William Hogarth ‘A rake’s progress - in the madhouse’ (1753)

Not all in the mind

There is likely to be an acute crisis when the Met police stop responding to mental health calls. Ian Spencer takes us from Bethlem to Huntercombe via Enoch Powell

The decision of the London Metropolitan Police to withdraw from attending mental health calls from August 31 has the potential to exacerbate a crisis in mental health provision.

The Guardian has reported that it has seen a letter from Met commissioner, Mark Rowley, saying that he will order officers “not to attend the thousands of calls they get every year to deal with mental health incidents”, because, he believes, officers are being “diverted from their core role of fighting crime”. However, the Met has said in a statement that it will continue to respond “where there is an immediate threat to life”.1 This is likely to be a high proportion of the total mental health calls, given that the police tend to be called where there is a threat to harm oneself or others.

One of the reasons why the police are called is that they - unlike paramedics, for example - have the power, under section 136 of the Mental Health Act, to detain someone, in a public place, without a warrant, who appears to have a mental disorder and remove them to a “place of safety”. They can even remove someone from their own home with a warrant from a magistrate, under section 135. In both cases, detention is for 72 hours.

The Met’s actions have been prompted, in part, by the 2022 decision of Humberside police to divert police resources away from responding to mental health crises in a policy known as ‘Right Care, Right Person’. The argument, which is hard to refute, is that police officers are not the best people to carry out psychiatric intervention.2 This is likely to become policy across the country, just as soon as the government can find a way of recruiting thousands of mental health responders for a system which is haemorrhaging staff.

This poses other important questions, such as: how did it come to be the case that the police have become one of the most important “first responders” to mental health incidents? What is the nature of the crisis in mental health? And which agency should be responsible for acute distress in this field?

To assess the changes to mental health provision, we need to examine some of the history of the last 60 years, starting with the decision to close the old psychiatric hospitals. The steady decline of mental health provision accelerated rapidly after the defeat of the healthworkers’ dispute in 1982. Mental health and class struggle are intimately connected.

In 1961, Tory health minister Enoch Powell, in a slightly less well-known speech than his ‘Rivers of blood’, announced the decision to begin the process of closing the asylums, which “stand isolated, majestic, imperious, brooded over by the gigantic water tower and chimney combined, rising unmistakable and daunting out of the countryside”. The aim was a move to mental health in-patient provision in general hospitals and community-based out-patient services. The changes were justified with reference to improvements in mental healthcare and a projected decline in beds required.3 This effectively began the process of ‘privatisation’ of healthcare, even before the term was coined - Powell was a Thatcherite before Thatcher!

The closure of the psychiatric hospitals was preceded by a sell-off of the associated land. Many of the hospitals were founded to be partly self-sufficient, with patients engaged in agricultural labour. While the oldest of them, the Bethlem Royal Hospital in south London, can trace its history to the 15th century, the great period of asylum building was in the 19th century, when legislation first allowed and later obliged county councils to fund the care of the mentally ill from local rates. The development of the asylums was a corollary to urbanisation, industrialisation and the Poor Law. The mentally ill were seen as a disruptive part of the poor and indigent in workhouses, while asylums were the counterpart to the Poor Law infirmaries in the health system before the NHS.4

The asylums were also an important trade union base within the NHS. The first ever nurses’ strike was organised in 1910 by the Asylum Workers Union - except, of course, that those who then cared for the mentally ill were not regarded as nurses from the point of view of the Nurse Registration Act of 1919 and were therefore not recruited by the Royal College of Nursing. In the 1980s, the RCN had few members in mental health. The Confederation of Health Service Employees was made up of a merger between the Mental Hospital and Institutional Workers Union and the Welfare Services Union.

Together with the National Union of Public Employees, the TUC-affiliated unions led a campaign in 1982 for a 12% pay raise for all NHS staff. The defeat of the healthworkers, after the Royal Colleges of Nursing and Midwifery accepted a separate pay award for qualified nurses and midwives, led to an accelerated campaign of privatisation, particularly of ancillary services, and then hospital closures.


When the sociologist, Erving Goffman, published his book Asylums in 1961, his analysis of the “total institution” was pushing at an open door.5 His facile critique, which equated asylums with concentration camps, found a ready audience among critics of institutional psychiatry and provided a justifying ideology for closure.

