3. The Group Management Committee
5.43 At the time of Critique No. 1 St. Augustine's Hospital was managed by the St. Augustine's Hospital Group Management Committee, which consisted of 15 members and a chairman appointed by the South East Metropolitan Regional Hospital Board. This Committee was also responsible for St. Martin's Hospital (186 beds) situated near the centre of Canterbury. The two hospitals comprised a group which was devoted entirely to the care of the mentally ill. The Hospital Management Committee was responsible to the South East Metropolitan Regional Hospital Board both for the management of these hospitals and for the maintaining of an adequate standard of patient care, subject to the regulations, and directions made by the Secretary of State and the Regional Hospital Board.
5.44 To carry out this commitment the Hospital Management Committee set up the following sub-committees:
Finance sub-committee
Nurse Education sub-committee
Estate and Equipment sub-committee
Medical Services and Patient Care sub-committee
Group Medical sub-committee
5.45 In putting forward their recommendations to the full meetings of the Management Committee, these sub-committees relied upon the Group Secretary, the Chief Nursing Officer and the Chairman of the Group Medical Executive Committee for their information and advice, for it was they who would eventually have to implement any decisions reached by the Hospital Management Committee. These three principal advisers met weekly to co- ordinate the various activities of the Group, to deal with day to day matters on which immediate action was required and to identify other matters on which joint agreement would be necessary before making a recommendation to the Hospital Management Committee. Contrary to the advice of the Hospital Advisory Service they continued to meet informally and without any agenda or minutes.
5.46 Ideally, and in most hospitals, these three would have equal status, but for reasons we have already explained this was not so at St. Augustine's, and the main consequence of the imbalance was that the nursing staff, who carry the brunt of the day to day pressures, were not always as adequately represented as they should have been. Furthermore, this triumvirate had put themselves in a position of considerable insularity and were, in consequence, out of touch With the needs of middle administration and the views of the junior nursing staff. This concentration of power in the hands of a small group of men also tended to destroy initiative from below, and it is not surprising that Mr. C, the former Principal Nursing Officer, who displayed considerable willingness to initiate change, left in the circumstances we have described.
5.47 Mr. B. the Group Secretary, also held the post of Treasurer and Hospital Secretary with St. Augustine's (but not St. Martin's). In addition he was Group Supplies Officer until 1971 when the responsibilities of this post were taken over by an Area Supplies Officer and a subordinate officer based at St. Augustine's Hospital. Notwithstanding this transfer of responsibility, Mr. B maintained that since his appointment had not been officially terminated by the Management Committee he was still the Group Supplies Officer.
5.48 By virtue of his appointment and his undoubted ability and energy, Mr. B exerted considerable influence in the Group, and his authority and power tended to grow as Dr. A's diminished. He was a very able administrator, respected by the Hospital Management Committee and, we understand, by other group secretaries in the Region, as well as the Chief Officers of the Regional Hospital Board. His achievements were considerable, especially in the relatively stable period prior to the major reorganisation which took place between 1971 and 1974. This reorganisation involved fundamental changes in the organisation of the medical and nursing services, and Mr. B's considerable administrative skills should have been used in planning and coordinating the division of the hospital into its three virtually autonomous clinical areas. It is regrettable that Mr. B underestimated the importance of his role in this respect and continued to pay too Much attention to routine matters which he should have delegated to others. It must be remembered, however, that this period coincided with the years immediately prior to his retirement during which he was also Secretary to the Local Joint Liaison Committee set up to deal with the preparatory work for the reorganised health service in Kent which would come into operation on April 1st, 1974. It was noticeable, however, that even before this period Mr. B tended to rationalise and ignore any advice unless it fitted in with his own pattern of thinking. This was exemplified by his unwillingness to support much of the advice of the Regional Advisory Team and the National Health Service Hospital Advisory Service, particularly those sections which stressed the necessity for delegation and the need for him to become more involved in achieving effective interdisciplinary co-ordination. Mr. B also failed to devise new, and revise old, systems for such essential services to the wards as supplies, laundry, and patients' moneys.
