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This paper reviews the current status of psychiatric rehabilitation in the UK. The term is not fashionable; in fact, the word “rehabilitation” rarely appears in UK mental health policy documents. The first and last major UK textbook on the topic was published almost 2 decades ago (1). Despite a long-standing policy focus on severe mental illness and the large proportion of mental health spending allocated to long-term care, few UK mental health professionals specialize in rehabilitation. A survey undertaken by the Royal College of Psychiatrists identified only 46 consultant psychiatrists working full-time in rehabilitation in England in 2000 (that is, less than one per million population). This current low profile reflects the history of rehabilitation services (which flourished in the traditional mental hospital), shows the continuing ambiguities over the meaning of the term, and reveals a long-standing difficulty in acknowledging the realities of continuing disability in an era of community mental health care. Bennett (2) provided an overview of the development of psychiatric rehabilitation services in the UK. Historically, these services were based in the mental hospital. Rehabilitation aimed to enable individuals to move out of hospital, either back to their home or to a supported care setting. Long-stay patients moved down and then up a ladder, from the acute ward to the back ward, on to the rehabilitation unit, and eventually out of hospital. The second half of the 20th century saw a dramatic decline in psychiatric bed numbers in England, from a peak of over 150 000 in 1954 to 38 000 in 2000 (from 330 per 100 000 population to 70 per 100 000). However, it was only in the late 1980s that the mental hospitals began to close. Rehabilitation as a process of resettlement proved spectacularly successful: approximately 100 of the 130 large English and Welsh mental hospitals have closed in the past 15 years. Much of the reprovision within the hospital closure program was based on Wolfensberger’s normalization or social role valorization theory (3), an ideology that can be interpreted as denying the reality of the severe psychiatric disabilities experienced by former mental hospital patients. Denial of disability has been a recurrent theme in the era of community mental health care (4). The hospital closure and reprovision programs that took place in England during the late 1980s and 1990s were carefully evaluated. However, less is known about the fate of the many thousands who left the declining hospitals in the decades before the closure program—anecdotally, often with only the price of a railway ticket and the address of a boarding home in a seaside town. Psychiatric rehabilitation, frequently defined as a set of specialist services, could be defined as an area that considers the needs or characteristics of people who would benefit from rehabilitation inputs. Wykes and Holloway defined the potential client group as “people with severe and long-term mental illnesses who have both active symptomatology and impaired social functioning as a consequence of their mental illness” (5). The development of specialist rehabilitation services is very patchy and, following the hospital closure program, there is also a much larger de facto system of continuing care within generic mental health and social care services. Each locality has a substantial population of severely mentally ill people receiving supportive care in what might be termed a “virtual mental hospital.” This largely comprises an uncoordinated network of private and voluntary sector residential provision, family care, and support from the generic community mental health teams (CMHTs). These and their associated acute inpatient units form the backbone of UK mental health services. Services for forensic (offender) patients are provided at a regional level (medium-secure units) and within 4 high-secure hospitals. Some localities can arrange for specialist forensic community supervision and, in recognition of the long-term nature of some patients’ needs, there is an emergent specialty of forensic rehabilitation (6). The UK rehabilitation tradition tends to concentrate on the provision of a caring and supportive environment that maximizes the individual’s capacity to live as ordinary a life as possible, despite any residual disability (5). This is in contrast with the US focus on rehabilitation readiness and the achievement of behavioural change, which would enable the person to live without support (7). UK practitioners have always been skeptical of the value of behaviourally based social skills training for patients with schizophrenia (8), despite the optimistic claims in the US literature (9). Even so, the UK tradition has sought to improve patients’ functional abilities through occupational therapy and behaviour-oriented nursing inputs, to the extent that they could live in the least restrictive possible environment. Recently, the rhetoric of recovery has begun to influence the UK discourse on rehabilitation (5), partly in response to intellectual trends emanating from the US and partly influenced by the burgeoning indigenous UK user or survivor movement. This paper describes recent trends in health and social care policy. Further, it reviews research and practice relevant to the treatment and support of people who are categorized into the definition provided by Wykes and Holloway (5), most of whom will fall outside any formal rehabilitation service. Health and Social Care in the UKThe UK is a federation; health and social policy is in the hands of its constituent Departments of Health. The same broad service principles apply throughout the UK, although health spending is significantly higher in Scotland, and the move toward community mental health care has been slower in Wales, Scotland, and Northern Ireland. Total UK health spending, which is largely public rather than private (84% public), is lower than in other advanced industrial nations (per capita US$1418, compared with, for example, US$2102 in France and US$3950 in the US) (10). A lesser proportion of gross domestic product is spent on health in the UK (6.7%, 9.4%, and 13.0%, respectively, for the 3 countries). Health care is free at the point of delivery, funded from taxation, provided by the National Health Service (NHS), and, in principle, comprehensive. Access to specialist services, including psychiatric care, is traditionally from general practitioner referral. Individuals with a severe mental illness, however, commonly enter specialist mental health services, having bypassed the primary care filter (11). Health service providers (“trusts”) have clear-cut geographical responsibilities that are defined in contracts with their commissioners. The precise organizational structure regularly changes, but commissioners are essentially agents of the Department of Health (DoH). Providers are currently agglomerating; in fact, a number of mental health trusts are responsible for a catchment area of 1 million people. Access to social supports such as residential, day, and domiciliary care is means-tested and provided through local authority social services departments. These departments contract out many services to a mixed economy of voluntary and private sector providers. Local government receives block grants from central government, with a local political process that decides on spending. In addition, the Department for Work and Pensions (DWP) disburses welfare benefits. Newly formed, the DWP is responsible for programs that bring people back into the workforce. Approximately 11% of health spending is allotted to designated mental health services for all age groups, while 5% of social service spending goes toward mental health. Although health and social care policy for England is set and monitored by the DoH, actions by the Treasury, the Home Office (responsible for the criminal justice system), the DWP, local politicians, and local commissioners have a profound impact on the welfare of people with severe mental illness. For example, a lack of funding from DWP for employment programs, combined with the regressive policies toward income from employment by people with disabilities, makes reintegration of individuals with severe and recurrent mental illness into the workforce particularly difficult. This is despite a strong policy emphasis on social inclusion. There is a long-term continuity in the UK’s mental health policy that takes away from the institution and toward community care. Nevertheless, since the early 1990s, a moral panic over community care has resulted in policy being dominated by concern over the risks people with mental illness present to themselves and others (12). This has led to increasing emphasis on monitoring and coercing patients into treatment adherence and over the past decade has been associated with a marked trend toward more compulsory inpatient admissions.
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