Chapter 11 of Report on Ely Hospital

The Hospital Management Committee

399. It is necessary now to consider, so far as is possible on the evidence before us, the responsibility of the HMC for the various matters which we have had to criticise. In this context, it must be understood that we refer not only to the present Group Committee (which came into existence in April, 1965), but also to the Whitchurch and Ely Hospital Management Committee, which controlled Ely until that date. In the same sense it will also be impossible for us to distinguish clearly between the responsibility of the HMC itself and that of its administrative and other officers, who are, in fact and in law, the HMC’s advisers, servants and agents. Here too it must be borne in mind that most of them came into their present posts only three years ago, at the time of re-organisation. It is no part of our purpose in this section to criticise particular individuals but only to examine the way in which the system has worked in practice. Our examination is far from exhaustive. In particular we exclude—in the absence of sufficient evidence—any consideration of the system of financial administration and control.

Nature of Responsibility

400. A number of the matters which have caused us concern are plainly the primary responsibility of particular hospital officers. We refer, for example, to the responsibility (discussed in Chapters VI, VII, IX and X above) of the Chief Male Nurse and Physician Superintendent for standards of nursing and medical care. But there is a more pervasive atmosphere about Ely, summed up in Mrs. “Z’s” phrase about the “perpetuation of inertia”, which must be regarded as the prime responsibility of the HMC.

401. It is true that the duty “to promote the establishment… of a comprehensive health service” is laid, by the National Health Service Act, 1946, upon the Minister and that, just as Hospital Boards discharge their duties” on behalf of the Minister, Management Committees act “on behalf of” the Board. Thus a Management Committee is strictly no more than a sub-agent of the Minister himself. But the Act defines a Management Committee’s duties precisely as “to control and manage” their hospitals. And the early Ministry Circulars (see, for example, RHB(47)1 and HMC(48)1, emphasised that Committees were to enjoy “the maximum of autonomy in regard to local day-to-day administration” and “a real measure of responsibility within their own sphere “. It was stressed that the ultimate power of the Minister and the Boards should be exercised “as infrequently as possible” and that Management Committees would “inevitably have a part to play in the development and improvement of their hospitals as well as with their management and control”. We were told that the RHB had, from its inception, followed the spirit of this advice and delegated the maximum degree of autonomy to control and manage hospitals to the Management Committees. This position has subsisted to the present time. Subject, therefore, to some confusion (to which we refer in Paragraph 440 below) about the way in which responsibility for initiating change is divided between the HMC and its officers, there is no doubt that the HMC is the body that has the primary responsibility for the overall standard of the facilities provided at Ely.

Matters of Concern

402. In this context, almost all the matters discussed in the earlier Chapters of this Report fall, to a greater or lesser extent, within the HMC’s area of responsibility: standards of nursing care and discipline; the establishment, status and training of staff; investigation of, and reaction to, complaints or other adverse reports; over-crowding and standards of amenity on the wards; the lack of occupational therapy or other activity for patients; and the absence of clearly defined areas of responsibility for each of the hospital officers. We have had much that is critical to say on each of these matters. One of the most disquieting features of this scene at Ely is summarised in the following answers given by a senior member of the HMC at an early stage of our proceedings: —

Q. Have you always been perfectly happy about what you have seen here?

A. Perfectly.

Q. In fact, you did a long inspection of the hospital yesterday?

A. Yes.

The responsibility of the lay member of an HMC, it has been said, “is first and foremost to the patient, whose representative, in a sense he is”. (The Work of the Management Committee Member (2nd Edition), IHA 1960.) It is his responsibility to assure himself, so far as he can, that an adequate and up-to-date patient service is available. In this context, we shall now consider briefly the activities of the HMC on some important, representative matters.

(A) Nursing Staff Establishments

403. We have noted in Paragraphs 247 to 252 above, the inadequacy of the nursing establishment on the male side at Ely, which was last reviewed by the RHB in July, 1965. We asked to be shown any available HMC minutes dealing with this topic and the following came to light: —

15th October, 1965: Extract from Rota Visitors’ Entry in Hospital Visitors Book: The staffing situation is deteriorating and calls for urgent attention. We suggest a review of the establishment

21th April, 1966: Extract from Rota Visitors’ Report: Suggested that the hospital should apply forthwith for an increase in domestic staff (cleaners). Twelve additional cleaners would appear to be desirable.

(As noted in Paragraph 234 above, this recommendation has been partly implemented: 4 of the extra cleaners suggested are in post on the male wards).

