6.1 We have already reported that there is at present no formal body between the clinical area level in the hospital and the District Management Team. The need to create Some kind of body to fill this gap is recognised not only by the District Management Team but also by all the disciplines working in the hospital. All accept that the Medical Executive Committee, Which by definition is medically orientated and dominated, is unsuitable to fulfil, this role and that the answer is not provided by the Heads of Department meetings or the informal meetings of the Sector (or Unit) Administrator, the Chairman of the Medical Executive Committee and the Divisional Nursing Officer.
6.2 Later we suggest a multidisciplinary framework for the hospital with multidisciplinary teams at hospital, clinical area7and ward levels. Apart from the Hospital Team we suggest that the teams should have a coordinating and persuasive, but not a managerial, role. Their task, in broad terms, will be to complement and strengthen the managerial structure and function of the individual disciplines.
6.3 Before we develop these proposals further we wish to make some suggestions which, in our opinion, will lead to better functioning of the individual disciplines, including all levels of administration, and to a greater ability to use their skills and resources as members of teams for the common good.
1. Those with a managerial role must manage
6.4 A manager is defined by 'The Grey Book' as "a person who is responsible not only for his own performance but also for that of his subordinates. They are accountable to him, just as he is accountable to a superior authority (either a manager or a statutory authority). The manager participates in the selection of his subordinates and is responsible for the training and development of his subordinates, for delegating to them work which is within their competence and for assessing their performance."
6.5 All managers should ask themselves not only "who am I responsible to?", but also the much more important and challenging question "who am I accountable for?"
6.6 Let us look at the managerial role of the Nursing Officer as an example of how this definition should work:
(i) Unless he knows the policy of each ward and has in mind minimum and desirable standards, he will be unable
(a) to participate usefully in the selection of ward staff;
(b) to Understand the varying fields in which those for whom he is accountable need further training and/or counselling;
(c) to know whether those for whom he is accountable are carrying out their work satisfactorily;
(d) to know what enquiries and investigations and checks should be made by him to ensure that those for whom he is accountable are providing the best service possible within the resources available,
(e) to decide priorities for expenditure.
(ii) He is therefore responsible for seeing that there are clearly understood policies and standards in each of his wards. If they do not already exist he must formulate them with the help of all disciplines. If they do exist he must ensure that they do not require revision in the light of fresh ideas and knowledge or changed circumstances.
(iii) He must ensure that he is consulted about the appointment and moving of staff.
(iv) He must check that those for whom he is accountable are performing satisfactorily. Simply to ask his subordinates whether they are doing all they should is an unreliable form of checking. He must be able to say of all people and matters for Which he is accountable "I know", not "I have been told".
(v) If things have gone, or are going, wrong, he must take immediate corrective action. This will not necessarily entail an order. Counselling or persuasion may be all that is necessary, but if these fail there must be an order.
(vi) If a member of staff is unsuitable for the ward he, must consider whether further training will make him suitable. If it may, he must ensure that it is obtained. If it will not, he must recommend and press for the removal of that member of staff. His duty, first and foremost is to the patients and other members of the staff-whose work will be hampered by having to carry and endure unsuitable members.
(vii) If it is necessary to obtain a certain item of equipment or extra staff for the ward he must see that his request is made in clear terms on paper, and if it is not granted he must ensure that he understands the reasons and that he passes them on to his subordinates.
(viii) Through the exercise of the above functions he will know just how far he can delegate and will be able to delegate to the maximum extent compatible with his accountability. Delegation without the exercise of those functions is abdication.
(ix) He should keep written notes on important matters concerning individual members of staff. Not only are they important as an aide mémoire in carrying out his duties, but they will assist when he takes part in a formal appraisal or assessment of his subordinates, and will help a new nursing officer or senior nursing officer to know the strengths and weaknesses of the ward staff in his unit.
6.7 This list is, of course, not exhaustive. It can be applied at any level where there is a managerial function.
2. Those with a monitoring role must monitor
6.8 The 'Grey Book' tells us "The person who monitors has the authority to require to be kept informed about the, activities of the persons monitored and has authority to persuade them to change but in the final analysis, he cannot order them to do anything and, if not satisfied, must refer the matter to higher authority. Monitoring does not call for any particular managerial relationship in the ranks of the persons concerned."
6.9 In our view the phrases 'has the authority to require to be kept informed' and 'has authority to persuade' are thoroughly unsatisfactory. They are permissive and connote no duty. Far too much monitoring consists of waiting to be told and then of taking no effective action when information does come. The monitoring function requires penetration downwards. We suggest the following definition. "The person who monitors must keep himself informed by personal enquiry and inspection about the activities of the persons monitored and, where necessary, must try to persuade them to change, but in the final analysis, he cannot order them to do anything etc."
6.10 This clarifies the role. A person charged with monitoring does not keep himself informed by waiting for information or simply by receiving reports from those whom he is charged with monitoring. He is responsible for devising a system which provides him with reliable information, and personal visiting and inspection of the services provided by those whom he is under a duty to monitor, is an integral part of the monitoring role.
