lr. J. Med. Sc. June, 1%4, pp. 267-270 Printed in the Republic of Ireland

THE SPECIAL CARE SERVICE IN NORTHERN IRELAND: ORIGINS AND STRUCTURE

B. G. SCALLY, L.R.C.P. and S.I., D.P.M., Senior Registrar, Muckamore Abbey Hospital, Muckamore, Co. Antrim.

D. N. MACKAY, M.A., Psychologist, Muckamore Abbey Hospital, Muckamore, Ca. Antrim.

Introductio~

T HE legal and administrative differences which exist between the countries of the United Kingdom make a comprehensive survey of the health services in all four countries rather difficult. Thus

general texts tend to concentrate on either England in particular, e.g., Eckstein (1959), or on Great Britain in general, e.g., Ross (1952). 1 Northern Ireland, which is virtually the difference bet~veen Great Britain and the United Kingdom, does not receive so much attention. While it is obviously not the purpose of this paper to make good this deficit, an attempt will be made to describe briefly the provisions which exist in Northern Ireland for mentally retarded, ineducable persons.

General Northern Ireland has an area of 5,258 square miles and a population

of 1,435,400 (Registrar General's estimate, June, 1962). Although it is part of the United Kingdom, it has a measure of self-government exercised by a local parliament and has its own legislation for certain matters including health, ,both physical and mental (Weir, 1949).

Provisions for the Mentally Handicapped Historical Note

Although mentally retarded persons did not legally exist in Northern Ireland before ]948, their plight was appreciated over 1,000 years ago in Ireland in the enactment of the Brehon Laws (McCartan, 1963) which provided safeguards for the community care of the mentally ill. The five categories--idiots, fools, dotards, persons without sense and madmen--in the laws were presumably generic enough to include at ]east some mentally subnormal persons whose behaviour could not be distinguished from that of the mentally ill. Although the nature of the provisions for persons suffering from mental disorder fluctuated throughout the years, any relevant Acts passed in Ireland before 1920, and in Northern Ireland after the division of the country until 1948, did not distinguish between the .mentally ill and the mentally subnormal. It is obvious, however, that the distinction was informally applied, at ]east in institutional administration long before 1948 (Royal Commis- sion, 1908).

1Ross gives a very short account of the Heal th Service of :b~orthern I re |and on pp. 110, 11,.

267

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Modern Legislation Mental Health Act (Northern Ireland), 1948. This Act amen'ded existing arrangements for the mentally ill and, for

the first time, introduced measures to provide for the mentally handi- capped. While in Great Britain they are officially called mentally su~bnormal, or severely subnormal, they are referred to in Northern Ireland as " persons requiring special care " and are not, for statutory purposes, graded according to the severity of their handicap. Since 1948 the term " mental deficiency " has disappeared from professional and public comment. Special care patients are define~d as persons who have been found to be " suffering from arrested or incomplete develop- ment of mind (whether arising from inherent causes, or induced by disease or injury) which renders them socially inefficient to such an extent that they require supervision, training, 'or control in their own interests, or the interests of other persons " (Mental Health Act-- Northern Ireland--1948, 1961).

The ascertainment and care of special care patients both in hospitals and the community are the responsibility of the same administrative body. For the purposes of special care administration, Northern Ireland is divided into three regions and in each a Special Care Manage- ment Committee makes provisions for its patients. These committees are responsible to the Northern Ireland Hospitals Authority (equivalent to the regional hospital board in Great Britain) which in turn is respon- sible to the Northern Ireland Ministry of Health and Local Government. Potential special care patients are notified to the management com- mittees by the Education Authorities, general medical practitioners, welfare authorities and other statutory bodies.

Mental Health Act (Northern Ireland), 1961. Although this Act lacks the pioneering quality of the 1948 Act, it

nevertheless makes important contributions to the welfare of the special care patients. Important features are the emphasis on informality of care, reduction of documentation and the provisions for safeguarding against undue prolongation of a patient's stay in the early stages after admission into a hospital.

In neither Act is there a separate category for psychopathy as there is in the Mental Health Act of England and Wales, 1959, although the need for accommodation for this type of person is fully rea]ised.

Community Cave In December, 1962, there were 2,597 special care patients living in

the community. Medical officers carry out the ascertainment work and make recommendations to the parents on the basis of their diagnosis, the home circumstances and available facilities. Social workers visit each family regularly and make frequent visits when crises arise with which the parents cannot cope.

For the younger special care patients there are day schools which specialise in training the children in basic social skills and simple 3R work. Speech therapy, home training and physiotherapy are provided in certain eases. For the older patients there are day occupational centres where they concentrate on different forms of manual skills.

