09 February 2025
This critique has been written in an attempt to draw attention to and to clarify the present situation in St. Augustine's Hospital regarding policy for the treatment and care of psychiatric patients.
As members of the nursing staff of this hospital, we feel the situation regarding policy, as it exists in the hospital at present, to be an untenable one and one which should not be allowed to persist. The normal channels of criticism within the hospital have proved to be so ineffective and frustrating that we are obliged to try alternative pathways.
The Salmon Report of 1966 states:-
"The starting point is the patient, whose cure or care is the object of the enterprise, and to this end many functions are discharged by very many people working together ... We see the nursing function in hospitals as caring for patients and carrying out treatment under the direction of doctors and in co-operation with other professional and technical staff."
The prime concern is the patient.
In this article the question of what policy exists for such care and treatment of the psychiatric long-stay patient in this hospital, and where the responsibility for this care and treatment rests, is discussed.
One would expect that for the care and treatment of the patient to be of the highest order one would require a system of treatment which would provide for the highest possible standards of assessment, diagnosis, formulation and implementation of treatment policy and care. 'The highest possible standards' one must unfortunately accept do not mean standards which are beyond improvement, but the best standards which can be obtained within the present framework of psychiatric nursing with all its limitations - conceptual, financial, human and otherwise.
What we must ask is this: are we utilising the present facilities, structure and staff of St. Augustine's Hospital to the maximum advantage in terms of treatment and care? The question of what could be done if financial resources were greater, if staff/patient ratios were increased, if staff were more widely trained, etc. is not posed here. Here, at present, we are asking whether we Are using effectively and imaginatively what we have got.
Within this hospital there are three fundamental questions to be asked and answered:
1. What is the hospital's policy for treatment of patients, particularly those in long-stay wards?
2. Who is responsible to ensure that such policy is implemented?
3. What is an acceptable standard of care for patients?
It is our contention that the management in this hospital exercise a policy by default with regard to the treatment of long-stay patients in this hospital. They in fact acquiesce to a policy of laissez faire, which results in either the complete absence of policy on long-stay wards, or alternatively, the formulation of policy by nursing staff without encouragement or guidance.
If, as a nurse, you offer patients custodial care, then that is acceptable. If, however, you wish to involve yourself in doing more for the patients in a therapeutic sense, such as trying to offer the patient a co-ordinated therapeutic team to which he is entitled, which should in turn provide the patients with an individual constructive treatment and rehabilitation programme - then that is up to you. If you wish to organise excursions out of the hospital for patients and not allow them to rot in chairs, as some have been doing for years, then that too is up to you - that is your initiative, no-one else's - no-one asked. you to do it. The sad part is that if you don't do it there is no policy implemented that says you should, and no-one will tell you that you should.
The hospital should have;
(a) an effective policy with respect to the general needs of all patients, and (b) an effective policy with regard to the individual needs of each patient, i.e. the right of the patient to expect a, high standard of care and an individual treatment programme.
For long-stay patients in St. Augustine's Hospital care and treatment are largely of a custodial nature with a heavy reliance being placed upon chemotherapy. For some patients the 'treatment' may well be one of containment. It is a, very sad fact that this hospital allows many of its long-stay patients to slip into a situation where their medication may not be regularly reviewed; often no guidelines are offered on wards to nursing staff regarding a concerted psychotherapeutic approach; and therapeutic activities become almost non-existent. For many the therapeutic community has never existed. The hospital has no clearly defined policy which does not allow patients to vegetate.
A great many long-stay patients have little or no contact with a psychiatrist or with the consultant who is supposed to be responsible for their treatment. Indeed, consultants are sometimes unaware of the treatment that their patients may be receiving. One would expect that responsible medical officers should be leading and directing the psychiatric team; involved in their wards; be introducing and encouraging the implementation of progressive ideas; and ensuring that their patients are not deprived of the best possible treatment available.
