Medical and Administrative Leadership
369. We did, of course, interview all three medical officers on the staff at Ely. On the administrative side, however, we saw only the present Group Secretary and Hospital Secretary. We did not interview the former Hospital Secretary, who retired at the end of 1966 after 40 years’ service at Ely. We did not feel able, if our Inquiry was to be kept within reasonable bounds, to conduct a detailed investigation of the purely administrative side of the hospital and the group. In this Chapter, therefore, we confine ourselves to an assessment of the present Hospital Secretary and the three medical officers and a consideration of the medical/administrative structure within Ely itself.
The Hospital Secretary
370. The present Secretary came to Ely in December, 1966, and, after three weeks in double harness with his predecessor, assumed responsibility as Hospital Secretary on 2nd January, 1967. He is 48 years old and, apart from six years in the Army during the war, had spent the whole of his working life until he came to Ely on the clerical and administrative side at Hensol Castle, a nearby sub-normality hospital. He was Deputy Hospital Secretary there from 1948 until 1966.
371. He prepared and presented to us a number of memoranda about the administration of Ely and some of the steps which he has taken since he arrived there. Plainly and understandably he has felt inhibited during his first year in office by the fact that he was a “new boy” taking over a concern whose pattern of administration had taken shape during the long term of office of his predecessor. Moreover, the Hospital itself has been overshadowed since the autumn of 1967, by the investigations being conducted by our Committee. The new Hospital Secretary has, therefore, been able to make only a limited impact upon its administration since he came into office.
372. Even in the context of this comparatively limited experience at Ely, however, we have formed the view (which was confirmed by several of those who gave evidence before us) that he is, and is likely to remain, an energetic and effective Hospital Secretary, with a modern and lively approach to his work. He has a real and substantial contribution to make to the future of Ely.
The Junior Hospital Medical Officer
373. The JHMO, who is qualified as LRCP, and LRCS(I) has been at Ely in that capacity since 1956 and is due to retire in March, 1969. Before coming to Ely his only experience of mental hospitals was during a period of some seven or eight months at Hensol Castle in 1955. For about 10 years before, during and after the 1939-45 war, he was on the staff of the Caerphilly District Miners’ Hospital. Apart from that his, experience has been solely in general practice. He makes no claim to specialist knowledge or experience of mental illness or mental subnormality, has attended no specialist conferences or other comparable hospitals, training centres or institutions and reads no specialist literature. He has concerned himself almost exclusively with the organic disorders of his patients, and has not felt himself competent to make any contribution as a psychiatrist.
374. Since 1966 he has been primarily concerned with the male wards of the hospital (while the SHMO has been correspondingly concerned with the female wards). These two doctors have, however, shared the responsibility of providing weekend and night”cover” for both sides of the hospital.
375. The JHMO is the one doctor in respect of whom XY confirmed his initial complaint to the News of the World that he “did not appear to care very much”. XY amplified this by explaining that the JHMO’s ward rounds were conducted more swiftly and casually than those of the Physician Superintendent. He agreed, however, that the JHMO had never failed to examine a patient to whom his attention had been drawn by a ward Charge Nurse.
376. Within the self-confessed limitations of his interest, experience and qualifications, the JHMO cannot be said to have failed in the discharge of his duties. However, we have already referred to the low standard of medical care and record keeping in the male wards. These must be attributed at least in part to the shortcomings in the JHMO’s interest, knowledge and experience. They must reflect also a lack of effort on his part.
377. It is plain that his duties in respect of physical illness could be performed at least as well by general medical practitioners visiting the hospital on a parttime basis for regular sessions, provided appropriate cover for weekends and emergencies could also be arranged. We consider below the extent to which this would be the best arrangement to make when the present JHMO comes to retire next year.
The Senior Hospital Medical Officer
378. No criticism was made before us of the SHMO. As explained above, he has, at least since 1966, been primarily concerned with the female wards, which were outside our main terms of reference. He would seldom have come into contact with XY.
