I welcome the committee of inquiry's recommendations for the sharing of responsibility within the hospital service, and the proper monitoring of the hospital's activities, clear guidance for both medical and no-medical staff. Particularly important is the recognition by the panel of initiative open to nurses and their duty to exercise it.
I cannot but express my admiration for the work undertaken by the distinguished panel and fully support their decision to make the report public. The inquiry arose out of a brief seven-page document, written by Mr Olleste Weston and myself and addressed to the responsible authorities, which sought to draw their attention to matters arising out of our experiences while working at St Augustine's.
That document indicated a lack of policy for the decent and humane care of unfortunate people, many of whom will have to spend the rest of their lives in the hospital.
The inquiry would not have taken place if it were not for the intransigence adopted by the district and area authorities when they received our document. We were both surprised and saddened by the refusal of the authorities to recognise that there was a case to answer.
Instead of coming to see things for themselves, they preferred to take refuge in expressions of goodwill and support for their nearest colleagues and denying the existence of any problem at all.
In contrast, the committee's members went to the words where we worked to see for themselves what resemblance conditions there bore to those we had experienced and described. They spoke to people at all levels at the hospital, read hundreds of statements and spent a month hearing witnesses and listening to the views of those about whom we complained.
In many cases, the committee have adopted the evidence and backed the judgement of the nursing staff at ward level, often preferring their evidence to that of the doctors (who claimed exclusive jurisdiction of so much) and to that of the hospital administration at middle and upper levels.
In many cases, too, the committee adopted the nursing staff's judgement as to the responsibility for the apathy, overcrowding and lack of privacy in the back wards.
I welcome the report's positive and forward looking approach and its demand for more help and training for all concerned.
The committee have called for clearly stated policies and the setting of both minimum and desirable standards, and made sensible proposals to improve nurse education. To achieve this they have proposed devolution of responsibility to hospital level, through a multi-disciplinary approach at all levels.
However, I must make it clear that the committee has still failed to get at the root of the problem.
1. There is no guarantee that the report's criticisms and suggestions will be acted upon at St Augustine's, and as to their prospects of being generally applied, there is no reason to suppose that this report will not join the 14 other reports of inquiries made into similar hospitals in the past seven years and then pigeon-holed.
2. The committee rely on the 'clear duty on the regional and area health authorities and on the district management teams to see that hospitals for which they are responsible are run properly and that patients are well cared for' (p 136), when the report itself makes clear that these people cannot be relied upon to discharge that responsibility.
3. Their most unrealistic recommendation is that the Community Health Council should regard it as part of its duty 'to assess the extent to which action has been taken on their recommendations'. That body has neither the expertise nor the authority to take such action and its present secretary is the former group secretary of St Augustine's Hospital.
This man, Mr B, was responsible for the hospital immediately before the publication of the first critique and came under severe criticism in the Report of the Committee of Inquiry.
Recent press reports indicate that Mr B's reaction to the report on St Augustine's is one of flat contradiction. First, he states that: 'Everything you see in this report is due to lack of resources', and second, he claims that 'the recommendations of the Committee are going to require considerable financial support'. (He has also maintained that the inquiry was conducted in an improper manner). These statements by Mr B are misleading about the past, which is serious enough.
Their implications for the future are even more disturbing:
(a) Ill-treatment and neglect of patients is not a question of resources, but of attitudes.
(b) The main recommendations of the inquiry's Report relate to changes in attitudes and organisation, and not to matters of expenditure.
4. The committee has excused much unsatisfactory behaviour, including acts of violence, on the grounds of understaffing and overwork, and has pointed out that some nurses were misguided, rather than deliberately cruel, It should be remembered that patients have a right to be protected from such behaviour, whether misguided or intentional. No effective measures to ensure their protection have been proposed.
Attitudes: The report makes it clear that our attitudes towards the mentally ill must change and in my opinion this involves everyone's attitudes, both inside and outside the hospital, but especially those of the medical profession.
The doctors at St Augustine's placed themselves in a position of total supremacy where only they could make decisions regarding the care and treatment of patients.