Despite the shortage of medical staff and the resulting heavy work load the present situation is unacceptable.
The need for an individual treatment programme for the patient is obvious and yet the hospital operates no policy to ensure that the patients will be discussed as an individual by all disciplines involved in his treatment, nor does it ensure that a treatment programme is decided and acted upon. Such a, treatment programme must involve the patient's needs in terms of medication and therapy, the patient's objectives and our objectives for the patient, and the performance of both staff and patient during such a programme should be periodically monitored.
If this hospital does have a comprehensive treatment policy which is effectively implemented, then why is it that some patients have been left to stagnate in chairs for years? Why is it that some ambulant patients have not left the hospital and its grounds for years - goodness knows how long, for there is no policy implemented that patients should go out as part of their treatment, nor that records should be kept. A charge nurse of long-standing in the hospital maintains that some patients have not to his knowledge been into Canterbury (the nearest centre of population - 3 miles away) for perhaps 10 years, maybe longer, who knows?
If we are supposed to be treating these patients, then is social isolation within St. Augustine's part of their treatment? Does being mentally ill in the long term mean that one should not visit Canterbury, attend the local cinema, visit a pub or restaurant, or walk through the countryside? Long-stay patients suffer from social and sensory deprivation, which contribute to disorientation and the inability to communicate and interact with ordinary people if they do go into society.
To quote the Annual Report for 1969-70 of the National Health Service Hospital Advisory Service:
"Many hospitals (for the mentally ill) fail to provide an environment which gives either the opportunity or the demand for patients to meet society's normal expectations".
Part of the process of attempting to meet society's normal expectations necessarily involves the patient actually entering into the community to participate in normal activities. In order to do this financial support is
required. No finances are apparently set aside specifically for this purpose at St. Augustine's Hospital.
It is our belief that long-term patients do not receive an acceptable standard of care in St. Augustine's Hospital. An acceptable standard of care should encompass:
(a) suitable surroundings that ensure the comfort and self-respect of the patient,
(b) the patient's right to be treated respectfully by staff as an equal fellow human being, so protecting the patient from loss of personal identity, responsibility and initiative,
(c) normal contact with other people and an awareness of patients sexual and emotional needs,
(d) the right of the patient to be kept fully informed regarding the running of the hospital community of which he forms a part; his legal rights and his rights as a resident; and the right to be informed about his treatment insofar as this is practicable,
(e) a dignified life in hospital which takes into account the fact that this is his temporary or long-term home.
In this hospital totally unsuitable nursing staff are permitted to occupy positions of responsibility on wards where they subjugate patients, disrupt any attempt to create a therapeutic climate, and generally block progress. Such staff are also entrusted - by nature of their seniority - with the training of learners on wards. Mistreatment and malpractice occur and often, when such instances and unsuitable staff are brought to the attention of senior nurses, no action is taken. Generally though, such instances and individuals are not reported due to a false sense of loyalty to ones colleagues, the fear of victimisation, or the difficulty in substantiating such problems.
We feel that the outworn, custodial attitudes of such staff, which might well have been acceptable twenty years ago are still very much in evidence in this hospital because these staff are protected by the authorities out of a false sense of gratitude for their long service or simply because they constitute a regular work force. The nursing administration appears to be incompetent in dealing with such problem's, despite allegations being made by concerned staff. One questions exactly what allegations and evidence must be presented to the nursing administration for satisfactory, appropriate action to be taken.
With the present state of affairs concerning patient treatment policy, who then is responsible for it? Responsibility must lie somewhere in the chain:
Hospital Management Committee --> Consultants and Medical Staff --> CNO
--> PNO --> SNO --> NO --> Ward Charges --> Nurses.