SPECIAL CARE S E R V I C E I N NORTHERN IRELAND 269

A total of 833 persons was enrolled in 19 day schools and occupation centres in Northern Ireland in December, 1962. In the region which has the largest number of special care patients the mean ratio of teacher to pupil was 1:11.

Residential Care In December, 1962 a total of 1,843 special care patients was provided

for in hospitals, 50 of them in hospitals outside Northern Ireland. Before 1949 no residential achommodation solely for special care patients existed in Northern Ireland and such patients were admitted to mental hospitals in Northern Ireland, or sent to mental deficiency hospitals in Eire. A number of patients still remain in these hospitals.

Following the introduction of the Mental Health Act, 1948, various buildings were taken over and adapted for residential purposes. These buildings catered for patients requiring urgent institutional care while the admission of patients to mental hospitals was reduced. A new building programme was initiated at Muekamore on an estate of 350 acres, about 15 miles from the capital city of Belfast. These new buildings were planned on the colony system, and patients were admitted to completed villas in 1958. The building of additional villas is still going on and it is hoped to have accommodation eventually up to a maximum of 1,000 beds. There are at present 723 patients in residential care at Muckamore Abbey Hospital of all ages and grades, both male and female. All ancillary services for the care and training of the patients are already provided.

There is a school for the training of male and female nurses leading to their registration by the General Nursing Council as nurses of persons requiring special care. This training course lasts three years and, for the preliminary examination, covers the same course as for general nursing. The ratio of nursing staff at present is 1 to 3.3 patients, but this figure is below full establishment.

Treatment Through Traiwing The importance of training the mentally subnormal person in occupa-

tional, recreational and social requirements has always been to the fore- front in the planning of the Special Care Service. The phrase " treat- ment through training " is used to emphasise the work. In order to staff the day schools and centres in the community and the residential school departments, a college for the training of special care teachers has been established at Muckamore Abbey Hospital. Selected students do a two-year training course leading to a diploma as a special care teacher.

In order to follow through on the " treatment through training " programme and to provide a " halfway house " between hospital and community, a female hostel has been establis~fed in the city of Belfast, and it is hoped to obtain a male hostel in the near future. Employment officers, attached to the service, are engaged full-time in obtaining employment for special care patients in the general community. Small pilot schemes have been started in sheltered employment and it is hoped that eventually sheltered workshops will be set up to cater for those patients who cannot fit into the normal work environment.

270 IRISH JOURNAL OF MEDICAL SCIENCE

Voluntary organisations .and groups, including a very active Northern Ireland Parents' Association, have much to contribute towards the pro- vision of extra facilities outside the scope of the Service. They have provided gifts and sums of money mainly towards the recreational side of training, and at present they have an ambitious scheme to provide a large indoor swimming pool for the patients at Muckamore Abbey. They also greatly assist the entertainments officer in the provision of entertainment for the patients.

Research

Par i passu with the programme of " treatment through training " research projects have been established to examine from the medical and psychological standpoint various problems in relation to the causes and treatment of the mentally subnormal. Most of these research projects are run in conjunction with research workers attached to the Queen's University, Belfast. Active work in chromosomal analyses, metabolic analyses, psychological and sociological problems is being carried out. An example of this is to be found in the work of Carson and Neill (1962), in metabolic abnormalities among special care patients. The setting up of a Genetics Unit at Queen's University will greatly accelerate the work being done on chromosomal abnormalities. Close liaison is also maintained with the Mental Health Department of Queen's University and medical students, as well as students in clinical psychology, receive instruction and practical training in the field of mental subnormality.

S u m m a r y

The introduction of the Mental Health Act (Northern Ireland), 1948, saw the beginnings of a comprehensive service for the mentally sub- normal in Northern Ireland avhere previously no such service had existed. I t differs in its structure from the equivalent services in England in that one authority is responsible for the community and hospital care of the mentally subnormal, thereby overcoming the defects of divided responsibility. An attempt has been made to describe the evolution and function of this service.

Acknowledgments

We wish to thank Dr. T. W. H. Weir, Medical Superintendent , Muekamore Abbey Hospital for his guidance and help in the preparat ion of this report and Dr. :N. O'Connor, Medical Research Council for his comments on it.

References

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H.M.S.O., Belfast. Mental Health Act (Northern Ireland), 1961. H.M.S.O., Belfast. Ross, J. S. (1952). The National Health Service in Great Britain. Oxford Universi ty

Press, London. Royal Commission on the Care and Control of the Feeble Minded (1908). H.M.S.O.,

London, 3. Weir, T. W. H. (1949). Modern Practice in Psychological Medicine. Ed. J . R. Rees.

]3utterworth & Co. (Publishers) Ltd., London.