5.49 The Management Committee seem to have been unaware of the extent of the deficiencies in the long stay wards and did nothing to see that there were policies and standards for them. In our view they regarded patient cape as being primarily a matter for the doctors, and did not want to impinge on the Consultants clinical autonomy. Unfortunately the boundary of clinical autonomy was entirely fluid and varied from individual to individual.
5.50 The minutes of the Management Committee reveal very little consideration of policy and standards of care, and we consider it probable that the following views of Mr. B were shared by many members. In his written statement he said "Regarding the programmes, or policy for each patient, I think the Committee were satisfied that the medical staff reviewed each patient's requirements on admission and subsequently at intervals, but I think they would have admitted that more medical time was required in some of the longer, stay wards. These matters were not discussed formally by members of the H.M.C. I think it is inconsistent with the responsibility of a doctor for a layman to assume that he is not doing his job and it is seen as part of the Consultant Psychiatrist's responsibility to programme a patient's course of treatment as a matter of routine. A layman cannot go to a doctor and enquire what he is doing for a particular patient. The H.M.C. have never had any occasion to doubt the integrity of the medical staff here". Honest and hard-working doctors may, nevertheless, fail to co-ordinate their activities with other professions, and thus provide an inefficient service.
5.51 Mr. B was asked to amplify his written statement. "You say in your statement that a layman cannot go to a doctor and enquire what he is doing for a particular patient?" He replied "On clinical grounds. Are we talking about clinical grounds or general care?" In answer to the next question "Where do you say clinical grounds end?" He replied "Where the doctor says that they end." The difficulties created by such views is demonstrated by a report from the District Management Team to the Area Team of Officers in January 1975 that "The Medical staff say holding multidisciplinary ward meetings is a matter for clinical judgment although it is generally agreed it is part of the therapeutic programme".
5.52 The former member of the Management Committee who is now a member of the Area Health Authority gave evidence about the functioning of the Medical and Patients Care Committee. She told. us that it discussed "matters concerned with patients, matters concerned with complaints by relatives, matters concerned with things like the amenity fund which the hospital had for the benefit of patients, for instance how many visits had been paid to various places, and also things to do with the voluntary services organisation which we had at the hospital."
5.53 Her evidence included these two questions and answers:
“Q. Where did you as a lay member of this body draw the line on subjects you could reasonably discuss at H.M.C. meetings? Was there a line first, and if there was where did you draw it? -
A. I would have thought there was a line, the sort of thing which doctors would expect to be their professional preserve.Q. Was that a line that the doctors drew, Mr. B drew, or Mr. C drew or anybody drew?
A. I think it was just acceptable procedure."
5.54 Of the complaints that came from relatives Mr. B informed. Us "I think in the main I found the complaints were without foundation. I do not remember having to take any action with regard to a complaint by a relative."
5.55 The minutes reveal that the Management Committee and the Medical and Patients Care sub-committee showed frequent concern about the lack of occupational therapy, but there was no attempt to fill the gap in the way now being worked out by the occupational and nursing services.
5.56 We have already commented that the resources of the hospital seem to have been concentrated on the admission wards at the expense of the long stay wards. This accorded we believe with Mr. B's understanding of priorities. In his written statement he said "Regarding the point in the Critique that the long stay and elderly patients' treatment is of a custodial nature, you have got to remember that the Department itself laid down the doctrine that where a patient has came to regard the psychiatric hospital as his home, nothing should be done to disturb him. Some old people do not react favourably to an abrupt change in their routine. HM Circular (72)71 specifically says that those patients who have come to regard the hospital as home shall be allowed to remain undisturbed. By that definition those patients are bound to become institutionalised. They have become established to a pattern of life which suits them. What is wrong with institutionalisation if you are happy?"
5.57 In fact that Circular had a very different emphasis. It said of patients who had grown old in mental hospitals and became institutionalised, "Every effort should be made to provide as full a life as possible for all such patients and to prevent them from being cut off from regular contact with people outside the hospital".
09 February 2025
