8. The relationship between the professions
6.24 The relationship between the professions in any multi-professional organisation must be crucial for the success of the organisation. This is particularly true in hospitals where there have been very significant changes in the relationship between the professions in recent years. Ten years ago, in a psychiatric hospital which had a medical superintendent, this doctor was indeed, the 'Head of the Hospital' with responsibility over all other staff within it. Not only was he in charge of the nurses but he was also in charge of any social workers who might be at the hospital, and was responsible for the administration. The senior nurse, the senior social worker and the Group Secretary would all report to him. This situation had been gradually changing and in the more progressive hospitals, irrespective of the presence of a Physician Superintendent, there had been a recognition that the senior doctor, senior nurse and senior administrator were each responsible in their own sphere for the staff under them.
6.25 These changing attitudes and practices received formal recognition when the post of Physician Superintendent was abandoned in many mental hospitals, and the old system was of necessity swept away when the "Salmon" organisation was implemented for the nursing staff, and the Seebohm recommendations were implemented for social workers. From that time onwards, whether there was a Physician Superintendent in post or not, he had no authority over the nursing staff or over social work staff, each of which were responsible to their organisation. The significance of this has not percolated to all corners of the system even now, and there is no doubt that some doctors have resented this reduction in their power.
6.26 It will be clear, therefore, that a multidisciplinary approach to patient care by all these professions is essential if their separate and overlapping skills are to be used to the best advantage of the patient, and, indeed, each other.
6.27 For obvious reasons, it is likely to be to the detriment of the patient if the professional staff caring for him disagree over any significant matter. Equally, it is obvious that treatment policies must be agreed between the professions by a consensus, and not because any one profession has authority over the others.
6.28 The most effective organisations are likely to be those where there is parity of esteem between the professions. This means that each profession recognises that in some fields the other professions have a greater expertise and additional skills to offer. Each profession should recognise that the development and encouragement of other professions will be to the benefit of all, and of the patient in particular, and that any attempt by one to dominate the others will inhibit the professional growth of those concerned.
6.29 Unfortunately not all doctors have been able to accept this and some have felt compelled to keep what they consider the clinical side of care outside the multidisciplinary ambit. Moreover, their definition of clinical responsibility is sometimes very wide indeed. The Report on the Committee of Enquiry into South Ockenden Hospital which was submitted to the Secretary of State for Social Services in March, 1973, stressed the need and called for central guidance in this matter, but it has not yet been forthcoming, although the Third Cogwheel Report tiptoed round the perimeter of the problem.
6.30 In our view true multidisciplinary team work requires that each member recognises and accepts that no one profession can be totally responsible for any aspect of the patients clinical care, even though the initiative and main responsibility at any given moment may lie almost entirely with one or other. For example, the making of a diagnosis or prescription of medication is largely the responsibility of the doctor. However, even he in many cases is unlikely to make a sound diagnosis without the additional information which may be provided for him by nursing observation, or the psychologist's report. In the final event, however, having heard the opinions of others, it will be for the psychiatrist to write the diagnosis in the case notes. Again, in the case of medication, the prime responsibility lies with the doctor, but he will be wise to consult the nurses and Others involved, and agree a policy. An obvious example lies in the realm of night medication The doctor may well prescribe a particular sedative, but whether or not it is given lies very much in the hands of the nurse. The patient may be asleep at the time, and the nurse will have to decide in the light of the patients agreed treatment programme and agreed ward policy whether, or not it is reasonable to wake the patient. The nurse will also have to decide whether or not to give a sedative to a patient who has been on leave and has returned under the influence of alcohol. Even the type of medication needs to be discussed and agreed with others.
6.31 Equally, the nurses have a prime responsibility for many parts of the patients' care in hospital, for example bathing, dressing and feeding. For example, where a patient with diabetes needs to have a special diet, the exact form of the diet may well be a matter largely for the doctor to decide, but whether or not the patient could or should be persuaded to take it, in the light of difficulties present at any given moment, is very much a nursing matter and, in a final analysis, the nurse will probably have the day to day decision as to how far a patient should be persuaded to eat any particular meal.
6.32 Similarly with dress; the time of dressing, whether the patient dresses himself or has assistance, and the kind of dress likely to be available, are very much in the hands of the nurses. Whether or not a patient's dress is restricted, for example by keeping him in night attire in order to reduce the likelihood that he will run away, is very much a nursing matter, as only the nurse is likely to know from minute to minute the number of nurses available on the ward for observation and the attitude of the patient to absconding at any particular moment in time. There must, however, be added to the knowledge and skill of the nurses that of the other professions. The doctor, from the information he has obtained in the clinical interview, may have much of value to say on the on the risks of absconding or attacks on other people. The remedial professions may also have valuable suggestions to make on the sort of activity which will or could be available, either to the individual patient or to the ward as a whole, and which might reduce, or sometimes increase, the likelihood of a patient absconding. The nurse, therefore, may well have the final decision on the patient's clothing, but will need to consult with her clinical colleagues and justify her actions if there are problems.
