It is both easy and fashionable to dismiss the asylum era as a dark chapter in the social history of the nation, when society set about the wholesale warehousing of some of its most vulnerable individuals. This analysis, however, belies a more complex reality.

Against the social backdrop of the Enlightenment, the early asylums were built in a spirit of therapeutic optimism. Their location, mostly on the semi-rural periphery of towns and cities, owed less to NIMBYism than the 1845 Lunacy Act, which enabled legislation that directed local councils to establish asylums with access to space, fresh air and a clean supply of water. So-called “moral treatment” was widely accepted at the turn of the 19th century and held that it was possible to improve or even cure mental disorders if individuals were treated humanely, with dignity, in a therapeutic environment that offered opportunities for occupation and purposeful activity. It was only in the latter part of the 19th century, with overcrowding and the realisation that compassion and kindness alone failed to “cure”, that asylums began to acquire their now familiar, dismal, reputation.

The demise of the asylums is better known: fuelled by scandals of patient abuses, the emerging civil rights movement, a rising backlog in maintenance costs and the development of effective drug treatments, the long-stay patient population has declined from a peak in the mid-1950s of more than 150,000, to less than 5,000 by the millennium. Sadly, only rarely did resources follow the patient into the community. The much-vaunted shibboleth of community care, although well-intentioned, became for many a tragic euphemism for community neglect. The suffering of many patients and the impoverished lives they lead is not simply a matter of resources, but also a failure to recognise that there is a small cohort of individuals who require institutional care, where their quality of life is immeasurably richer and, paradoxically, they become more independent. Most importantly, given a choice, many prefer it!

In this collection of essays the St Luke’s Hospital Group, one of the best known and most respected providers of care for people with learning difficulties, have brought together a distinguished group of authors from disparate backgrounds to argue the case for the provision of institutional care for a limited, but significant number of people who are all too often failed by the (mostly inadequate) services and support available in the community. They argue that institutions are more a state of mind than “bricks and mortar” and that it is possible to bring together an imaginative range of services and expertise that enable individuals to develop their strengths and minimise their dependency whilst in an environment that offers dignity and protection as well as sanctuary and respite. Paradoxically, these institutions can actually increase freedom and choice. They are themselves a part of the wider community and make an important contribution complementing those services available in the community.

An important, but neglected, maxim of medical ethics is the so-called reciprocity principal. Put briefly, this states that when an individual is unable to exercise choice in relation to the care or treatment they receive, then those that care for them, be they health authorities, professionals or workers from the voluntary sector, have a moral and ethical duty to provide not just good enough, but the best possible care. How is best possible care defined? It is simply that which we would wish for ourselves or our loved ones if we had the misfortune to find ourselves in a similar situation.

We traditionally pay lip-service in defining ourselves as a civilised society by measuring our willingness and ability to look after our most vulnerable citizens: few groups are more vulnerable than those with learning difficulties. Providing a comprehensive range of high quality services that addresses the needs and enriches the lives of individuals who all too often are unable to exercise choice, should be a priority area for investment and not the Cinderella service languishing at the bottom of the list of health priorities, as is all too often the case.