The report of the enquiry into St Augustine's became front page news in the latter half of March. Like all news, it quickly became history and history, we are led to believe, should hold valuable lessons for us. By now, many people will have read and, I hope, mentally digested the contents of the report, for there are, indeed, many lessons for us contained within its pages.
I found it interesting that the committee decided against advising disciplinary action against staff mentioned in the report. In this respect the St Augustine's report was very different from others.
The report was excellent in describing certain situations at the hospital, for example, the relationship between the professions. But any report, no matter how well written, cannot convey the exact 'anatomy and physiology' of a large institution.
For this reason, the decision not to advise disciplinary measures was, in my opinion, the correct one. The 'anatomy and physiology' of St Augustine's, the balance of power, the management styles, the professional jealousies, in fact the total institution, led individuals into seeing the world through blinkers.
Let me assure the reader that St Augustine's is not some dreadful dark Victorian asylum, neither is it staffed by vicious morons. In fact, compared to many hospitals I have seen, St Augustine's is in good order.
As for the staff, they have a wealth of talent, particularly the nursing staff, but as the report so ably showed, that was often stifled.
The consultant medical staff are not exactly ogres, they are run-of-the-mill consultants facing run-of-the-mill problems.
Lesson number one. Many people in St Augustine's, particularly senior staff, believed that the standard of care in long-stay wards was beyond reproach. They were brought sharply down to earth when the report was published. Professionals are experts in the art of self-deception; it is less painful to believe that all in the garden is rosy, a soft option.
In my opinion, nurses, doctors and administrators are far too keen on soft options. How about you?
The report paid much attention to the relationships between the doctors and other groups. It also stressed the need for the development of the team approach to patient care at all levels. In doing so, it has highlighted one of the most important problems facing psychiatry today.
Unfortunately, many doctors, not just in St Augustine's, believe that holding the odd meeting in the wards constitutes team work. These meeting allow all staff to meet the consultant and are so often nothing more than a sham for democracy. Teamwork does not start and finish through meetings of this nature, it has to be a continuing process and it can succeed only in an atmosphere of total trust.
Professionals in the Health Service are too quick to believe that their specialty holds all the answers. In psychiatry, which, to say the lest, is an inexact field of knowledge, this stance is dangerous. Yet at St Augustine's, the doctors bleated continually about their 'clinical autonomy', but when asked to define this wonderful concept, where it began and ended, none could answer coherently. The answer to the pompous attitude of the medical profession lies in its history.
Conversely, many nurses are content to accept a subservient role, for in that role they find security, and the answers to this attitude lie in the history of our own profession. As we all know, established patterns of behaviour are difficult to break, but broken they must.
The doctor's clinical autonomy goes as far as his diagnosis and prescription of treatment. That is what he is trained, and indeed paid, for. But any doctor who carries out this function without utilising the skills of others is a very foolish person. The occupational therapist, the nurse, the radiographer are not there to usurp the role of the doctor, they are there to help him reach a decision that is correct in terms of the needs of the consumer.
as the report points out, the professions at St Augustine's could not adopt this approach in the long stay wards. Had this not been the case, the inquiry would probably never have happened.
An inquiry of this type is traumatic for health service staff. Sadly, the South East Thames Regional Health Authority saw fit to release the St Augustine's report to the media before allowing the hospital's staff the opportunity of reading and discussing it.
The bulk of the press did less than justice to the report and, unfortunately, many staff only had the scaremongering reports of the newspapers by which to judge it.
Copies of the report took time to reach hospital staff - in fact we still haven't enough copies - but I was able to read the report before the press filled its front pages. When I saw the papers the following morning I could not believe I was reading the same report. The handling of the release of the report did a great deal of damage to staff morale. Health authorities have a lesson to learn here.
Since the report, more money has been allocated to the hospital and it would seem that certain aspects of service, such as laundry, supplies and clothing are to be improved. At the moment, however, I do not see many signs of emphasis being placed on the need to develop teamwork or modification of relationships between the professions, though one may add that this cannot and will not happen overnight.
Many people in the higher echelons of the service are licking their wounds. Those wounds need licking, for I am sure they are painful, but when the wounds are healed I hope people will see that this report provides us with a golden opportunity to move forward.
Others are saying that the hospital is better than many others and it was just bad luck that we were the subject of such a detailed and searching inquiry. This attitude will provide no answers, for the fact remains that St Augustine's was the subject of the inquiry, and things must be put in order.
Nursing will require strong and vociferous leadership in St Augustine's. Middle line nursing managers came in for a lot of criticism in the report, but Mr Inskip pointed out that middle managers were never allowed to develop their skills. In many instances, skills are there. Courses and in-service training can only provide some of the answers.
Middle managers in the nursing service fulfil a vital role: they must be equipped to carry out their functions, and once equipped, they must be allowed to manage. In the past, their role was stifled by a penny-pinching administration and the concentration of a great deal of power in the hands of too few people. In the present structure of the NHS this situation could occur again.
Doctors will have to come out of their shells. Psychiatrists today are faced with an enormous workload. The development of true multidisciplinary teamwork can ease their burden considerably. If nurses and other groups are trained and encouraged to develop and extend their roles, health care in our hospitals can be improved.
Nurses do not wish to become mini-doctors; all that is required is for all health workers to have trust in each other's skills and abilities in an atmosphere of mutual respect.
This objective, given the history of health care professions, will be hard to achieve. It has been achieved in other parts of the country with remarkable results - there is no reason why it should not be achieved at St Augustine's, provided that heads are kept out of the sand.
If St Augustine's is no worse than many other psychiatric hospitals, and I believe it is, then this report has far reaching implications for the whole of the psychiatric service. The original critiques were of policy, or lack of it.
The report has courageously dealt with the real issues, how we run our psychiatric hospitals; and I would fully endorse the comments of Keith Newstead and others, that the time has come for a complete reappraisal of the way psychiatric care is given.
In recent years it has become increasing obvious that something is wrong somewhere. That something is an intricate tangle of problems that arise in institutions. The problems are often subtle and extremely difficult to define and eradicate.
On visiting St Augustine's, Mr Ennals, Secretary of State, asked some interesting questions about the problems of psychiatric hospitals. He asked: 'Is there something fundamentally wrong in the management, staffing and treatment in our mental hospitals? Is it a shortage of staff or a question of attitudes? Is it overcrowding? Is it a lack of public involvement? Are there communications problems at all levels? Are the roles and relationships of professional groups clearly defined and understood?'
He then pledged to provide the answers. In effect, he provided the answers by his questioning, for all these problems plague the average psychiatric hospital.
It was be easy to say that David Ennals is the Secretary of State so let him find the answers, but all health care workers should be anxious to find some of the solutions for themselves. Nurses spend more time than any other group in a direct patient/client care situation and that positions places great responsibility upon our shoulders.
It also gives us the power to mould the psychiatric service into something we can be proud of. The lessons are there for those who see them, How long until the next report?
09 February 2025
