Quality of Medical Care and Amenities
334. Clearly it was not possible for us to make anything like a full assessment of the quality of medical care provided, even in the male wards at Ely, having regard to our comparatively limited terms of reference. Equally it is right to acknowledge that we learnt of some improvements in accommodation as well as in medical care, which had been effected during recent years. There were, however, a number of other matters which seemed to us to call for attention, in the light of modern standards which we know to prevail elsewhere. These matters are the subject of this chapter.
335. So that the matter may be seen in context, we record first of all our opinion that a hospital for the subnormal has a distinctive contribution to make to the mental health services by providing: —
(a)Continued care for subnormal (including severely subnormal) patients who require special or continuous nursing;
(b)Supervision and control for those subnormal patients whose behaviour is too disturbed for care in the community;
(c)Short-term care for subnormal patients who normally live at home, or in local authority accommodation, during crisis in their mental disorder;
(d)Short-term care for sub-normal patients who normally live at home, in order to give relief to their families at times of crisis, if they are too severely disabled for care in local authority accommodation;
(e)Short-term care or special treatment while the patient’s disability is being assessed or re-assessed;
(f)Care or treatment for a medical condition other than mental disorder of subnormal patients whose disability is too severe, or whose behaviour is too disturbed, for care or treatment in any other kind of hospital.
(Care of types (d) and (e) may alternatively be provided in district general hospitals when there are suitable facilities for doing so).
336. In addition to these provisions Ely provides: —
(g) Continued care for elderly patients who suffer from mental illness and whose behaviour is too disturbed for care in a hospital unit for the elderly or in local authority accommodation;
(h) Care for a variety of mentally disabled patients who might be cared for elsewhere, where suitable accommodation available.
Standards of amenity
337. For most of the patients in-classes (a) and (g) above, and for some in class (g), a hospital for subnormal becomes their home and normal place of residence over a period of years. Judged from this point of view, the amenities provided at Ely fall, in our opinion, far short of what should nowadays be expected of accommodation provided by a public authority.
338.It is right, of course, to acknowledge that all the wards under consideration are designed to contain many more patients than the maxima of 30 adults or 20 children recommended in circular HM(65)104. In addition, they are seriously overcrowded. Two of the male wards contain more than 40 patients, one more than 60 and one more than 70. The two children’s villas, erected a little over ten years ago, contain two and a half times the number recommended in the circular.
339.Moreover, the buildings are old and of poor design. The wards do not lend themselves to subdivision. Measures taken to improve them during recent years include improvements in lighting, the provision of false ceilings, redecoration in pastel colours and the provision of better furniture, curtains and window blinds. Capital expenditure on buildings during the first 20 years of the NHS has been as follows :
1948/1956 £12,000 Occupational therapy facilities.
1956/61 £200,000 2 children’s villas, boiler house and laundry extension, school and improvements to wards 7 and 8.
1966/67 £30,000 Sanitary annexes in wards 21, 23 and 17B.
(Figures given to the nearest £1,000)
340. In the foregoing circumstances, standards of privacy are necessarily below those recommended in circular HM(65)104. Patients are unable to keep with them any personal possessions other than the few small articles that can be kept in a bedside locker. Some of the domitories are too overcrowded to leave room for lockers for all the patients who should have them. Too much of the floor space is literally occupied by beds. As the HMC rota visitors reported on 24th April, 1967:—”The day rooms are very small and some ambulant patients must remain in bed until after dinner as there is not sufficient space for them to sit and eat”. It is not surprising, in these circumstances, that the Group Secretary had written to the RHB, on 24th May, 1965, as follows:—
“In paying tribute to the services continued to be rendered by the medical and nursing staff under extremely difficult conditions, more than one member asked the question as to whether or not the time had arrived for those parts of the hospital where conditions are extremely bad to be closed down until they are replaced or modernised “.
341. We have much sympathy with this protest and cannot emphasise too strongly our conviction that the only real relief is to be found in the complete reconstruction of a hospital such as Ely. Much money has been spent over the years in patching and improving a structure which is basically beyond redemption. Such money has often been spent in response to particularly pressing needs or when extra public money suddenly becomes available at times of unexpectedly high unemployment. It is beyond our resources to assess whether such money could not have been more wisely spent in the context of a long term capital programme, prepared well in advance. We can only hope that the lesson has been learnt for the future.
342.All this might seem to excuse, if not to justify, the low standards of amenity which we observed. It can, moreover, be argued that many of the patients are too disabled mentally to appreciate anything better, or so destructive that anything more than the bare necessities could hardly be justified. This view is, however, belied by the experience of each member of our Committee. When furnishing and equipment of a ward is upgraded, standards of behaviour tend to rise correspondingly. The furnishing at Ely is in general poor in quality and quantity. (For instance, modern types of high backed chairs for the elderly or physically disabled were notably absent in some wards (for example, 17A and 17B), where use might be made of them.)
