newly referred psychiatric patients above a specified age.
In 1977, the Royal College of Physicians of London (RCP) proposed reintegrating geriatrics into general medicine.Footnote 140 This had the potential to discourage the DHSS from recognising psychogeriatrics as a separate specialty in case a similar debate followed. Most reasons for geriatric reintegration related to difficulties of recruiting to the specialty. An anonymous editorial in The Lancet in 1977 commented that ‘bringing geriatrics into the main stream of medicine’ might help in ‘attracting to the specialty the talent it needs and deserves’.Footnote 141 In 1979, the Royal Commission on the NHS commented that old age work was not an ‘attractive category’ for full-time clinical specialisation.Footnote 142 That might have reflected the situation in geriatric medicine, but for psychogeriatrics it was contrary to evidence that more doctors were choosing to work in the field. An internal DHSS memo discussing reintegration of geriatric medicine was attached to papers concerning developing psychogeriatric services.Footnote 143 Although this hints that the DHSS linked the two issues, definite conclusions about the impact of the geriatric reintegration question on psychogeriatrics cannot be inferred from a single memo. In particular, internal civil service memos mention many ideas, but their significance in decision-making is variable. No documentation has yet been identified to confirm a direct impact.
Geriatricians shared with psychogeriatricians the experience of fighting for the existence of their specialty. In 1984 a debate at the RCP proposed: ‘The care of the elderly is harmed by the specialty of geriatrics’ contending that general physicians were as good as specialist geriatricians at looking after older people.Footnote 144 This reflected tensions common to new medical specialties,Footnote 145 and was reminiscent of the complex relationship between general psychiatrists and psychogeriatricians.Footnote 146 The RCP’s proposition was not unique, but was compatible with sociological critiques, for example by Stephen Katz, that specific old age services helped to make older people ‘inherently separate and inevitably pathological’.Footnote 147 This undesirable outcome, was contrary to the pragmatic aims of geriatricians and psychogeriatricians to improve health and well-being of older people through opportunities for treatment equitable with those for younger people. Also in 1984, the Nuffield Provincial Hospitals Trust, (which supported independent research and policy analysis for improving health care in the UK) commissioned Sir Ivor Batchelor, Professor of Psychiatry at Dundee, to write a critique of DHSS policies for old age. He included comments on: the low professional status of geriatric medicine despite its clinical success; its ‘undistinguished’ contribution to research; and the need for ‘a more talented intake into the training grades’.Footnote 148 His comments were surprising, for example, criticising the professional group and hardly mentioning their clinical achievement, since clinical work is the raison d’être for the profession. His comment on geriatric research may have reflected rejection-bias by editors of prestigious medical journals because of the subject matter rather than on grounds of scientific rigour, as happened to some psychogeriatric research.Footnote 149 His criticisms may have contained an element of truth, but they perhaps also reflected a broader lack of professional interest in older frail patients or, in Batchelor’s words, the ‘snobbery of physicians, who have viewed the geriatrician as more often than not a failed physician or at best a physician manqué’.Footnote 150 Snobbery, or stigma by association, might have made senior physicians reluctant to serve older people while stigmatising physicians who did, just like psychiatrists who neither wanted to work with older people nor to support their colleagues in doing so.Footnote 151
Batchelor wrote on psychogeriatrics:
Its practitioners have got off to a good start …initiatives have come largely from the profession itself …. Psychogeriatrics, which has its own ‘head of steam’ as a specialty, will be best left to develop in its professional context without much Departmental urging.Footnote 152
This positive stance might be a bias related to his personal interest as a psychiatrist, although he rebuts that possibility.Footnote 153 It suggests that psychogeriatrics was gaining momentum, a view supported by the expansion of services. However, Batchelor’s praise did not correspond with his barely lukewarm conclusions: DHSS support for geriatrics and psychogeriatrics should enable them to ‘lead, innovate, develop, and research into the services necessary, and establish and teach exemplary high standards of caring and treatment’ without providing comprehensive services.Footnote 154 This was unrealistic: effective training in clinical work, a practical discipline, requires an apprenticeship of direct experience in high-quality services, not a theoretical model. Perhaps his unrealistic and impractical conclusion undermined his credibility on what had the potential to be a very damaging document for psychogeriatric development. Archival evidence is lacking, such as in relevant DHSS, RCP and RCPsych minutes, to indicate that Batchelor’s report directly influenced decisions on psychogeriatric recognition. However, along with other negative perceptions and concerns, it perhaps added to the DHSS’s caution.