379. The SHMO, who is Polish by birth, commenced to study medicine at Warsaw University in 1935. His studies were interrupted by the war, including a period of detention as a political prisoner. After 1941, however, he commenced (although not formally qualified), to practise medicine with the Polish Army and finally qualified in 1948, as a doctor of medicine at the French University in Beirut. He commenced to practise medicine in this country in 1949 and from 1951 to 1961 was successively Junior Medical Officer and Senior Registrar at two mental hospitals in South Wales. He took the first part of the examination for DPM in 1960 but has been unable to pass the second part of the examination. He came to Ely as SHMO in 1961.
380. As a result of our discussions with the SHMO (which were primarily concerned with conditions in the children’s villas), we formed the impression that he has performed his duties as SHMO and responsible medical officer adequately within the circumstances, which he appears to have accepted. He carries a reasonable clinical load. All his sessions, however, are at Ely, and he has little opportunity to widen his knowledge and experience. (When the Physician Superintendent is on leave, the SHMO does, however, conduct his two outpatient clinics at the nearby general hospital). We question whether the SHMO should not take on, when the opportunity arises, clinical duties for, say, two sessions a week outside Ely in some other branch of the mental health services in the area. He is certainly capable of playing a useful role in the psychiatric work of Ely.
The Physician Superintendent
381. The Physician Superintendent of a hospital for the subnormal has traditionally been regarded as the paramount officer, with overall responsibility for all the services provided for patients by the hospital. He has concerned himself, therefore, with all medical and nursing and many administrative matters. Views on the desirability of the Physician Superintendent exercising such a wide authority have changed during the two decades since the passing of the National Health Service Act, 1946. That he should have overall control was thought at one time to be necessary for the smooth and efficient running of the hospital. More recently, emphasis has been put on the tripartite structure with responsibility shared between senior medical, nursing and administrative officers. Even where there is a tripartite structure, the officer responsible for the medical policy of the hospital has sometimes still been called “the Medical Director”. However, since the Mental Health Act, 1959, gave responsibility in clinical matters to every consultant and others with the status of “responsible medical officer”, the title of Medical Director has become less common, except in hospitals and units where there is only one consultant. When there is more than one consultant, the medical staff has usually been represented by the chairman of the Medical Advisory Committee.
382. These changes have been welcomed in many quarters. They have, or should have had, the effect of giving more authority to the senior nursing officers and Hospital Secretary and have taken many administrative duties out of the hands of consultants, who have, in consequence, been able to devote more time and effort to their clinical work. The consultants have, however, continued to play a part in the management of the hospital.
383.More recently still, opinion in some quarters has tended (not only in mental hospitals) to move away from the tripartite structure referred to above and towards the concept of appointing a single director of the entire hospital medical and other administration.
384. It is not, of course, for us to reach any conclusion about this debate. What is plain is that whichever system is adopted it must be clearly defined, with plain guide lines for all concerned.
At Ely Hospital
385. The Physician Superintendent, the Chief Male Nurse and Matron have not, as noted above, been provided with any standing orders, affording a clear definition of their roles. The Hospital Secretary, however, was provided (at the time of his appointment, early in 1967) with “Particulars” relating to his post, which makes him responsible for all aspects of the general administration of the hospital and provides that his duties will include ” in conjunction with his medical and nursing colleagues planning and co-ordinating the services of the hospital to achieve the most effective use of available resources and ensuring the efficiency of the medical auxiliary departments”. He is given direct managerial responsibility for the service departments of the hospital.
386. In practice at Ely it is clear that functions of the various senior officers have not been defined with sufficient precision. The line between the Hospital Secretary and the Physician Superintendent was described as “sometimes thin, sometimes faint and sometimes wavy”, so that “there are fields where who does what is not very clear”. The Physician Superintendent has continued to exert a wide co-ordinating authority and has concerned himself with nursing and administrative matters as well as with medical policy. His concern with nursing disciplinary matters, for example, is well illustrated by the cases discussed in Chapter VII above. We have the impression that he has begun to play a lesser part in administrative matters since the appointment of the new Hospital Secretary, although he has continued, as we have observed, to take a close interest in nursing matters.