9th June, 1966: Extract from Minutes of Whitchurch and Ely House Sub-Committee: It was noted that there is a shortage of trained nurses on the female side which is offset by the employment of additional nursing assistants, while on the male side the shortage is of nursing assistants.

10th November, 1966, and March, 1967: Female nursing establishment considered. In light of ‘the present financial position” recommended that no action be taken but noted that the greatest contribution could be made by the establishment of a nurse training school at Ely.

As noted in Paragraph 252 above, the male nursing establishment has not yet been reviewed. The Chairman of the HMC was not able to tell us the staffing ratio at Ely but expressed the view that the hospital was short of qualified nurses but “reasonably staffed” with nursing assistants.

(B) Nurse Training

404. The total absence of any induction or in-service training for nurses at Ely is noted in Paragraphs 255 and 256 above. Relevant minutes and other documents reveal the following recent history: —

15th October, 1965: Extract from Rota Visitors’ comments (see above) We suggest… encouragement of visits by staff to other hospitals, confer­ences, meetings etc., the establishment of a Training School . . .

9th June, 1966: Extract from Minutes of Whitchurch and Ely House Sub-Committee: The Group Secretary reported that preliminary talks had taken place between the senior officers concerned and the nursing officer to the RHB on the possibility of initiating nurse training facilities at Ely.

31st July and 30th August, 1967: Correspondence about Mrs. “Z’s ” report to and from Group Secretary (summarised in Paragraphs 243 and 244 above). Group Secretary writes: “With regard to in-service training the possibility of a training school was explored several months ago, but without school facilities and better wards and other departments, we had long ago realised that recognition of Ely by the General Nursing Council would not be forthcoming”.

405. It appears that this correspondence—including Mrs. “Z’s” report itself—had not been considered either by the HMC itself or by the Whitchurch and Ely House Sub-Committee. The position about nurse training at Ely remains as noted above. The Chairman of the HMC expressed to us the view that the quality of staff at the hospital was ” very good “.

(C) Occupational therapy

406. The HMC’s consideration of this topic is set out in reasonable detail in Paragraphs 355 to 359 above. It appears that no further action to increase the provision of occupational or other therapy, on or off the wards, has been considered until the establishment of the projected occupational/industrial therapy centre. (Construction of which is due to commence in 1969).

407. The Chairman of the HMC told us that he did not know whether or not there was an occupational therapist on the staff of Ely. And another senior member of the HMC gave us what seems to be a revealing insight into the HMC’s attitude when he said that the staff at Ely “treat their patients here just like children, and children they are. There is an end product at Whitchurch; they do get better and go out; they have industrial therapy”.

(D) Over-crowding

408. The extent of over-crowding on the male wards has been noted in Paragraphs 338 and 345 above. We have also indicated the extent to which these wards, as well as the children’s villas (see Paragraphs 140 and 353 above), are in any case designed to accommodate many more patients than the maximum of 30 and 20 respectively recommended in Circular HM(65)104. This is a subject which has greatly exercised the HMC for a number of years. It is a matter for consideration how far the action now proposed is likely to abate the problem. The recent history appears to be as follows : —

September, 1963: HMC approved and submitted proposals to build two 50-bedded villa-type wards to replace wards 17A and 17B (which were to be converted into general stores) and a 50-bedded adolescent unit; estimated cost £420,000.

February, 1964: HMC Rota Visitors reported over-crowding in all the male wards and recommended that the needs of the hospital, “which are urgent, should be brought to the notice of the RHB immediately”.

June 1964: HMC resolved, in view of the “urgent . . . need for additional patient accommodation” and “serious over-crowding” to press the RHB for money to be made available for the foregoing capital projects (amongst others) now “outstanding for many years”.

July 1964 1 January 1965: HMC repeatedly expressed themselves very concerned at the continued over-crowding and the urgent need for the accommodation requested. This was said by the RHB to be included in their programme (First Amendment to Cmnd. 1604) but it was not possible to say when the scheme was likely to commence. The HMC expressed their view that the accommodation was “immediately essential “.

December, 1964: HMC first suggests the acquisition from Cardiff CB of the adjacent Children’s Homes, to be used for the purpose of relieving over-crowding at Ely. The RHB replied that the matter was ” under active consideration and . . . will be continuously reviewed “.

May- July, 1965: HMC, its Chairman and officers took every opportunity of pressing the RHB as to the urgency of providing the extra accommodation required to relieve over-crowding; and suggested (see Paragraph 340 above) that “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 “.

16th December, 1965: Reported to HMC that the Ely “major rebuilding scheme” was likely to commence in 1969.

June, 1966: The 3 50-bedded units approved and submitted in September, 1963, were re-submitted; estimated cost £504,000 (an increase of 20%).

