SECTION 5: WHY?
5.1 The main theme of the Critique is that without clearly understood Policies, both for the hospital and wards, the care of patients will not be as good as it could be with policies, and that on occasions it will fall below an acceptable standard. This is undoubtedly right, and the evidence presented to us clearly demonstrated that in the long stay wards of St. August's there was no policy, and that as a result there was no agreed standard of care for the long stay patients. On the contrary, there was confusion of ideas and practice, and, too often, a minimum, or below minimum, standard of care when judged against the standards of today. (We use the word care as embracing treatment as in our view they are incapable of separation).
5.2 In this Section we seek to isolate some of the strands from this confused pattern in order that we may see more clearly how and why the matters complained of in the two parts of the Critique came about. It will help us in this task if first we summarise the proposals which we make for the future in the next Section and which we believe will help to keep standards as high as possible within the limits imposed by the available resources, and will also release and channel to the best use the potential that exists at all levels. They fall conveniently under five overlapping headings.
1. There must be a policy for the hospital and for each area and ward. The setting of both minimum and desirable standards is an integral part of the formulation of policies.
2. Since all disciplines are involved in the care there must be (a) a clear understanding of how the disciplines can and should use their particular skills to complement and strengthen the skills of others in true multidisciplinary team work, and (b) a clearly understood multidisciplinary framework for the hospital which complements and strengthens the organisational structure of individual disciplines and co ordinates their services.
3. Those who have a managerial role must understand what such a role requires of them.
4. Those who have a monitoring role must understand much more clearly than at present the duty of positive action encompassed by it.
5. There must be increased and improved in service training at all levels. A. The Wards
5.3 At the time of the Critique many of the long stay wards provided, and to a lesser extent still did in the Autumn of 1975, out of date custodial care. It often amounted to no more than the bare minimum of physical care and, on occasions, fell below even that. At times nurses were guilty of uncouth and rough handling and speech. On at least two wards shifts set about their Work in very different ways, and some members of staff who should have been immediately sent for further training and then, if suitable, moved to other wards, were permitted to remain in post. The Consultants attended infrequently, no patient had an individual treatment programme, and a year or more would often pass without a case being reviewed. What all this meant in human terms can only be understood by reading Sections 2 and 3 of this Report.
1. The Nurses (including Nursing Officers)
5.4 We take the nurses first because not only are they the people around whom all other activities must be centred, but they are also in the unenviable position of frequently being left 'to carry the can’ if they fail in some way because of insufficient guidance and help in overcrowded, understaffed wards.
5.5 The nurses who gave evidence, and others whom we met on the wards, presented the variety of ability and insight to be found in any profession. Some who had worked for many years in the hospital without adequate assistance to keep up to date still regarded themselves as under the control of the Doctors. This meant that they waited for the Doctors to initiate changes in wards and when this lead was not forthcoming they were often acting as little more than bare custodians of the patients. Even within this limited concept, however, the great majority of nurses cared deeply for the patients, showing and doing for them many kindnesses, both on and off duty. With further in service training of the right kind and imaginative leadership they have much to contribute to St. Augustine’s, and its long stay wards in particular.
5.6 Suitable in service training would have assisted in giving nurses a continuing insight into the patients needs, without which there is an increased risk of staleness and dulled sensibilities leading to the kinds of roughness and coarseness of which we heard. It would also have helped the nurses with long experience to work more closely and easily with those who lacked experience but were brimful of ideas.
5.7 The Lack of any policy or treatment programmes meant that nurses tended to work in the idiom in which they had been trained, and whether old or new ideas prevailed depended very much on the personalities involved instead of the pursuit of clearly formulated and understood ward policies.
5.8 The nurses working in the wards should have been supported and led by their Nursing Officers, who occupy positions of considerable responsibility, but with a few exceptions they failed to measure up to their responsibilities. The evidence revealed failure to check by detailed inspection that nursing standards were being maintained and that such rules as existed were being obeyed. Requests for assistance from the ward staff often met with inadequate response. Counselling was often primitive, if not totally absent. As a result the majority of the Nursing Officers, although liked as people, did not carry the confidence of the ward staff who felt that they were insufficiently aware of problems and ineffective in remedying them.
5.9 The Nursing Officers, however, were in a difficult position and had to overcome the following difficulties:
(i) In the main they belonged to the old school of psychiatric nursing and were promoted from within the hospital.
(ii) Although they attended middle line management courses, these were largely theoretical and, by definition, concentrated on the manageria1 side of the role. A man or woman is not transformed into an adequate manager by a course of this kind, and much continuing support and advice will be necessary. This was not often forthcoming because some of the Senior Nursing Officers were suffering from the same deprivation. Training for the clinical side of the Nursing Officers job seems to have been ignored.
(iii) They were not in practice given authority to match their theoretical responsibility. For example, they did not appear to have had a proper voice in the selection, appointment and allocation of staff, or to have been fully consulted on matters affecting their units. More positive steps should have been taken to see that they met officers and members of the employing authority on official visits.