343.Many of the patients for whom admission to hospitals like Ely becomes necessary because the relatives who have care for them at home have died or become infirm, have been accustomed to higher standards. Relatives caring for patients at home commonly express great concern over the low level of amenities in hospitals for the subnormal, and are often very worried in consequence over the future when by reason of death or infirmity, admission becomes necessary. Furthermore, low standards of amenity make it much more difficult to attract and keep nursing and other staff, and especially staff who want to take a pride in their work. Caring for subnormal patients is hard work, even when conditions are good. It is hardly tolerable when conditions are poor, or when equipment is lacking or of poor design.
344.With these factors in mind and notwithstanding the difficulties to which we have referred, we have concluded that the standards of amenity provided at Ely can, and should, be significantly improved if they are subjected to thoughtful and imaginative criticism by people who have equipped themselves with real knowledge of what has been achieved in equally unpromising settings in other hospitals.
Admission policy:
345. We have noted already the extent to which all the wards with which we were concerned are seriously overcrowded. It should be remembered, moreover, that the hospital is at present intended to cater not only for subnormal but also for psycho-geriatric patients. The design of the buildings at Ely, with very large wards, makes it difficult to classify and accommodate such a diversity of patients in a convenient way. An additional difficulty arises from the fact that one of the male wards is on an upper floor to which there are no lifts. This produces the situation of which several patients’ relatives complained to us whereby: —
(a) Patients of widely differing ages have to be accommodated in the same ward. It was reported to us that 39 males under the age of 22 were in adult wards;
(b) Patients with very wide variations in their disability have similarly to be accommodated in the same ward.
These two factors combined together so that elderly mentally ill patients have to be accommodated in the same ward as young severely subnormal patients. The hospital was admittedly making virtue out of necessity (in this case on the female side) by placing a number of subnormal patients in the same ward as psycho-geriatric patients and had found that this social stimulus had had a beneficial effect on the behaviour of some of the subnormal girls. But it was admittedly not an ideal arrangement.
346. There are four ways in which the pressure of admissions and difficulties arising from the mixed quality of intake might be reduced:
(a) Catchment area:
347. It was only on 12th October, 1966, that the RHB’s Mental Health Services Committee (in response to circular HM(65)104) resolved to define the catchment areas of subnormality hospitals within the region, including Ely. This should facilitate closer co-operation with identified local authorities. Upon this basis phase I of the Development Programme for Ely includes provision of three additional 30 bedded wards, to meet the existing deficiency of subnormality accommodation for the hospital’s catchment area (construction of this accommodation should commence in 1969).
(b) Psycho-geriatric intake :
348. Representatives of the RHB who gave evidence before us acknowledged that the policy of mixing psycho-geriatric and subnormal patients in a hospital such as Ely is not in principle a good one. The overcrowding of the existing accommodation for the subnormal at Ely is an additional argument for restricting the number of elderly patients in class (g) above who are admitted there. The number of those admitted in class (h) is said to be very small. It seems to us desirable that the admission of patients in either of these two classes should be reduced so as to cease as soon as possible when alternative accommodation is available for them.
Community care :
349.The serious overcrowding might have been reduced, had it been possible to return more patients to community care. The number of patients discharged has tended to be very small because of the lack of suitable accommodation for subnormal patients who continue to require a degree of supervision and care. The Physician Superintendent reported in the spring of 1967 that there were in the hospital 6 male and 11 female patients who were suitable for hostel accommodation; the corresponding figures in the autumn of 1967 were 8 male and 11 female patients. It may be expected that this number would be significantly increased if more intensive training was introduced for patients at Ely.
350. Correspondence between the HMC and the Glamorgan County Council, during 1967, was produced to us, from which it appears that the County Council consider that the provision of long term accommodation for subnormal patients is not part of their duty. The County Council does, however, have limited accommodation (two hostels) for subnormal adults below the age of 25 years.
351. Plainly there is room for improvement in co-ordination between the hospital and local authority services in this respect. Experience has shown that local authorities are more willing to co-operate by accepting subnormal patients into residential homes and hostels when they have close working relationships with the relevant hospital and can be given a degree of assurance that a patient will be re-admitted without undue delay if he becomes difficult or troublesome. The hospital in this way becomes a ” crisis centre ” for the homes and hostels associated with it in the service. In this way the number of patients in classes (a) and (b) above can be reduced, while those in classes (c) and (d) increased. One difficulty in the way of development of this kind of co-operation at Ely has, of course, been the lack of definition of its catchment area until the end of 1966. It is also possible that the Physician Superintendent has been, as he himself acknowledged, almost too kind in his willingness to admit patients under pressure, without insisting on any absolute limit on the numbers that the hospital can contain and without, perhaps, endeavouring to bring corresponding pressure to bear on the local authorities for them to undertake the care of a patient in exchange.