This led to a suppression of nurses and of initiative by nurses and resulted in the neglect of long-stay patients because doctors rarely visited the long stay wards.
The care of patients requires teamwork which should exist as partnership in care between all of the professions involved: nurses, doctors, social workers, occupational therapists. But attitudes don't change by themselves. This is shown by the need to introduce the Race Relations Act and the Sexual Discrimination Act.
If doctors won't give up their claim to exclusive power in the name of clinical freedom they have to be pressured into doing so. The application of such pressure should not be left to the chance exposure of hospitals by individuals such as Mr Weston and myself. In the interest of patients, doctors have got to be made accountable. Their insistence on clinical autonomy is unacceptable because doctors are not infallible.
Dr David Owen, in a statement to the House of Commons, accepts that the state of affairs at St Augustine's is an example of a national problem. But the Government has been put on notice about this problem time after time over the past few years by the many previous inquiries into hospitals in the chronic sector of the NHS.
With the exception of those inquiries arising out of individual tragedies within hospitals, these inquiries have usually arisen through staff working at ward level complaining, and maintaining their complaints in the face of considerable opposition from those responsible for the running of the hospital.
The findings of such inquiries often bear a close similarity to each other and to those of the St Augustine's inquiry. The South Ockenden inquiry asked the government to produce guidance on the care of the mentally handicapped. It also called attention to the unacceptability of clinical freedom. The Government has not acted on that report.
The Davies Committee was set up to look into hospital complaints procedure and made proposals for permanent machinery to deal objectively with hospital complaints. The Government has not acted on that report.
The Junior Minister, when asked about this in the Commons, gave the lame excuse that they were waiting for the doctors.
The St Augustine's report pointed out (para 6.29) that the report on the South Ockenden Hospital inquiry which was submitted to the Secretary of State for Social Services in March 1973, stressed the need and called for central guidance on how clinical autonomy fits into true multidisciplinary teamwork, but that advice has not yet been forthcoming.
The foreword to the St Augustine's report states 'Exhortation to a multidisciplinary approach is no good without ensuring that the medical profession fully participates, and this will not be achieved without giving clear guidance as to how this should be done, even if this does mean grasping some nettles'.
The time is long overdue for the Government to tackle the medical profession on such matters, remembering that the NHS is run for the benefit of patients, not doctors.
If nursing is to reach the stature it deserves, nurses themselves must examine their attitudes towards the mentally ill and towards other professions, and become aware of their position in relation to patients, doctors and administrators.
For too long, nurses have deferred to doctors, allowed themselves to be stifled by nursing hierarchies, tolerated what they know to be intolerable conditions for patients at ward level, and (often for understandable reasons) have not been prepared to blow the whistle when they see things that are wrong.
The state of affairs revealed at St Augustine's continued because people tolerated it.
The proposals made in the St Augustine's report for higher education and improved in-service training for nurses will, if acted upon, go a long way towards changes in basic attitudes, teaching nurses a critical approach, progress towards multidisciplinary management, the development of a therapeutic role for nurses, improved quality of nursing administration and the development of the community role for psychiatric nurses.
It is a matter of concern that although there are nurses at ward level in St Augustine's who care deeply about the quality of care offered to patients, the hospital now has to be led through its problems by the very people criticised in the report.
When Mr Weston and I first published our criticisms of St Augustine's we sent copies to the responsible authorities at hospital, district, area and regional level, to the Secretary of State and to the external bodies: the local Community Health Council, the Health Service Commissioner and the Hospital Advisory Service.
The St Augustine's report details the inept handling of this first critique by the various levels of the NHS bureaucracy. What the report does not detail is the fact that the external watchdogs also failed to take any effective action over our complaints.
The local Community Health Council was rendered impotent by the position as its Secretary of Mr B, the former Group Secretary of St Augustine's. In that capacity, he was sent, on the advice of Dr Owen, a copy of the first critique. His reaction was to ask what the authors meant by an unacceptable standard of care.
It should also be remembered that Community Health Councils cannot investigate individual complaints, but only advise on how and where to lodge complaints.