This theme was also taken up by what came to be referred to as the ‘anti-psychiatry’ school. People such as RD Laing, Thomas Szasz and Michel Foucault put forward a critique which focused on the supposedly repressive nature of psychiatry. This disparate group did much to popularise the notion that mental ill-health was somehow not ‘real’. Szasz’s book The myth of mental illness and Laing’s Sanity, madness and the family, for example, tended to locate mental ill-health in the realm of social definition. Peter Sedgwick was one of few identifiably Marxist writers who was able to put forward a critique of psychiatry and the ‘anti-psychiatry school’, and was able to locate illness in a critique of capitalism without diminishing the distress suffered by people with poor mental health.6

Those who worked in the asylums did not always actively oppose their closure, but few had illusions that the alternative, if done properly, would be cheaper. Perhaps more importantly, any attempt at making mental health provision an issue commanding support and sympathy from the left was frustrated by the defeat of the 1982 healthworkers’ dispute and the absence of a coherent perspective on the importance of mental healthcare.

The number of psychiatric hospital beds declined steadily from the 1950s, when community mental health services came to play an increasingly important role. By the time of the 1959 Mental Health Act (MHA) most residents in psychiatric hospitals were ‘informal’: that is, not detained and could discharge themselves, providing they were not a danger to themselves or others.

As an aside, while the mental health inpatient hospital population has declined, the prison population has increased. It is also worth remembering that by the 1980s about two-thirds of psychiatric hospital residents were elderly, either because they had grown old in the hospital or were suffering from organic mental disorders - typically dementia of one sort or another. Another sizable proportion were simply institutionalised with no other home to go to. Even if the facilities were institutional and often fell short of the kind of privacy and dignity that we would demand for ourselves, those with dementia were cared for free by the NHS. The elderly are now increasingly cared for in private care homes, most of which are run for profit, and dementia is now almost unique in being the only form of terminal diseases in relation to which many have to pay for their own care - often by the sale of their home - after a life-time of contributing to the NHS.

While care for the acutely mentally distressed as an in-patient is not always desirable, the proportion of people detained formally in the old psychiatric hospitals was always low. But we have now reached a situation where, in order to be admitted at all, the likelihood is that the patient will be detained under the MHA.


In 2021-22 there were 53,337 detentions recorded under the MHA. This is likely to be an underestimate, as not all providers submitted data and many provided incomplete data. Black people are four times more likely to be detained than white people, and are also 11 times more likely to be subject to Community Treatment Orders.7 Psychiatric hospitals have not gone away, but many are now in private hands, carrying out ‘NHS’ services on a contractual basis. Providers such as the Huntercombe Group have been the subject of scandals.8

We communists must take mental ill-health as seriously as any other aspect of health. While we acknowledge that psychiatry defines disorders with a social aetiology (the causes or cause) as individual and personal, that is no different to somatic - ie, bodily - disorders. As we are consistent materialists, mind and body are not separate substances. For example, suicide is one of the most significant causes of mortality in the young. We can also identify a clear relationship between class, inequality, morbidity and mortality across the board. The more unequal a society, in terms of the gap between rich and poor, the worse the health outcomes - and this is disproportionately so, the poorer people are.9

The withdrawal of the police from being first responders in mental health crises is not going to work in the absence of a significant increase in properly trained and paid mental healthworkers with the facilities to support care. But the ‘mental health crisis’ - like the ‘social care crisis’ - has its roots deep in the nature of capitalism. The NHS meant the nationalisation and rationalisation of a hotchpotch of private, Poor Law and voluntary provision - a scenario to which we have returned step by step.

Health is too important to be the sole concern of health professionals, politicians or the police. It must come under the direct democratic control of workers. The transformation to a truly human society is ultimately the only way to reduce the distress caused by class society and human alienation.

  1. www.theguardian.com/uk-news/2023/may/28/met-police-to-stop-attending-emergency-mental-health-calls.↩︎

  2. www.theguardian.com/uk-news/2022/nov/25/humberside-police-judged-outstanding-five-years-after-being-ranked-as-failing.↩︎

  3. studymore.org.uk/xpowell.htm.↩︎

  4. A Scull Museums of madness: social organisation of insanity in 19th century England London 1979.↩︎

  5. E Goffman Asylums: essays on the social situation of mental patients and other inmates Harmondsworth 1961.↩︎

  6. P Sedgwick Psycho politics London 1982.↩︎

  7. digital.nhs.uk/data-and-information/publications/statistical/mental-health-act-statistics-annual-figures.↩︎

  8. www.independent.co.uk/news/health/mental-health-hospital-sexual-assault-b2306909.html.↩︎

  9. R Wilkinson and K Pickett The inner level: how more equal societies reduce stress, restore sanity and improve everyone’s wellbeing London 2019.↩︎