8 Negotiating Recognition with the DHSS
In 1979, the SPOA requested that the RCPsych Council designate psychogeriatrics as a specialty. It was unequivocally recorded in SPOA minutes that recognition was ‘agreed in principle’ by Council, but Council stated that the final decision should be left ‘to see what the DHSS felt about it’ at their joint annual meeting.Footnote 155 This suggested that the College thought that the DHSS had the final veto, although the DHSS indicated that it would ‘be likely to be guided by the College on this matter if it endorsed the Section’s views’.Footnote 156 The protocol seemed unclear.
A letter to the president of the RCPsych early in 1980 from Deputy Chief Medical Officer (CMO) Dr Elizabeth Shore, gave the DHSS’s view:
if psychiatrists specialising in the elderly were to emerge as a separate group of specialists this might carry the implication in everyone’s mind that they would take over the burden of the provision of psychiatric services for the elderly mentally infirm with the danger that some general psychiatric care would be withdrawn from the elderly. Should the new specialty not prove to be popular the service needs of the elderly might not be met even to the inadequate extent that it is at present.
The creation of any new specialty adds to the already over rigid hospital medical training and manpower structure and makes manpower planning more difficult particularly if the specialty is relatively small …
We are, highly appreciative to the growing number of psychiatrists who have elected to devote much of their time to this work’Footnote 157
This letter raised reasonable questions which required a response. However, in other ways it was problematic. Addressing it to the president of the RCPsych may have been standard practice, but it prevented the SPOA from responding directly. The letter was critical and offered no constructive suggestions. Psychogeriatricians were already ‘a separate group’ taking on the ‘burden’ of psychiatric service provision for older people in the districts where they were appointed, although they were unlikely to regard it as a ‘burden’ – a pejorative term. The fear that some ‘general psychiatric care would be withdrawn’, might have been true, but the quality and benefits of that care was debatable: observing it stimulated the psychogeriatricians to develop their own expertise. Administrative concerns by the DHSS were legitimate, but, in the light of clinical achievements, seem excessive.
The observation that more consultants were leading more servicesFootnote 158 was not fully compatible with the statement that the new specialty might prove unpopular. However, precise historical analysis of the psychogeriatric recruitment argument has so far proved impossible. Failure to distinguish psychogeriatrics from general psychiatry in DHSS data,Footnote 159 and ‘weeded’ archives at the RCPsych, contribute to this difficulty. It is also conceivable that lack of DHSS recognition might have contributed to any difficulties of recruitment, associated with poorly designed, improvised training and uncertainty about the future of the new specialty.Footnote 160 At times there were insufficient recruits, but the degree of concern from outside the psychogeriatric field may have been extrapolated from geriatric medicineFootnote 161 or other low-prestige psychiatric specialties, such as mental handicap,Footnote 162 or may have reflected the personal opinions of the College or DHSS leadership, possibly projecting their own prejudices onto a field in which they did not want to work.
Shore’s letter also stated that
the Department is not wholly happy about the suggestion that the Psychiatry of Old Age be designated as a specialty. I must emphasise that the final decision is one for the profession.Footnote 163
The RCPsych perhaps felt obliged to conform to the first sentence, to maintain its overall constructive working relationship with the DHSS, despite the assurance of the second. Shore’s letter was passed to the SPOA with a request that they draft a paper for Council. ‘The problem of specialist status in old age psychiatry’ stated:
A reconsideration of our position has become necessary in order to respond to the letter …from Dr E Shore on behalf of the DHSS. There is no doubt reading the letter as a whole that the DHSS would not wish to see any disturbance of the status quo, …the case for specialisation is diluted with faint praise and the case against is more positively stated …
It is regretted that Dr Shore’s letter so long awaited fails to discuss in any detail …technical problems [for example, collecting statistics, providing resources] or offers any help in coming nearer to a solution.’Footnote 164
Like the College’s earlier response, the SPOA’s response was perhaps written in order not to upset the RCPsych/DHSS relationship. Subsequently Henry Yellowlees, the CMO, commented: ‘I am relieved that the College has rejected a new specialty!’Footnote 165 The College’s handling of the situation appeared politically motivated.
Through 1979 and 1980 the DHSS and the RCPsych played ping-pong with psychogeriatrics. Earlier historical analysis of how medical specialties develop, almost inevitably upsetting established practices and destabilising relationships,Footnote 166 seemed apposite. A further attempt was made by the SPOA to obtain official, relevant data, without specialty recognition. The DHSS acknowledged the data deficit in June 1981Footnote 167 but failed to remedy it at the annual DHSS/RCPsych meeting a month later.Footnote 168
The Conservative government’s policy was expressed in the 1981 White Paper Growing Older: ‘The increasing needs of increasing numbers of older people simply cannot be met wholly – or even predominantly by public authorities or public finance.’Footnote 169 Written answers to the House of Commons reinforced that Growing Older was ‘intended to provide a stimulus to thought and action throughout the community’.Footnote 170 These political imperatives were unlikely to encourage the government to recognise the new clinical specialty, which would require resourcing. Evidence that psychogeriatric interventions reduced long-stay institutional bed use, and thus had potential to reduce expenditure, was not acknowledged.