6.33 These are but examples by which we seek to demonstrate that the bringing of all patient care within a multidisciplinary team does not deny or denigrate the individual skills. In a matter of medication the team will normally be happy to defer to views of the doctor, just as in other matters the team will be happy to defer to the views of the nurse. This will be consensus agreement, as opposed to placing either the clinical skills of the doctor or the expertise of the nurses outside the team. In between these extremes there will be many decisions in which all discipline will have a substantial contribution to make to the final decision. Any member of the team can, and should, be called to account by the others if they are unhappy with his performance.
6.34 When a decision has been reached each member of the team should feel personally committed to putting it into practice. We were' most encouraged to hear while we were at St. Augustine's that the medical profession there are happy to work in such multidisciplinary teams. This opens up a most exciting prospect and we wish them well.
6.35 It will be convenient under this heading to refer to the vexed question at St. Augustine's of the confidentiality of medical records.
6.36 The medical profession has been rightly proud of its ethical standards in the matter of confidentiality of medical records over many years. It is expected that a doctor will keep confidential all matters which come to his notice as a result of the professional relationship with his patients. At the time when the psychiatric hospital had a Physician Superintendent, he was able to insist on this confidentiality at any level he wished, including the access to case notes by nurses, social workers and others. Since the nursing and social work professions achieved independent status, however, the problem of confidentiality has caused concern at St. Augustine's and many other hospitals.
6.37 There is no problem where the relationship is entirely between the doctor and the patient and no other profession is involved. With all in-patients and many patients in the community, however, more than one profession is involved. It is obviously essential that other staff working on the ward should have access to case notes, not only as part of their training, but also to ensure that they are up-to-date with information about the patient and can adopt the right attitudes and follow through an agreed line of treatment. Most doctors have assumed that the confidential information acquired by nurses from patients, will automatically be passed on to them, but the fact is they no longer have the right to insist on this. It must be quite obvious that if a doctor insists that information coming to him is confidential, and nurses and social workers take similar attitudes about information coming to them, the patient will suffer.
6.38 Neither should it be thought that the doctor always has the most reliable or the most confidential information. Many psychiatric patients will deceive their doctor, or fail to confide fully in him. It is common to find that when information is pooled from nursing, medical and social work sources, that all three have had a somewhat different account of essential matters in the patient's life history or current problems. A typical example will make the matter clear. A young girl may have had a difficult relationship with her parents, neither of whom she trusts. On the ward she gives a very limited history to the ward sister and the ward doctor, but forms a good relationship with a junior nurse on the ward and confides freely to the latter her conflicts, difficulties and problems. There is no doubt that a sharing of information between members of the therapeutic team treating the patient will benefit the patient. This sharing must take place on a basis of mutual trust and the patient should know from the beginning that, whatever member of the therapeutic team is involved, the team as a whole will receive all relevant information.
6.39 It would appear that some years ago the Medical Defence Union gave the St. Augustine's medical staff a very limited definition of the extent to which case notes should be made available to nursing staff. However, it was noticeable that even when this definition was amended to show that it was reasonable to allow access to case notes by nurses in training, the medical staff were reluctant to agree. In our view the medical staff do not have the right to refuse access to case notes, for the legal ownership in them is vested in the Secretary of State and not in the doctors. One can well imagine the medical reaction if the nurses, for some reason, decided that doctors should not have access to nursing notes.
6.40 It has sometimes been argued by doctors that nurses should not have access to the case notes of patients admitted to hospital who are their near neighbours, or where there might be embarrassment for a patient or member of staff if information became available to nurses on a ward. This is a valid consideration. However, just as most doctors are reluctant to treat close friends or relatives and will often advise the patient concerned to seek another medical attendant, so equally a responsible nurse will express a clear desire to avoid being involved in the treatment of a relative or close neighbour. These, however, are all matters which should be freely discussed at the multidisciplinary ward meetings so that everyone is aware of the need, indeed, duty, to avoid such a situation. One profession can no longer be dictated to by another. It is our strong recommendation that the case notes should contain medical, nursing, remedial and social work notes for each patient and that subject to the considerations already referred to, they should be available for all nurses.
09 February 2025