3. Training
6.11 Because of the recommendations of the General Nursing Council there is a division of responsibility between those charged with student and pupil nurse training and those charged with in-service training of qualified staff and nursing assistants. This at St. Augustine's has meant that the' Nursing Officer responsible for in-service training has been largely deprived of the facilities and expertise of the Lawson School of Nursing. Every effort must be made to secure the fullest co-operation and use of all educational resources and personnel in the hospital.
6.12 Training of Senior Nursing Officers and Nursing Officers is at present based on the policies of the National Nursing Staff Committee and takes place in training centres and colleges of further education. One of the weaknesses of the present system is that the courses are largely theoretical and take place away from the hospital setting in which those attending will have to work. The clinical side of the work is largely ignored. We recommend that there' should be continuing training and counselling for those holding these important posts. Course Tutors should familiarise themselves with St. Augustine's Hospital and make a skilled assessment of the particular needs of those attending management courses so that the training can really help.
6.13 Visits to, and periods of working in other hospitals will be of great assistance in broadening perspectives and identifying training needs in St. Augustine's. Much help could also be gained from inviting staff of other hospitals to come and work for short periods at St. Augustine's. These exchange visits would complement the formal management training and on-the-spot courses.
6.14 It should also be possible with the training facilities and clinical experience available to interest the Joint Board of Clinical Nursing Studies in providing an advanced nursing course of some kind at St. Augustine's. In addition, the resources of local colleges of further education and the University of Kent should be fully exploited. In the short term the possibility of a Diploma of Nursing course should be considered, and in the longer term the opportunity of participating in a Nursing Degree course should be kept in mind by the Nursing Education Committee for the District. The hospital will benefit from these suggestions in two ways:
6.15 Firstly, many of the highly intelligent and well educated members of staff in post are capable of an expanded nursing role from which the patients would ultimately benefit. Secondly, more staff of the right calibre will wish to come and work at St. Augustine's.
4. Staff Appraisal
6.16 This is closely allied with in-service training. Without an adequate appraisal system unsuitable staff are more likely to be promoted or left too long in positions for which they are unsuitable. Adequate staff appraisal will assist to identify the areas, if any, in which further training is necessary before a person is promoted or moves to a new post.
6.17 We suggest that staff appraisal should be carried out in two parts. Firstly it should consist of regular, close and constructive supervision and contact by superiors, and the noting of any important discussions or problems or strengths in personal files. Secondly it should consist of periodic formal appraisals using a common form of appraisal.
5. Patients Activities Team
6.18 We have already explained our proposals in paragraphs 3.38-40.
6. The Voice of the Patients - Patients Committees
6.19 Within the hospital a large number of meetings take place in which the staff are mainly involved. The voice of the patients we were told was mainly heard at ward meetings which are run by the staff. We believe that since the patient is at the centre of all activities there should be opportunities for patients to meet together to discuss their role in the hospital, to represent their own views, and to accept a participative role in the therapeutic community. This could be achieved by the establishment of formal patients committees for the three clinical areas of the hospital, or for the whole-hospital if preferred. Such committees should meet formally under their own chairmen, and facilities should be provided for the preparation of agendas and the taking and distribution of minutes.
7. Information Systems
6.20 We have already remarked on the District Management Team's unawareness of the significance of empty beds in relation to the known overcrowding and the apparent imbalance between the areas. Other examples of ignorance of available and relevant information could be given at various levels.
6.21 One of the most important functions of an administrator in a psychiatric hospital, and indeed at every level in the Health Service, is to assemble and convey to people or teams charged with managing or monitoring, the information which is necessary for them not only to arrive at the right decisions, but also to recognise matters requiring their attention.
6.22 Within a psychiatric hospital we suggest that disciplines and teams will require statistical information about the rate of admissions and discharges, the use of beds and their relationship to the catchment area population. Without such information it will not be possible to judge whether, or to what extent, the catchment area requires more resources than are currently available and whether admissions and discharges are in balance.
6.23 By producing a simple document at regular intervals the administrator can help all sections of the hospital in their work. The information which we suggest below and which should be regarded as a basic minimum, should be given in relation to each clinical area and could usefully be circulated to all wards so that those interested can see the position of their ward in the perspective of the whole hospital and bring any apparent imbalance to the attention of their multidisciplinary team.
(i) Available beds
(a) by type (e.g. acute, psychogeriatric)
(b) by Consultant
(ii) Beds required according to Government guidelines - by type.
(iii) Average daily occupancy.
(iv) Number of first admissions by Consultant.
(v) Number of readmissions
(a) by type
(b) by Consultant
(c) by length of stay in the Community
(vi) Number of discharges and deaths
(a) by type
(b) by Consultant
(vii) Number of patients admitted from outside the Team's catchment area.
(viii) Number of patients transferred from acute to non-acute wards.
(ix) Number of patients whose stay in hospital is approaching
(a) two months
(b) twelve Months
(x) Number of outpatients seen by each Consultant
(a) new
(b) follow up.
(xi) Total outpatients seen by each Consultant and other medical staff.
(xii)Number of domiciliary visits by
(a) Consultant
(b) Nurses
(c) Social workers
09 February 2025