8.1 Reopening the Recognition Campaign
The SPOA campaign for recognition was reignited in 1987. John Wattis, SPOA secretary, wrote to the president of the RCPsych, Jim Birley, concerning lack of official data and the need to persuade the DHSS ‘to behave in a sensible way’ about collecting it.Footnote 171 The concerns were as earlier,Footnote 172 and linked to significant frustration for the psychogeriatricians in their aim to improve services.Footnote 173 Citing support from the Health Advisory Service, the inspectorate for NHS quality standards, Birley proposed that the College initiates moves to define psychogeriatrics as a separate specialty.Footnote 174 A clear response from them has so far not been identified. Birley had previously shown interest in services for older people.Footnote 175 He was a social psychiatrist with a multi-disciplinary, ethical and human rights stance.Footnote 176 These factors might have stimulated the SPOA to approach him when he took office in 1987.
Strong feelings about recognition were reflected in a SPOA debate the following year. The turnout for this event in London was impressive: 113 participants, mainly consultant psychogeriatricians, when there were fewer than 280Footnote 177 in the entire UK. The vote was 101 in favour of specialty recognition, seven against and five abstentions.Footnote 178 The psychogeriatricians envisaged many advantages, with few administrative drawbacks,Footnote 179 although they acknowledged that some changes would be necessary to restructure general psychiatry training and ensure that psychogeriatric training would be led by psychogeriatricians.Footnote 180 The DHSS position had not shifted: the protocol for collecting data on ‘sub-specialties’ was: ‘they are ignored and the episode is coded under the appropriate main specialty. We have no plans to change this’.Footnote 181
Around the time Wattis approached Birley, Sir Raymond Hoffenberg, president of the RCP, established a working party on psychogeriatric services. According to the minutes, it was convened because of senior physicians’ anxieties about older, mentally unwell people.Footnote 182 Pitt, then SPOA chairman, expressed this more bluntly, that motivation came from ‘disgruntled physicians’ desiring to remove demented patients from their wards. However, Hoffenberg who had a long-term interest in human rights and equality and had been an anti-apartheid activist in South Africa, his country of birth,Footnote 183 seemed genuine in his concerns.
Hoffenberg initially chaired the working party, further raising the standing of the discussions. He invited Birley’s predecessor, Thomas Bewley, to join,Footnote 184 and he took over as chairman when he finished his term of office as president of the RCPsych.Footnote 185 Both Bewley and Hoffenberg remained committed to the working party so the leadership of both Colleges was represented. However, the main body of the working party consisted of four psychogeriatricians, Tom Arie, Colin Godber, Zoe Slattery and John Wattis, and two geriatricians, John Brocklehurst and Bernard Isaacs. The geriatricians were strong supporters of psychogeriatric services, and alongside the psychogeriatricians, guided the direction of the discussion and compiled most of the report.Footnote 186
The meetings moved away from the SPOA-RCPsych-DHSS stalemate but their content was old ground for the psychogeriatricians.Footnote 187 The objective was ‘to implement action on the betterment of care and training in the field of care of the elderly mentally ill’ (italics in original),Footnote 188 with the expected outcome that ‘any joint report by the RCP and the RCPsych, would have a positive impact on the DHSS and related services’.Footnote 189 Interestingly, the re-integration of geriatrics into general medicine, and Batchelor’s report, did not feature in the minutes; after a lapse of several years, they seemed to be less powerful detractors than might have been predicted.
Hoffenberg was the ‘first non-psychogeriatrician on the working party to state that Psychogeriatrics should now be a specialty in its own right’, and his endorsement was greatly appreciated by the psychogeriatricians.Footnote 190 Recognition as a specialty was recommended in order to facilitate service developments, education, training and research, and was justified by the number of consultants and service patterns (largely based on surveys by WattisFootnote 191), training requirements and the body of knowledge and research,Footnote 192 endorsing reasons proposed previously by the SPOA.