The present Physician Superintendent
387. The present Physician Superintendent is 47 years old and has the following qualifications: MB. BCh.(Wales), 1944, MB. BS.(London), 1945, and DPM. 1955. From 1944 to 1950 he held a series of posts in general hospitals (including a period of two years with the RAF). After a short period in general practice, he was obliged to give this up because of a coronary condition. (The same disability caused him to be absent from work for some eight months in 1958). He was JHMO from 1952 to 1958 in a mental illness hospital at Caerleon and thereafter SHMO in mental illness hospitals at Bridgend and Caerleon, until he came to Ely as an SHMO in November, 1959. He was appointed consultant and Physician Superintendent at Ely in March, 1961.
388.Every witness who spoke of the Physician Superintendent testified to his kindness and to the high regard in which he was held throughout the hospital. XY himself expressed warm approval of him, and withdrew completely the criticisms in this respect which were (erroneously) attributed to him in the News of the World statement. The Physician Superintendent plainly takes the view that it is his duty to perform a service to the community to the best of his ability, within the conditions and with the facilities which are available to him. He has no doubt played his part in implementing the improvements of medical care, to which we refer in Paragraph 362 above.
389. He very rightly denied any suggestion of indolence on his part but accepted that he might have been too easily satisfied with a state of affairs which he found to exist. In this sense he must have been aware of the low standards of medical care at Ely (discussed in Chapter IX above) and also of the low standards of nursing care (discussed in Chapter VI above)—although no doubt without a detailed knowledge of every matter to which we have referred in that Chapter. He has also been responsible for supervising the work of the JHMO. We think that he was aware of the low standard of this work in some respects and that he did too little to express his dissatisfaction with the efforts the JHMO was devoting to his work and to reduce his lack of knowledge. We suppose that he was not fully aware as to how low the standards were, since he has probably not kept himself informed about developments at other similar hospitals elsewhere in the country. Whatever the explanation, he does not appear to have exercised sufficient initiative to bring about the necessary improvements within the hospital itself. Nor does he appear to have brought to the notice of the HMC or the RHB with sufficient strength and emphasis the extent to which facilities and amenities at the hospital have fallen far short of those attainable. Thus, for example, he appears to have accepted too readily the difficulty in securing hostel accommodation for patients who could have been discharged from the hospital and, correspondingly, the consequent over-crowding of the hospital, probably because he was, as he himself put it, “too soft-hearted” when particular admissions came to be considered. Again, by way of example, he did discuss the circular HM(65)104 at a meeting of the Group Medical Staff Advisory Committee on 7th January, 1966; but he took no steps to see that the circular was considered by the HMC, who for this amongst other reasons remained ignorant of the circular. Finally, on the matter of nursing discipline—for which, in the peculiar conditions prevailing at Ely, he had an ill-defined de facto responsibility, he, like everybody else concerned, was not alert to the implications of the “U” /”T” /”B” incidents discussed in Chapter 5 above nor to the possible implications of the way in which they were investigated.
390. In a sense this is much too harsh a judgement on the present Physician Superintendent. He is, we repeat, a kindly and, within his limitations, conscientious man, popular with patients and staff alike, whom it is impossible not to like. But he has had an insufficient appreciation of his necessary role as a spur to the improvement of conditions and as a potential champion of Ely. He is the man responsible for the professional quality of medical services provided at Ely and so the man to whom the HMC must look for initiation of modern methods of patient care. And for the last seven years he has been the principal medical adviser to the HMC. It must be acknowledged that it was his duty, in that capacity, to say to the HMC over and over again, that the conditions prevailing at the hospital were unsatisfactory. In the same sense it was his duty to give the necessary stimulus and encouragement to his medical colleagues.
Medical Staffing Structure
391. In the light of our discussion of the role of Physician Superintendent and of his personal qualities, we recommend a stricter definition of his role. There is a similar need to define more clearly the duties of the senior nursing officers and the Hospital Secretary, so as to ensure that their responsibility in nursing and administrative matters is not blurred by the continuance of a tradition, which has been given up for sound reasons in many other places.
