5. Reaction to the report of the Hospital Advisory Service on St. Augustine' and St. Martin's Hospitals and the visit of the Regional Advisory Team
4.20 The Report was received at the Hospital in November, 1971. The Group Secretary circulated it widely and asked individuals for comments. The way in which the Group Management Committee were invited to consider it, and the form their consideration took, is instructive and explains why no action was subsequently taken on important parts of the Report.
4.21 The Group Secretary, the Medical Superintendent, the Chief Nursing Officer and Principal Psychiatric Social Worker each prepared written comments on those portions of the Report which were stated to refer to their particular areas of work. As will appear, on some important matters in the Report they made no comments at all. These were then presented to the Management Committee without any attempt at multi—disciplinary consideration. It is of some significance that although the Medical Superintendent asked his medical colleagues. to provide comments, none were received from any other nursing staff or heads of departments.
4.22 The minute of the Management Committee meeting which discussed the Report reads "The Chairman stated copies of the above Report had previously been circulated to members with comments thereon by the Group Secretary the Medical Superintendent, the Chief Nursing Officer and the Principal Psychiatric Social Worker. The Group Secretary stated that comments made by (a Consultant), Dr. R and Dr. I since then had been laid on the table for the members information. The Chairman went on to say that broadly speaking a large number of the items reported on were already included in our Capital and Extra Ordinary Maintenance programmes and were awaiting finance to carry out the work involved. The Committee considered the Report in depth and following a very lengthy discussion on the recommendations made by the Team agreed that the Group Secretary would collate the Committee's comments for submission to the Regional Hospital Board". As we have already said, the recommendations were by individuals not a Team. The Management Committee selected what they considered an appropriate comment sometimes adding one of their own. Where there was no comment they occasionally provided one. Moreover, this took place during a normal Management Committee Meeting and is, so far as we could discover, the only consideration the Management Committee gave to the Report's observations and advice on policy matters.
4.23 There is no doubt that the Report was on the whole tolerated rather than welcomed, and that some parts were resented. Dr. A, the Medical Superintendent in his comments to the Management Committee, although 'quite prepared to accept the report with some reservations... as being in the main valid and reasonably constructive", went on to describe it as "a bit of a non event", and Mr. B in contemporaneous documents was no more enthusiastic.
4.24 Paragraphs 10 and 11 contained some very important observations and recommendations which were as follows:
“10. The triple role of the Chief Administrative Officer has enabled a highly centralised administrative pattern to be developed with effective financial control over all aspects of the Group's activity, inevitably however this officer has to give too much time to details usually delegated to other staff, and cannot give as much time as is usual to overall planning and policy. It is clear that the hospital is in the process of developing new patterns of medical and nursing management and it is essential to achieve effective interdisciplinary coordination.”
11. ADVICE
1. The functions of Group Secretary and Treasurer should be vested in separate individuals.
2. Special attention should be given to the development of personnel services including clarification of roles and preparation of job descriptions, as well as coordinating the work of the various departments involved in the introduction of Salmon."
4.25 Those paragraphs received no comment from the Medical Superintendent, the Chief Nursing Officer or the Principal Psychiatric Social Work Officer. One Consultant, Dr. R, approved of the advice in paragraph 11.1, but his contribution had not been circulated and only 'lay on the table'. The Group Secretary wrote of paragraph 11.1 "In view of the changes in the whole administrative structure in 1974 it would seem-that the reorganisation advised must in any case take place then." The Management Committee endorsed that, and added "the administration has always been effective despite the dual role". No consideration seems to have been given as to whether there was a need for a change, and, if so, whether it could wait over two years before taking effect.
4.26 It is remarkable that no comments whatever were made on paragraph 11.2. We would have expected very positive comments from the Group Secretary and the Chief Nursing Officer.
4.27 Paragraphs 17 and 18 were as follows:
"17. No general meetings of heads of departments are held, although a number of meetings of certain heads of departments take place, for instance the Group Secretary, Physician Superintendent, Principal Nursing Officer, Group Engineer and Building Supervisor meet regularly to discuss building works. There is a need for more general and positive discussions on policy matters. The Chief Officers consider that consultation is adequately achieved by informal means but some areas feel themselves to be excluded; for example the adolescent unit clearly feels itself cut off and remote. The team is convinced that there is an immediate need for the fullest possible discussion between all senior staff on policy and planning.