(iv) They work from a central nursing office instead of having offices of their own within their units. This inevitably increases the sense of remoteness. Moreover there is no significant secretarial help.
(v) Any desire that was present to formulate new ward policies was thwarted by the absence of true multidisciplinary working and the difficulty of having up to four consultants with patients in one ward.
5.10 As a result of all these matters new ideas were not being generated at the Nursing Officer level, and the necessary correctives for slipping standards were not being applied. Without further training and continuing support some of the Nursing Officers have been over promoted in the sense that they are at present unsuited to the task. This is not their fault. They are the victims of the national policy of absorbing staff in post into the middle Salmon structure, and of the failure to prepare or support them sufficiently
5.11 If there had been clear policies with minimum and desirable standards there would have been no Critique. Ward staff would all have known what they were seeking to achieve, and both old and new, young and not so young could have formed a cohesive whole. Moreover Nursing Officers would have had standards below which they knew the wards must not fall, and reasonably attainable targets towards which they could help the ward staff to work.
5.12 Time and again in this report we have referred to wards being short of staff. The agreed nursing establishment for St. Augustine's based on the Regional Hospital Board review of 1973 was 706 nursing staff for 1,143 beds — a ratio of 1 nurse to 1.6 beds. The position on July 31st 1975 was that there was a funded establishment of 504 for 1,068 beds. This gives a ratio of 1 nurse to 2.32 beds which is only just above the minimum standards recommended by the Department of Health and Social Security. In numerical terms this does not seem unusually low for a large Mental hospital, but when it is remembered that some of the many wards are designed for a small number of beds, that there is a shifting student and pupil population and that there are very few Occupational Therapists and Domestic Staff, it is clear that nursing resources have been reduced to a low level. The continued use of the hospital for general surgery has meant not only that beds are taken up which could be Used to reduce the general crowding elsewhere, but also that nurses are diverted from psychiatric nursing.
5.13 The large discrepancy between the agreed and the funded establishments was attributed to both shortage of funds and difficulty in recruitment. We very much hope that with the improved prospects for recruitment the Regional and Area Health Authorities will make it possible to reduce this gap, for there is no doubt that the low number of nurses on shifts was a significant cause of much that we had to report in Sections 2 and 3.
2. The Doctors
5.14 The Consultants failed to give sufficient attention to the long stay wards. They admitted that they knew that they had insufficient time and that reviews of patients took place at unacceptably infrequent intervals, but they preserved their old image of having total ultimate responsibility for patient care and failed to ensure that nurses were encouraged to develop their own initiative in ward activities and policies generally.
5.15 In this setting ward policies and standards, to which all disciplines subscribe, are essential to maintain an acceptable standard of care and make the best use of the resources. For example, if there had been policies requiring individual treatment programmes, whether largely determined by nurses or not, the District Management Team and Area Team of Officers would not have remained in ignorance from April, 1974, until September, 1975, that there should have been such programmes and that there were none. Neither would they have said in answer to the Critique's, charge that there was an unacceptable standard of care for many patients, "the problem here is to define a standard of care".
5.16 Sections 2 and 3 of this Report establish the need for some form of assessment and review of doctors’ workloads. This only confirms the lesson that has emerged from other hospital enquiries in recent years. We deal with this later in paragraphs 6.41-49 of our report. Suffice it to say at this stage that, in our view, if hospital and ward policies and standards are agreed by all disciplines, any doctor, including consultants, who declines to follow the policy or whose performance falls below an agreed minimum standard should be required by the District Management Team to explain his failure so to do and failing a satisfactory explanation his employers, the Regional Health Authority should be asked to intervene.
5.17 As we have already indicated, without such a common policy and standards there are liable to be confusingly different approaches in wards, especially where there are up to four consultants.
3. Patients Activities
5.18 As related earlier, there were serious inadequacies which were very largely caused by shortage of staff. If there had been true multidisciplinary team work and agreed policies and standards we are satisfied that the improvements which have now been suggested would have been put forward much earlier. The Patients Activities Team which we have recommended in paragraph 3.39 will help to co-ordinate all these activities. The aim must be to fill the present gap by helping nursing staff to extend their role in the wards with suitable guidance from the trained specialists.
4. Supplies of clothes, sheets, flannels, etc.
5.19 These were very inadequate. The ward staff’s frustration and difficulties were increased as they battled with or gave up under the systems which have already been described. (See paragraphs 3.83-08)
5. Mentally Handicapped and Disturbed Patients
5.20 Mentally handicapped patients cause difficulties in St. Augustine’s as many of them do not fit into the way of life of a hospital for the mentally ill. The policy for the admission of such patients should be reviewed and advice should be sought from a. consultant and nurse experienced in mental handicap as how best to care for those who are already present.
5.21 We have many times referred to the problems created by violent and disturbed patients in over-crowded and under-staffed wards. The question of how best to care for such patients should be reviewed. We do not advocate the use of special "disturbed wards", and we deplore the restoration of order by "heavy squad" reinforcements. Care must be taken, however, to see that suitable staff are employed on wards where such patients are to be found, and that they are all prepared in advance for such eventualities as may occur.
09 February 2025