352. (At the request of a member of his family, we considered the case of one patient, Tennyson, who, it was suggested, could have been more appropriately accommodated outside the hospital. There is room for two views about the suitability of this proposal; we were, in any event, satisfied that the Physician Superintendent had, in this case, done his best to find alternative accommodation for Tennyson in a religious institution, which was unable to accept him because he was a non-ambulant patient.)
(d) Management of violent patients:
353. Some subnormal patients are liable to be destructive or violent sometimes for only part of the time they are in hospital. The proportion of the whole who are at any one time destructive or violent tends to be small. Our study of the documents at Ely showed that the number of such patients amounted to no more than about a dozen. Most of these patients were in Wards 21 or 23. The presence of potentially violent or destructive patients on a ward may well have a considerable influence on the way in which the ward as a whole is managed. It may also account for the poor furnishing and decoration on these wards. Consideration should, in our opinion, be given to the making of special arrangements for these few patients during the periods in which they are liable to be destructive or violent. This might be done by setting aside an area in one of the wards in which such patients could be temporarily segregated. It has to be acknowledged that none of the wards as at present designed permits the separation of a self-contained area suitable for this purpose. Moreover, the segregation of a few patients under semi-security conditions would require some addition to the nursing staff. Yet the benefits would be considerable. In particular, the other patients could be cared for in a more relaxed and liberal way. There would be no occasion for the forcible removal of a patient who might become a danger to other patients (as in the Housman case, see Paragraphs 89-96 above). Isolation or “seclusion” in a small side room would be less often necessary, as would control through the use of drugs of uncertain effect. The two wards at present housing patients of this kind (wards 21 and 23, each of them with more than 60 beds) are in any case too large for convenient management. There is thus something to be said for separating off a part of one of them for the segregation of patients during periods in which they are liable to be violent. A convenient size for such a separated unit would be 10-15 beds.
354. Destructiveness or violence on the part of patients imposes serious stresses on nursing staff, and there is need for frequent review of the methods used to deal with it. Staff tend to be helped when they are given opportunities to discuss the feelings they experience. We formed the impression that many of the nursing staff whom we have found it necessary to criticise in Chapter 6 above would have welcomed help of this kind, had it been offered by senior nursing staff or medical officers.
Occupation of patients.
355. Circular HM(65)104 points out that : “the most important need for adults is regular work” and that “provision should be made for all patients to spend part of the day off the ward unless this is contra-indicated for medical reasons”. The HMC as appears from reports by Rota Visitors dated 18th February, 1964, and 15th October, 1965, are well aware of the extent to which standards at Ely fall short of this ideal. “We paid particular attention,” says the October, 1965, report “to the facilities for occupational therapy, industrial therapy, diversionary and recreational activities and sports. All these facilities are seriously inadequate and there is a serious lack of suitable staff. There are no remedial baths in the hospital. If there is no prospect of rapid development of these facilities at Ely we suggest that enquiries should be made for the daily use of whatever is available elsewhere, for example, the industrial therapy unit at Whitchurch Hospital.” When this report was considered on llth November, 1965, it was agreed that “consideration be given to use being made of the industrial therapy unit at Whitchurch Hospital and to an increase in the establishment of trainers and trainees”. This suggestion has not, however, been implemented.
356. There is no doubt that the existing facilities, human and physical, for therapy of this kind are very limited at Ely. There is only one trainer to supervise male occupational therapy and the building cannot accommodate more than 30 patients. The “Industrial Therapy Department”, supervised by one nursing Assistant, can cope with only 15 patients of both sexes. There is a vacancy for a Senior Occupational Therapist, but there were no applicants for the post when it was last advertised.
357. There are, of course, considerable advantages in being able to send patients to a day centre, where there are opportunities for occupation, training and recreation. The routine of going out of the ward for several hours each day, as if to school or work, gives a pattern to the day which is invaluable. The patients can be looked after at the day centre by special staff without nursing qualifications, and this relieves nursing staff. The emptying of wards for several hours of the day makes it much easier for the nursing staff to attend to the nursing needs of the patients too disabled to go out or requiring special attention. At the day centre itself there can be mixing of the sexes. A variety of activities can be provided, some useful in training for work, some useful in social training, others recreational. At other hospitals, staffing has not proved difficult, although few if any of the staff have had any professional training.
358.It is in this context encouraging that phase I of the Hospital Redevelopment Plan includes the provision of an occupational/ industrial therapy centre for 195 patients. Links with local authorities and the community will be significantly improved by the fact that this centre is intended to cater for 30 day patients.