The Health Service Commissioner, Sir Andrew Marre, steered clear of the first critique because he maintained that it contained matters involving the clinical judgement of doctors, an area which his terms of reference prevented him from examining. Once again, clinical autonomy serves to protect the doctor.
It is interesting that the Health Service Commissioner seeks to draw a line between clinical and non-clinical matters when the St Augustine's report makes it quite clear that the distinction is unreal.
It was the maintenance of this artificial division between clinical and non-clinical matters, with doctors giving a very wide definition of clinical responsibility, which gave rise to many of the problems the inquiry revealed.
The Hospital Advisory Service (HAS) referred the authors back to the health authorities. The existence of the St Augustine's report demonstrates that neither the present administrative structures nor the external bodies established by Parliament (Community Health Councils or the Health Service Commissioner) are capable of controlling the performance of psychiatric hospitals.
The HAS has the expertise to identify some of the shortcomings but lacks the power to rectify them. The guarded language which, for reasons of tact, it has found itself obliged to use in commenting upon the inadequacies of such institutions has not helped those responsible for the problems the service has noted to recognise them clearly.
The St Augustine's report suggests that the DHSS should extend the work of the HAS to enable it to make regular three-yearly visits and repeat visits where necessary. Dr Owen recently announced an extension of the service.
But in view of the findings of the Committee of Inquiry at St Augustine's, that the HAS report on the hospital of 1971 was 'treated with something approaching patronising disdain', there is no reason to expect that future Hospital Advisory Service or any other advice would be treated any differently.
Indeed, the inquiry revealed that those responsible for the running of St Augustine's, both inside and outside of the hospital, have repeatedly shown a remarkable inability to respond to criticism and advice. In fact, they acted with complacency right up to, during, and even after the inquiry. There will be no guarantee of continuing improvement until there is power to ensure compliance.
The committee said, in discussing the managerial role of the Nursing Officer: 'Counselling or persuasion may be all that is necessary, but if these fail there must be an order'. This should be applied at all levels of the administrative structure.
The HAS at present does not have any power to give such orders. Furthermore, it cannot examine matters deemed to involve clinical judgement, but can only examine the interface between doctors and other professions.
Consequently, the Service did not identify many of the shortcomings revealed by the critiques or by the inquiry. In the last resort it is yet another toothless watchdog.
Radical improvement in the short term, prevention of backsliding, and the maintenance of impetus towards further improvement in the long term necessitate the establishment of a hospital inspectorate. This would inspect hospitals regularly, give advice, and ensure compliance with such advice, and raise standards to an acceptable level. such a body should also act as a fail-safe mechanism to investigate complaints.
My submission that there is a need for an outside hospital inspectorate was regarded by the Committee of Inquiry as outside their terms of reference, yet they considered the need to extend the work of the HAS as within their terms of reference.
A permanent inspectorate, combining the expertise of the HAS with the best features of inquiries such as that at St Augustine's, could intervene effectively at an earlier stage than is possible with a committee of inquiry for the investigation of complaints, and could in many cases carry out its work without having to bring to bear the panoply of a formal inquiry.
We require preventative measures to attack the problems at their root cause.
The St Augustine's report reveals that psychiatric patients are particularly vulnerable to the abuse of power, whether that abuse is committed by nurses at ward level, or by doctors, the various levels of nursing or lay administration, or the Government.
Patients need protection from such abuse. No effective machinery exists at present for the vindication of the existing rights of psychiatric patients.
The report shows that psychiatric patients' rights require to be clarified and where necessary, enlarged: that further definition of minimum standards for the care and treatment of patients is required and that formulation of desirable standards requires to be regularly undertaken. A hospital inspectorate would fulfil those needs.
The St Augustine's report reveals the gulf between what ought to be happening and what is happening in psychiatric hospitals. It reveals that long-stay patients are not receiving the quality of life they are entitled to.
The government should now take effective action on the public's behalf and issue guidelines backed by deadlines to protect patients and establish adequate machinery to ensure compliance,
Until it does, long-stay patients will continue to be neglected and ill-treated and the public mislead.
09 February 2025