13th October, 1966: HMC expressed concern at “lack of progress” in acquiring the Children’s Homes.

10th November, 1966: The case prepared by the RHB for Phase 1 of the Development of Ely was approved by the HMC. This provides for 3 new 30-bedded wards “to provide accommodation for mental sub-normality in addition to that in the existing hospital”. Apparently none of those wards is intended for use as the proposed adolescent unit.

9th March, 1967: Foregoing proposals approved by Welsh Board of Health.

24th April, 1967: HMC Rota Visitors report, with details, the fact that the 3 male wards then visited were “very over-crowded “.

8th February, 1968: Reported to HMC that the Children’s Homes should be transferred to Ely later in 1968 and that the RHB had been invited to consent to the use of this accommodation to relieve over-crowding.

409. It was made clear to us that the Welsh Board of Health’s approval of the 3 new 30-bedded wards proposed at Ely was given upon the basis that they would be used to provide additional beds for mental sub-normality, since it is intended that Ely will be providing 606 beds of this kind by 1975—as compared with the present figure of 422. None of the 90 extra beds proposed will, therefore, be available for the relief of over-crowding at Ely.

410. Thus, despite repeated pleas by the HMC during the last four years at least, the only prospect of relief for serious over-crowding at Ely is to be found in the possibility of finding extra accommodation in the Children’s Homes (when, and if, these are transferred later this year) and not at all in the first phase of the hospital’s development programme, as so far approved.

411. We do not know what accommodation the Children’s Homes would provide, nor how far advanced are the H.M.C.’s plans for redistributing patients when the Homes become available, nor what effect their availability will have on the rebuilding programme. But additional accommodation will do something to relieve Ely’s problems, only if there is a corresponding increase in staffing.

Effectiveness of HMC

412. In the four representative fields which we have considered—nursing establishment, nurse training, occupational therapy and over-crowding—it is apparent from the history which we have recorded above that, although they have been intermittently aware of substantial short-comings in all these respects the HMC have not in fact achieved any significant progress towards an improve­ment in standards.

413. They scarcely deserve to be criticised in respect of their efforts to relieve over-crowding. In this respect they have, in the result, been largely frustrated by “the system “—itself understandably restrained by the chronic shortage of money. And their frustration in this respect has no doubt done something to induce a feeling of hopelessness in other directions. Thus a medical member of the HMC explained to us that any scheme for linking Ely with Whitchurch for nurse-training purposes would not “come off the ground” until “Ely is replaced”. And the Group Secretary explained that he “came into this only three years ago and it would not be right for me to turn the place upside down in three years”. This attitude is, in some respects, understandable. But if it is allowed to persist it will mean that many of the essential, and practicable, improvements at Ely will be postponed until the Greek Kalends.

What can be done

414. Fortunately, in some respects, it is apparent that a substantial part of the inertia which we have identified can be traced to specific, and remediable, causes. The most important are as follows: —

(A) Committee Structure

415. Since the establishment of the Group HMC in April, 1965, one house committee has served both Whitchurch and Ely Hospitals. This has thus continued, in form, the pre-1965 Whitchurch and Ely HMC. But whereas, the former HMC used to meet on alternate months in each of the 2 hospitals for which it was responsible, the post-1965 Joint House Sub-Committee has always met at Whitchurch. During the last three years, there has been no regular meeting of the HMC, nor any of its sub-committees, at Ely. Moreover, the title “House Committee” is in this context something of a misnomer; for the membership of the Whitchurch and Ely House Sub-Committee has been the same as that of the entire HMC (although a different person has been designated Chairman of the House Sub-Committee) and the House Sub-Committee has been regularly scheduled to meet (along with all the other sub-committees of the HMC) on the same monthly morning as the HMC itself. Typically, the Gardens, Engineering and Works Sub-Committee has been timed to start 10 minutes after the Whitchurch and Ely House Sub-Committee. And the monthly business of all committees and sub-committees is customarily completed in about 2 hours.

416. This attempt to involve all members of the HMC in every aspect of management seems to have prevented the accumulation of adequate or specialised knowledge of specific topics and interests; and the condensed time-table to which we have referred must have made it difficult for any subject to receive extended or stimulating consideration.