359. What is less satisfactory is the extent to which the substantial inactivity of the great majority of patients is accepted at the present time. The Physician Superintendent acknowledged that there are “a lot of patients who are aimless” and who would benefit if adequate therapy could be provided. Yet the examples which we have quoted (see cases Chaucer, Goldsmith and Newbolt in Paragraphs 46 (b), 86 and 135) amply confirm what we were told, that little therapy is at present provided within the wards. We noted that no member of the senior nursing staff had been given the responsibility of ensuring that facilities for activities, occupation and training were used to the full and for enlarging such opportunities as were available. Here again an imaginative and energetic appreciation of what has been done in other hospitals in this respect is clearly needed.
Short term accommodation:
360.Beds are specially kept for patients requiring short term care on the basis of two each for non-ambulant male and female children, two each for ambulant male and female children and two each for male and female adults. The number of short term admissions has averaged 71 per annum during the last 8 years.
361.We have discussed in Chapter IV above several cases of children admitted upon this short term basis. It is to be regretted that existing accommodation does not permit the provision of any reception wards for such patients, particularly in the case of children. It must be recognised that immediate admission into one of the large villas described is likely to involve a substantial emotional shock for the parents as well as for the child. It is of the utmost importance that such parents should be fully prepared with all the information necessary for them to organise such admission—as to clothing, visiting, person to whom inquiries should be addressed and so on. In this context particularly, the preparation of an introductory booklet about the hospital, now under consideration, is of urgent importance. Ideally, it would be desirable to have accommodation available for parents to spend a day or two at the hospital with their child, before the child is left in these circumstances.
Clinical care and records:
362. Once again it is right to acknowledge he improvement that has been made in recent years. Since January, 1965, the Physician Superintendent has held an outpatient clinic for subnormal patients at St. David’s (General) Hospital, Cardiff. Arrangements have been made for a psychologist to be attached to the hospital and for visits by a paediatrician from Llandough Hospital. A dental surgery has been provided at the hospital, regularly visited by a dental surgeon. A dispensary has been created. Electro-convulsant therapy has been introduced. Drugs, principally tranquillisers and anti-depressant drugs, have been used more extensively (indeed, the case of Quiller referred to in Paragraph 153 (d) above suggests that there is, if anything, a tendency to over use of such drugs). And, of course, the hospital school, to which about 40% of the children go regularly, has been opened since 1960.
363.XY did, however, say of the medical staff that he “did not think they cared too much”. He made it plain to us, however, that this allegation was certainly not intended to refer to the Physician Superintendent nor indeed to the SHMO, with whom XY had little or no contact. He maintained this allegation, however, in respect of the JHMO. We consider in Chapter X below how far, in personal terms, it can be justified (if at all) even in his case. In this section we are concerned to express a more general view.
364.In Chapter VI above we indicated a number of respects in which the standards of nursing care fell below those reasonably attainable. We instance the laxity in dealing with cases of sudden death, in the control of seclusion and in the supervision of nurses in the administration of drugs, reporting of incidents and handling of injuries. Matters discussed in this Chapter, such as the occupation of patients, also come, to a significant extent, within the medical sphere of responsibility.
365.Consideration of the many patients’ records which we saw also gave us some insight into the general standard of medical care. Most of the patients in the four wards with which we were chiefly concerned were in classes (a) or (b) and had been in the hospital for many years. We were concerned at the small amount of information about them in their case notes, much of it dating from the time of their admission. The forms on which notes are recorded are of an old-fashioned design, not conducive to the presentation of the kind of information required in modern practice. A typical record gives a few lines of history, recorded when the patient was admitted, and a few subsequent references to the presence or absence of signs of organic disorder. The intervals between notes after admission tended to be lengthy often as long as 12 months. When made, subsequent notes tended to refer tersely to inter-current illness. It was unusual to find any useful information about the patient’s behaviour, for example, as to what he is able to do, in what ways his behaviour is defective or disordered or in what ways it might be modified through training or stimulation. It is exceptional to find a reference to the patient’s family or significant persons in his life.
366.Judging from these notes, the medical staff have tended to concern themselves almost exclusively with the patient’s physical condition or illness. Such little interest as they have displayed in his behaviour has betrayed a low order of expertise. They offer little or no advice about the management or training of the patient. The treatment referred tends to lie in the use of drugs.
367.The occasional notes by the psychologist which we observed were in striking contrast, and tended to give sophisticated and useful descriptions of the patient’s behaviour. In some cases the administrative file gave more information about the patient. Copies of correspondence gave fuller information about his family. More ample histories were occasionally available, but these were often in the form of reports from other hospitals.
368. All these matters have compelled us to the conclusion that the standard of medical care provided at Ely has been to some extent lacking in energy and sophistication and has fallen short of that which could reasonably have been expected.