Let us start at the shop floor with the nursing staff and ward charges who have day-to-day contact with the patients on the ward. These staff, in that they spend more time than other links in the chain, with the patient, share the major burden of appreciating the patient's needs. The chain:
Ward Staff --> NO --> SNO --> CNO --> H.M.C.,
with the exception of the Consultants and Medical Staff, extends outwards away from the ward and away from the patients. The further along the chain one goes the greater the need for communication with what goes on at ward level. And yet there seems to be a. gulf between ward staff and the higher governing body.
It is our experience that for the lot of the long-stay patient to be more than custodial care, i.e. he enters a therapeutic community and receives an individual treatment programme, requires the ward staff to exercise its own initiative and persistence to a considerable degree. This involves repeatedly calling for interdisciplinary ward meetings to discuss each patient in turn and setting up one's own policy of treatment and then imposing this upon the structure within the hospital and working to get this accepted and consistently implemented. If you are prepared to do this then no-one will stop you - but no-one will have asked you.
In one ward it has now been agreed to discuss one patient a month at an interdisciplinary ward meeting - with 49 patients in the ward this means it will take four years to obtain a full treatment programme.
To quote the Annual Report for 1969-70 of the N.H.S. Hospital Advisory Service:
"The organisation of a psychiatric ward is primarily concerned with the human relationship of the therapeutic team with the patient group."
For the therapeutic team to even show signs of existence requires considerable drive and initiative predominantly on the part of the nurse.
It is asking more than a lot for all nursing staff to be expected to show such initiative, drive and insight in determining and implementing major policy objectives, especially in view of the inevitable criticism of the present laissez faire system which lies with such initiative. Many nurses who are naturally concerned with their careers find themselves compromising their own views for fear of being too outspoken and critical. Many are concerned but few will express it openly. Quite often the nurse with genuine concern and compassion for the patient finds him/herself so frustrated by the impasse of the situation that he/she leaves for greener fields. Surely, the existence of therapeutic communities on wards, with patients involved with a coordinated team in therapeutic activities, and each patient embarked upon a definite treatment programme is not asking for too much. If it does not exist, as is the case on many wards, then there should be realisation and recognition that it does not exist and procedures implemented to make sure that it does. There should be effective policy to prevent stagnation.
St. Augustine's Hospital appears to be a hospital with day to day tactics but no overall strategy.
Who then is responsible if stagnation does exist?
Surely all of the people in the chain from the D.H.S.S, to ward staff are involved? Although ward staff cannot escape censure we feel that the main responsibility for the situation must lie with the medical and nursing administration and the Hospital Management Committee. The D.H.S.S. is implicated in this responsibility in failing to recognise the paucity of resources in this psychiatric hospital, the abnormally heavy work load placed upon doctors, and the low wage which nurses receive which is itself no incentive.
What responsibility do doctors have for their patients? One would think that consultants have a duty towards their patients in
(a) prescribing and ensuring appropriate treatment,
(b) ensuring a suitable therapeutic environment, and
(c) maintaining contact with each of their patients.
The Salmon Committee on senior nursing structure recommended that nursing policy should be formulated by CNO's and PNO's who would Control or co-ordinate its implementation throughout the group. SNO's and NO's would work out the detailed application of nursing policy in specific areas or units. The actual carrying out of the work would be done by first-line management. Enough said.
The responsibilities of hospital authorities were defined in regulations issued in 1948(;) Regional Hospital Boards, as the Secretary of State's agents, were responsible for guiding and controlling the planning, conduct and development of services in their regions; Hospital Management Committees, as the Boards agents, for administering these services. The functions of members of H,M.C.’s and their officers were summarised in the 'Handbook for members of H.M.C.'s' published in 1966. To quote - "The Management Committee is responsible for the running of the hospital, subject to any direction from the Minister or the Board, and in discharging this responsibility the Committee has a duty to see that the interests of the patient and the public are taken fully into account. If the Committee is to give enough consideration to matters of prime importance it has to delegate responsibility for other matters as fully as possible to its officers and in no way attempt itself to play an executive role … An obligation rests on the Committee to set standards of performance and to see that full use is made of modern management aids … The task of the officers is to manage the affairs of the Group in accordance with the Committees policies … The distinction between the role of the Committee to determine how the hospitals are to be run and that of the officers to undertake their management is important, and, in the interest of efficiency, should be strictly observed".