18. ADVICE
Active steps should be taken to implement regular full interdisciplinary meetings for comprehensive discussion, i.e. Heads of all Departments within the ambit of the hospital. The use of, and interrelationship of each department in turn should be a first item on the agenda."
4.28 The Chief Nursing Officer commented "a degree of informal meetings do take place. I am sure the advice given will be useful". However, the contribution endorsed by the Management Committee was that of the Group Secretary "The administrative arrangements in psychiatric hospitals generally achieve by other means the results which would accrue from the advice. There would appear to be an implication that departmental heads are unaware of the use of an inter—relationship of each department. That does less than justice to those at St. Augustine's." The Management Committee added "In matters affecting everyone all Departmental Heads are invited to discuss and are consulted in detail." The Report's emphasis on policy and planning was again missed. The Heads of Departments meetings that followed were not concerned with policy and planning in the broad sense.
4.29 Paragraphs 21 and 22 concerned laundry and linen services which have caused real discontent for years. After referring to substantial criticism of services at ward level, and evidence of unmet requisitions leading to shortages or stockpiling, the Report advised that the requisitioning system for linen should be replaced by a topping up system which would initially require a more generous provision of supplies, The Chief Nursing Officer supported that advice. He pointed out that shortages occurred at weekends and holidays, in part because it was a four-and—a-half day service for a seven day week. He wrote with justification "We query whether topping up system is proper answer without further supplies". The Management Committee, however, accepted the Group Secretary's recommendations that the Report's advice should be rejected, even though he failed to comment on the deficiencies referred to. He told them "It is difficult to see how a topping up system would, offer a better service than the present system with the same or less effort", and that it would require "a quite disproportionate amount of linen", and additional staff. He explained the difficulties of providing a topping up service in, St. Augustine,'s because there Were no lifts to first floor wards, and the topping up trolley therefore could not always reach the topping up point. In our view the topping up system should have been tried when recommended by the Hospital Advisory Service.
4.30 Out of the many further examples we could give of observations and advice in the Report being ignored or rejected, we have chosen the following:
4.31 Paragraphs 75 and 76 observed that "although there is goodwill and informal discussion, there is little evidence that effective Tripartite administration of a multidisciplinary Team Management exists, and this is reflected in bad communications, delay and frustrations", and recommended "There should be regular meetings (weekly until many of the existing problems are solved) of the Chairman of the Medical Committee, Group Secretary and Principal Nursing Officer with a formal agenda" The Chief Nursing Officer's comment was that this seemed to be quoting history and was not "really true of the existing situation regarding co—operation between the disciplines", and that "regular formal meetings would he welcomed" although they already took place informally. Most surprisingly no comments were received from the Medical Superintendent or Group Secretary, presumably because these paragraphs were included in a section head "Nursing Administration". The Management Committee adopted the Chief Nursing Officer's observations after deleting his support of formal meetings. Thereafter the informal Tripartite meetings continued as before.
4.32 Paragraphs 85 and 86 concerned the operating-theatre and read:
"85. In the period 21 July 1970 to the 21 July 1971, 143 operations on male patients were performed, but in the period the 22 July 1971 to the 31 September 71 only 16 operations were performed. In the whole of the period referred to above only 15 operations on female patients were done because of the shortage of beds on Cherry Ward. The operating theatre has to be prepared and fully staffed for, a list of one or two patients. I was told that all realise it is an uneconomic project no longer required as a means of reducing the Kent and Canterbury waiting list, but is regarded as having prestige value in furthering good relationships with the public. St. Augustine’s Hospital's reputation is dependent upon the quality of the psychiatric service it provides, not the surgical amenities.
86. ADVICE
No patients, should be admitted for the sole purpose of surgical operation and the operating theatre team should be deployed elsewhere and the theatre closed."
4.33 Neither the Medical Superintendent nor the Group Secretary commented. The Management Committee simply endorsed the note of the Chief Nursing Officer "Views expressed referred to S.E.M.R.H.B." The operating theatre continued in use, and eight beds, only about half of which are used for not more than two days each week are kept for minor surgery in a relatively well up-graded Ward, whilst psychiatric patients in many wards live continually in far less satisfactory conditions.
4.34 Paragraphs 95.2 and 97.2 stated that access by student nurses to patients case notes was severely restricted and that students had to apply in writing to the Medical Officer in charge of a patient before they can see them. The Report recommended that patients case notes should be available to student nurses after consultation with the nurse in charge of the ward. The Report also observed that there were too few ward conferences in which there can be an exchange of information between doctors and nursing staff.
09 February 2025