417. In particular, Ely appears to have fallen between two stools: —

(a) It has not been possible, as we were told, to identify any particular members of the HMC who were closely associated with and “batting for” Ely in particular. It has been and remained a “poor relation ” within the Group and has not received the help, which we were told it needed, to “ask for more”. Thus although the HMC has undoubtedly been aware of and sympathetic towards its plight, Ely has had no specific champions, no “pressure group” to argue its case;

(b) Ely does not, on the other hand, appear to have benefited from the fact that it is, and has been for 20 years, part of a Group which has included (amongst others) a mental illness hospital of high repute, Whitchurch. Thus the advice contained in Circular HMC(48)1, that an HMC “should administer the group as, essentially, a single whole” and “seek to develop … a unified system of staffing ” has been insufficiently developed in practice. And yet the need for such unification has been increased by the enlargement, in April 1965, in the size of the Group. The absence of close and effective co­operation between the two mental hospitals (with widely differing reputation) over such matters as nursing administration, nurse training and medical care means that Ely has been denied the advantages that are meant to flow from group administration. As the Physician Superintendent told us, he “does not honestly think that it makes much difference” to Ely to have had a large psychiatric hospital within the group.

418. Fortunately, this diagnosis of one cause of Ely’s troubles has now been made by the HMC itself. Discussions which began in April, 1967, have led to the conclusions, infer alia, that: —

(a) ” The existing pattern left no room for matters other than finance and staffing to be dealt with except through the HMC itself “;

(b) ” If the HMC were to be the “ public relations officer’ between the hospitals they serve and the public served by the hospitals there is little opportunity to feed the members with hospital information at present”.

(c)” There have been occasions when time has not permitted full discussion on all matters “.

419. In consequence, the recommendations of a Special Sub-Committee have been adopted (to come into effect on 1st April, 1968) whereby a small number of HMC members are to act as House Committee to each hospital, spending a whole day each month at their hospital, visiting as much of the hospital during the morning and meeting in the afternoon with the senior hospital officers to consider reports and to make recommendations.

420. This change represents an important step in the right direction and should go far to eliminate one of Ely’s principal difficulties (discussed in Paragraph 417 (a) above). The new system will need to be supplemented if Ely’s other main trouble—its actual and appreciated isolation (see Paragraph 417 (b) above) is also to be overcome.

(B) Reports from officers

421. As we have noted in Paragraph 268 above, the Matron and the Chief Male Nurse have not in the last 12 months attended regularly at meetings of the House Committee. Nor have they been required to submit written reports. There was no communication or report from them, for example, in two typical agenda which we were shown for February and March, 1967. And they have seldom, if ever, submitted written requests to the HMC or House Committee. Both the senior nursing officers and the HMC have thus had little chance to appreciate each other’s anxieties or point of view.

422. The Physician Superintendent, on the other hand, has submitted regular reports. But those which we have seen were short, contained very little information and no requests or recommendations for action.

423.The Hospital Secretary’s reports appeared to be equally sparse and largely confined to such matters as the gardens (a disproportionate part of the HMC minutes appeared, in the circumstances, to be devoted to gardening and marketing matters).

424. It is plainly important to establish the major role that should be played, in connection with the general standards of care for patients, by full, regular (and, if necessary, insistent) reports from the hospital’s senior officers. The new House Committee system, discussed in Paragraph 419 above, should help in this respect. But it will be important for matters raised in such reports to be effectively minuted and carried forward for action.

(C) Action on matters raised

425. We have referred, throughout this Report, to a number of Ministry Circulars, containing specific advice and instructions for action by HMCs. In particular, we have referred repeatedly to Circulars HM(64)45 and (65)104 on improving the effectiveness of hospitals for the mentally ill and sub-normal respectively. Although neither of these circulars was printed on pink paper (the indicator of the need for a Circular to be expressly considered by HMC members), HMCs were expressly required to act upon each of them.

426. In fact, Circular HM(64)45 was apparently never circulated to or considered by the old Whitchurch and Ely HMC. (The Chairman of the HMC did, however, claim to have received it; but, he said, “we have not taken any action yet that I am aware of on this particular document”). And, although the necessary extra copies of Circular HM(65)104 were obtained, they never reached members of the Group HMC. It is true that the Physician Superintendent was invited to, and did, report on this circular to the Group Medical Staff Advisory Committee. His report (made on 7th January, 1966) is minuted as follows:—

” Hospitals for Mentally Sub-Normal : [The Physician Superintendent] spoke on the Ministry Circular recently issued which suggested ways in which, without major building improve­ments, much could be done to improve the effectiveness of these hospitals”.

427.This was one of 17 matters discussed at the meeting. No recommendations were made; and the matter was not, apparently, reported to the HMC.

428. Thus two of the most important recent Circulars, affecting the two largest hospitals in the Group, have never been seen, still less considered and used as a basis for self-criticism and action, by the HMC.