How far in these terms of reference has the Hospital Management Committee proved equal to its tasks? Although these people are no longer with us, they were the responsible governing body until a few weeks ago.
This article is an attempt to constructively criticise a disquieting situation which exists despite the genuine concern and effort of many people. It is an attempt to clarify a situation which is affecting patients in this hospital now. Some staff in the hospital service are deeply concerned about the quality of care which they offer, and it is as a, result of this concern that this article has been written. It is an attempt to be honest, without tempering such honesty by shielding it in half-truths, which are often made to accommodate people for fear of hurting their feelings.
In conclusion, we would like to summarise the main points of this article and venture to make recommendations which we call upon the new Canterbury and Thanet Health District Authority together with all staff of this hospital to consider.
1. There is a lack of policy for treatment of long-stay patients.
2. The majority of patients do not receive the benefits of individual treatment programmes.
3. There is an unacceptable standard of care for a great many patients.
4. On long-stay wards the care is primarily of a custodial nature.
5. Far too heavy a reliance is placed upon chemotherapy, and medication is often not regularly reviewed.
6. It is our experience that often no guidelines are offered on the ward to nurses regarding a concerted psychotherapeutic approach to their work.
7. Nurses are not required to implement therapeutic activities on wards. If they take the initiative and do so, then that is up to them. But there is no obligation that they do sO.
8. The therapeutic community does not exist for the majority of patients.
9. Totally unsuitable nursing staff are permitted to occupy positions of responsibility on wards.
10. Mistreatment and malpractice occur in the hospital.
1. General policy objectives for the treatment of long-stay patients should be formulated and instigated.
2. Each patient should have an individual treatment programme.
3. The standard of care should be raised to an acceptable level.
4. The regular review of patients conditions, treatment and. medication.
5. The establishment of therapeutic communities on long-stay wards through the concerted efforts of multidisciplinary teams.
6. The hospital should provide the financial means to support therapeutic activities. Medical staff should show greater involvement at ward level.
8. Ward policies and objectives should be clearly stated so that nursing staff can ensure that they are fully implemented.
9. The suitability of certain nursing staff to work with the mentally ill must be given very careful consideration and where necessary appropriate action taken.
10. The image of remoteness and ineffectiveness of the nursing administration should be dispelled by positive involvement with patients and staff at ward levels as outlined by the Salmon Report.
11. We are concerned that the recommendations contained or implied in Paragraphs 26.1, 361 371 64, 95.21 96s 98, 991 1061 1071 1081 117 and 1251 of the Report on St. Augustine's and St. Martin's Hospitals of November 1971, compiled by the National Health Service Hospital Advisory Services have not been fully implemented.
The final words are taken from the National Health Service Hospital Advisory Service Annual Report of 1969-70.
"A hospital which has a high morale and is well organised can often accept and make good use of constructive criticism; a hospital with a low morale and major problems may find any criticism difficult to accept and be reluctant to consider change.""Every professional persons whether he is engaged on therapy or research, bears the burden that, to the extent he fails to do his utmost, he is responsible for the continuing degradation of his fellow human being."
- Ullman "Institution and Outcome."
The Critique was published in April 1974
Copies were sent to:
The Secretary of State for Social Services
The Department of Health and Social Security
The Regional Health Authority
The Kent Area Health Authority
Canterbury and Thanet Health District
The Hospital Advisory Service
Within St. Augustine's Hospital:-
Ex-members of the Hospital Management Committee for St. Augustines Hospital
Consultant and Medical Staff
The Nursing Administration
The Lawson School of Nursing
The Psychology Department
Social Workers
The Occupational Therapy Department
09 February 2025