Early development of Psychiatry as a separate independent medical specialty

RE: Michael Twomey’s discovery of the Royal College of Psychiatrist’s Gaskell publication


Edited by German E, Berrios and Hugh Freeman.

Over a number of years Dr Michael Twomey was a most active Honorary Secretary to the Society of Clinical Psychiatrists (SCP). Sadly, he died suddenly at home on 21 September 2007. Very shortly thereafter, 2-3 days, Royal Mail delivered a 5 pages bundle of documentation to me. Page one was the title frontispiece of the book. The rest consisted mainly of highlighted quotes from different pages which caused me some difficulty in organising for the sort of contribution I am attempting now. Michael was a meticulous person in such matters and it would not surprise me if any unclarity was perhaps due to some awareness of his impending mortality. (The aims of the Society are “To advance the study and practice of psychiatry on all matters relevant to clinical, academic and administrative psychiatry”.)

He had been intrigued with the earliest obstacles to the advancement of psychiatry as a properly respected medical specialty in its own right. The SCP which had been founded in 1958, (still active), played a significant role in achieving this goal.

Dr John G. Howells formerly Director, Institute of Family Psychiatry, Ipswich Hospital, Suffolk, an early active member of the SCP, would later, write, at the invitation of the Society, a monograph in the Society’s, “Blue Book” series, titled The Royal College of Psychiatrists 1971. Hugh Freeman, another greatly appreciated figure, remained a member of the SCP until his death in 2006. The steps which eventually led to the formation of that Royal College were fraught with obstructive difficulties.

In the 1940s and into the 1950s psychiatrists seemed to have parity with other specialty fellow consultants, but the control of their clinical work lay with the medical superintendents of psychiatric hospitals who had powers of admission and discharge. Unsurprisingly perhaps, the Royal Medico-Psychological Association (RMPA) was dominated by medical superintendents. Opportunity for redress came with the Mental Health Act 1959, and through the Society’s influence, the power of admission and discharge was given to the “responsible medical officer”, that is, the consultant. Feelings ran so high just then that when the sentence about the “responsible medical officer”was passed by Parliament, Dr Sommerville Hastings, a medical Member of Parliament, waved his order papers in the air and shouted, “At last we are rid of them”. At last, psychiatrists had achieved clinical freedom.

The National Health Service,1948 (NHS) also opened the way to addressing the balance between physical and psychological medicine but it needed power to influence, decision-making authorities. After a few years, psychiatrists were increasingly moving into general hospitals and by 1961 they were the third largest group of specialists, surgeons numbering 1193, physicians 1178, psychiatrists 1063, pathologists 800, Obstetricians 590. But the protagonists of a Royal College were faced with a forbidding and degrading situation. A profession’s control of its own standards lies in its examinations achieved by its training programme. However, the examination in psychiatry was not under the control of psychiatrists. The Certificate of Efficiency in Psychological Medicine was founded by the RMPA in 1885. This was replaced by a Diploma in Psychological Medicine in 1948 and, in 1954 was released to the Conjoint Board of the Royal College of Physicians and Surgeons. There was no higher examination in psychiatry on a par with those of the Colleges. Yet, most psychiatrists felt it unreasonable to have their competence in psychiatry assessed by an examination in another discipline.

Matters were no better in terms of representations to the government on services policy. On psychiatric matters, the government looked for this to the Royal College of Physicians. Members of the RMPA, especially Alexander Walk, spent much time and effort in preparing evidence for the Royal Commission on Mental Illness which reported in 1959. Yet its deputy chairman, Sir Cecil Oakes, declared that the Commission would be guided by the evidence coming from the Royal College of Physicians, which they regarded as being of paramount importance in psychiatric affairs. The sidelining of the sapiential authority of psychiatrists on psychiatric policy went deeper than the difficulties described above: e.g. no representation on committees appointing consultant psychiatrists: no representation on Joint Consultant Committee; none on the regulatory General Medical Council; none on merit awards (only 14% of psychiatrists received a merit award in 1962 compared with over 60% of consultants in medicine and surgery).

The above difficulty in describing the studied powerlessness and tiny incremental steps in achieving basics of clinical freedom of a legitimately defined medical specialty, psychiatry, within the aims of the SCP (as described above), the machinations thus far are quite remarkable. The attempted normalising of psychiatry as an independent separate medical specialty were prodigious. Indeed, the process might be accurately described in current demotic argot as a can of worms. Yet, even greater obstacles resided in the pursuit of a Royal College which many psychiatrists felt was necessary to fully legitimise psychiatry’s independent specialty status, firmly free of the subordinating tendencies, albeit possibly well intended, of the the London Royal College of Physicians. However, we must never forget that the ultimate authority of the doctor arises from the needs of the patient.

The foundation of a Royal College of Psychiatrists, was detailed in one of the SCP’s Blue Book series titled Royal College of Psychiatrists which was published in 1971. It was written by Dr John G Howells at the invitation of the SCP and is a hugely impressive document in the context of the development of the Royal College. If the earlier part of this essay described the achievement of psychiatry as a separate medical specialty in itself a Pyrrhic victory, the emphasis was indeed on a complexity of endeavour. However, the sweat and tears of the ups and downs, of creating a Royal College of Psychiatry as Howells did was coloured even more with machinations of ever more complexity involving political dealings with such as the Privy Council. Enter once more, Dr Howells one of the founder members of the SCP. As well as its Honorary Secretary of the SCP he was (and still is) remembered as founder of The Institute of Family Psychiatry in Ipswich which in its time was a highly respected psychiatric centre. Sadly, it did not long survive his demise.

Michael Twomey, sent me (in that 5-page bundle) an obituary, written by Hugh Freeman, a full page of the British Journal of Psychiatry, on Dr John Gwilym Howells who died in 2008. It noted that Gwilym, in the 1960s, became a prominent member of the SCP which sought to modernise the profession. Importantly he discovered from a colleague that since it had a Royal Charter, the Royal Medico-Psychological Association (RMPA), it could become a Royal College by obtaining a supplemental charter from the Privy Council. This however stirred up a hornets nest of bitter opposition and from some members of the RMPA. However, Howells was a leading figure in the Petitions Committee of the RMPA but the Royal College of Physicians continued to block progress while the psychiatry lobby struggled to keep the aim of a College alive, helped by votes of members at the annual general meetings and in a postal ballot. The fight was eventually won within the RMPA but the Royal College of Physicians continued to block progress by their influence on the Privy Council, until Lord (Robert) Platt became its President. Thus, what should have been a simple administrative change took 6 Years, but throughout that time Gwilym was tireless in his efforts to give psychiatry a truly independent voice.

Gwilim also received the Distinguished Fellowship of the American Psychiatric Association.

Michael Twomey’s widow, Anne, continues to have our deepest sympathy and she has remained most supportive of Michael’s work on behalf of the Society.

Dermot Ward