The RCP probably contributed to the low media coverage when the working party’s report, Care of Elderly People with Mental Illness, was published. The RCP had recently hosted a press briefing for a report on neonatal medicine which, Hoffenberg revealed, ‘got presented in such a distorted way in the press that day and led to an outburst from the Secretary of State’.Footnote 193 There was concern that the same might happen for this jointly published report on psychogeriatrics. Hoffenberg damningly stated:
If the press come …they will turn it into a Government-bashing session …They will latch onto the fact that the elderly mentally ill have not been well looked after and might easily manoeuvre us into the position of appearing to blame the Government.Footnote 194
This indicated a clear message, similar to that of the RCPsych in its response to Shore’s letter in 1980:Footnote 195 Royal Colleges were reluctant to risk offending the government. Whether as reality or excuse, Hoffenberg stated: ‘I am worried that the report does not have enough in it to justify the calling together of a large number of representatives of the press’.Footnote 196 It was therefore unsurprising that, despite being relevant to the health of a large sector of the population, the report received little coverage in the national press. The Guardian cited it on pages eight and twenty-six.Footnote 197 The press also overlooked subsequent Department of Health recognition, noted in the House of Commons on 4th April 1989: ‘Psychogeriatrics has been established recently as a separate specialty and there are plans to collect manpower figures in the future’.Footnote 198
The composition of the working party, with a preponderance of old age specialists, probably ensured that the psychogeriatricians’ arguments received a dispassionate hearing. The joint endorsement by the RCP and RCPsych was impossible for the DHSS to ignore. Neither the SPOA nor the RCPsych appeared to have sufficient clout to achieve this alone, which raises questions about the authority of the psychiatric leadership generally in the wider medico-political scene at that time.
Although some RCPsych committees had shown some shift in attitude, there is no evidence from committee minutes that enthusiasm for the specialty increased generally in the College. Not all psychiatrists welcomed the new specialty. Professor David Goldberg (knighted 1996), appeared to show little interest when specialty status for psychogeriatrics was announced at the RCPsych Manpower Committee, stating that his main concern was the difficulty of providing services with limited resources for the largest group of mentally ill patients, adults under 65.Footnote 199 Undoubtedly, younger people also had difficulty accessing services,Footnote 200 but Goldberg could have stated that resource issues applied to everyone. His response resembled earlier patterns: prioritise younger over older, despite clinical and humane arguments that equitable and age-appropriate services were required.
9 Discussion
I only fully understood Dr Jolley’s jubilation at achieving government recognition when this research revealed consistent negativity from most colleagues outside geriatrics and psychogeriatrics. There was little positive to find to balance it, despite extensive research in sources such as government papers which I had hoped, perhaps naively, would be logical, evidence-based and neutral. Opposition among general psychiatrists related to lack of clinical interest in older people and unwillingness to treat them or share resources with the psychogeriatricians. Bureaucratic inflexibility in the DHSS was another obstacle, such as being unable to collect specific data before the specialty was recognised. Pervasive negative attitudes towards work with older mentally ill people probably meant that neither the DHSS nor the RCPsych could envisage psychogeriatrics as a stimulating, rewarding career. It was therefore too risky to support. Notably, two medical Royal Colleges were cautious about how much they might advocate for the specialty in case their actions upset their relationship with the DHSS. If Colleges might hinder recognition due to conflicts of interest, this highlighted an awkward situation for under-resourced, under-valued and un-recognised specialities.
The government had to balance various competing interests. For older mentally ill people, rhetoric rather than responsibility prevailed, despite evidence that health improvement could be gained from accurate diagnosis and active treatment. The tendency to regard chronic illness of older people as a social problem continued, with an emphasis on social care from statutory and voluntary services. Expectations of, and for, older people remained low. Innovative medico-psycho-social methods which challenged widespread and firmly held beliefs and time-honoured practice encountered resistance or incredulity among senior doctors, including in the RCPsych and in government. Treating illnesses in older people was neither a political or social priority. Building up from a position of under-provision to a point sufficient to provide widespread and noticeable improvements in health and well-being for older people within a single parliamentary term, and thus impress voters, seemed unlikely. Stigma by association seemed to link the patients, practitioners and the services; all three could be ignored. Negative cultural beliefs, appeared to affect practices of policy makers, politicians, public and health service professionals. The RCPsych showed little identifiable change in attitude: if the RCP had not intervened, recognition might have taken even longer to achieve.
Recognition was an important landmark. It brought the desired objectives of better resourced training schemes and more service-focused data. But those improvements could not overcome other problems, such as continuing ageist attitudes, necessitating fighting for resources,Footnote 201 and the tendency of governments to plan and provide for younger before older people.Footnote 202 Mary Marshall, a social scientist, commented in 1990: ‘We have to challenge and defeat ageist attitudes in Britain today so that older people can feel proud to be old’.Footnote 203 Existential and psychological theories relating to ageing and ageismFootnote 204 may help to explain the recurring and hardly changing attitudes towards providing psychogeriatric services until 1989, with little evidence of improvement since.Footnote 205 In 2014, staff committed to NHS mental health services for older people still feel undercurrents of ageism when competing for NHS resources and identify with the struggles of their predecessors.
