The economics of psychiatric services in the UK and Ireland, 1845-1985

This study empirically describes the activity and costs associated with the psychiatric services in England & Wales, Scotland & Ireland from 1845 to 1985. Basic economic concepts are employed to structure data. Key hypotheses from the three historical schools (Progressive, Social Control and Epidemiological) are tested, using a neo-Popperian methodology. The literature is reviewed in Chapter 2 (general and socio-economic) and Chapter 3 (epidemiological). Chapter 4 sets the comparative legal and financing context. Chapters 5, 6 and 7 outline activity and financial data for each country. Major points common to each included: - relative stability in admissions and costs up to around 1945, - a major change after 1945 when admission rates (both first and total) rose sharply, - inflows exceeded outflows until around 1955 when the number of resident inpatients began to fall, - despite the fall in resident inpatients, spending, which was predominantly publicly financed and hospital orientated, continued to increase. Chapter 8 suggests that three hypotheses were not obviously falsified by the data: - a pharmacological hypothesis linking new drugs in the mid-1950s to the changes which occurred then, - Wagner's Law, which predicts continued high levels of spending despite reductions in hospital places, and - Hare's epidemiological hypothesis which relied on the increase in first admission rates between 1850 and 1900. Four other hypotheses related to costs were rejected. Three paradoxes are identified for further investigation. Chapter 9 shows that the decline in the stock of inpatients occurred almost entirely in the long-stay (over 5 years) group, due mainly to deaths rather than live discharges. This pattern helps explain the continued high levels of spending. Ireland's outlier status is linked to both demand and supply side factors. Chapter 10 draws some overall conclusions and offers priorities for further research.