392. As a consultant he has the right to be consulted in all matters affecting the care and treatment of the patients in his charge and to the continuance of his plain medical responsibility for such matters. He has much to contribute in the training of nursing and other staff working with patients. But the responsibility for the control and direction in nursing and administrative matters should not be his, but should lie with the senior nursing officers and Secretary respectively. It might be appropriate to give him the title of Medical Director, as he is the only consultant at present working regularly at the hospital. To do so might, however, lead to difficulties if in the future other consultants assume responsibility for patients in Ely. His status is, we think, sufficiently assured by his consultant appointment, without the necessity for giving him the title of Medical Director.
393. The SHMO has had the status of “responsible medical officer” under the Mental Health Act, 1959; but the Physician Superintendent has been the only consultant working regularly at the hospital. As such, he has carried a heavy load clinically as well as administratively. His consultant colleagues at Whitchurch Hospital have covered for him while he has been on leave, but have not contributed to the routine clinical work of Ely. No other consultant has visited the hospital regularly. We have noted the arrangements that have been made for a paediatric consultant to visit Ely regularly. These arrangements will give some relief if the paediatric consultant assumes an on-going clinical responsibility for a group of patients. We question whether the Physician Superintendent should not be given further support at consultant level. One way of achieving this would be to give another psychiatric consultant the clinical responsibility for psycho-geriatric patients at Ely. It would certainly appear desirable, in this or some other way, to diminish the extent to which Ely appears to work in isolation from the other more prestigious psychiatric hospital in the group.
394. We note, without making any recommendation, that the Group Medical Staff Advisory Committee has recommended that the post of SHMO at Ely should be recognised by the RHB as one of consultant status and not as that of “Medical Assistant”, in view of the duties of Deputy Physician Superintendent which are attached to it. The designation will not become an immediate issue until the present SHMO leaves the hospital. The Whitchurch and Ely Hospital House Sub-Committee recommended, on llth November, 1965, that this recommendation should be brought to the attention of the RHB.
395. We have indicated in Paragraph 376 above our view that some of the duties at present performed by the JHMO could equally well be performed after his retirement by general practitioners on a part-time basis. On 7th September and 12th October, 1967, the HMC endorsed the recommendation of the Group Medical Staff Advisory Committee that he should be replaced in due course by a Medical Assistant (who would have specialised knowledge), with an increase in the establishment by a Clinical Assistant, giving seven sessions per week. The RHB approved this in principle on 30th November, 1967, suggesting that it should be financed from the HMCs own budget.
396. The standards of medical work at Ely are at present too low for the hospital to be regarded as a suitable place for the training of registrars in psychiatry. Yet it would be reasonable to make an arrangement by which registrars based at Whitchurch Hospital, who are being given comprehensive training in psychiatry, should spend, during some part of their training, two sessions a week or so at Ely, where they could be given a limited responsibility for the development of some part of the work at Ely.
Additional
397. In our comments on medical staffing structure, we have had in mind that Ely, a hospital of some 600 beds, has depended upon a medical staff of only three doctors. Two of these doctors have worked full-time at Ely. The Physician Superintendent has spent two sessions or so outside Ely. With this limited exception, the medical staff have played no part in other components of the mental health services of the area. This we believe has led them to accept rather narrow attitudes towards their duties in the care and treatment of patients. It is for this reason that we have suggested that the SHMO should spend a certain amount of time outside the Hospital. There would also be advantages in including more doctors in the work at Ely—the psycho-geriatric consultant, the paediatric consultant and the psychiatric registrar. We think that the medical staff at Ely should be brought into a much wider medical community.
398. We do not make any specific recommendations about the overall level of medical staffing at Ely. Clearly it has been barely sufficient to provide even a modest level of clinical service. Implementation of the proposals we have discussed would increase the amount of medical work at Ely. Any recommendation about the medical establishment at Ely should take into account the medical staffing of the mental health services of the area, and this matter lies outside our terms of reference.