429. In the same sense, we have noticed (Paragraph 258 above) that the Chief Male Nurse only became aware in the course of our Inquiry of the relevant Circular (HM(55)49) on the training of nurses; and (Paragraph 329 above) that the Hospital Secretary was considering laundry arrangements in May, 1967, after his “first reading” of HM(60)1 and HM(63)52. These three Circulars, between 4 and 12 years old, do not seem to have made any earlier impact on Ely.

430. There is something of the same quality about the reaction to Mrs. “Z’s ” report, which appears to have been bedevilled by considerations of protocol. It emanated, of course, from an office of the Welsh Board of Health and reached the HMC through the RHB. It was considered by “representatives and senior officers of the HMC” but never apparently by the HMC itself. And, although the people referred to felt that Mrs. “Z” “should take the opportunity of having further discussion with them on these matters “, neither side felt able to take any formal initiative towards arranging any further meeting.

431. We have been similarly disquieted by the way in which the various matters reported by Rota Visitors, or brought before the HMC in other ways (see the matters illustrated in paragraphs 403 to 408 above) do not appear to have been the subject of further renewed or continuous consideration. The appropriate minutes do not seem to have been carried forward for further consideration until effective decisions for action have been taken and carried through.All these matters betoken an ineffective system of administration. When this is remedied, as it must be, Ely should begin to feel the benefit of the various spurs towards progress from which so far it seems to have been largely shielded.

(D) Rota Visiting

433. If visits are to serve a useful purpose they must be made by those who possess a satisfactory background knowledge of the hospital and its working and the needs of the individual patient. There are, it has been suggested, (The Work of the Hospital Management Committee, Op. Cit.) three specific purposes for such visits: —

” (i) to obtain a clear picture of the hospital and its work;

“(ii) to meet and become acquainted with the staff; and

” (iii) to carry out, from time to time, some form of inspection “.

434. How far, by these standards, has the rota visiting of Ely been effective?

XY was candid in his view of this: “I saw some of the members of the Committee coming every three or four months here. I am not making an accusation, of course. I am just saying how I came to the conclusion to say these things. They were coming in, seeing one or two of the senior staff, walking from one ward to the other, not asking the junior staff how they liked their job, or creating an atmosphere of co-operation or respect … I have no doubt that the Management Committee are very good at their jobs outside, but here they are ineffective. . . . There is no point in them coming around. Because they do not interest themselves in anything. They see (the Chief Male Nurse) or if they go into the wards, the Chief Nurse. They come round, pass through the door, and finish. What they are interested in is: “You have got a very nice shining floor’ “. XY was not the only member of the staff to have formed this impression. How far was it justified in fact?

435. The system of visiting in force until recently was designed to secure that each hospital in the Group was visited quarterly by a different pair of visitors. With seven hospitals and one clinic in the Group this means that any one member of the HMC would have visited Ely about once every twenty months. In line with this, a medical member of the HMC who gave evidence to us had visited Ely on three occasions in five years. And the Chairman of the HMC had visited Ely three or four times in the year before he gave evidence. All except one of his visits had been concerned with a particular topic or complaint. It was only on his one rota visit that he had spent any time in the wards— the female wards, as it happened, where he had spent about an hour. He did not regard it as part of the rota visitors’ function to “inspect” the wards. His principal purpose appears to have been “to talk to the patients “. (This is, of course, acceptable in itself but should not be the main concern.)

436. We have noted in Paragraphs 259 and 355 above a number of instances when rota visitors, in their reports, have raised such topics as the need for more therapy for patients or for training of the staff. It has been seen that these reports have seldom led to effective action on the matters raised. Once discussed, the reports seem to have been filed and, with few exceptions, forgotten. Moreover, there seems to have been no pattern about the visiting. Thus, for example, Wards 7 and 8 were seen twice between April, 1966 and April, 1967. But Ward 23 and Villa 2 were not apparently seen at all during that twelve month period. And it is plain that a number of more general matters which have caused us concern, have not been the subject of any report at all from any of the rota visitors. We do not, of course, overlook the fact that HMC members are—in many cases—lay people, who depend upon their officers for professional or technical advice. But, as the body representing the consumer, they should themselves have acquired sufficient knowledge and experience of the work and objectives of their hospitals to be able at least to ask the right questions and to bring the right degree of informed opinion to bear upon the standard of service provided. We cannot escape the conclusion that the HMC members who have been visiting Ely have lacked a true appreciation of their role, and the knowledge and confidence that is needed to make it effective.

437.In the upshot, we must conclude that the system of rota visiting that has been followed has been ineffective and has served little useful purpose. The following particular defects appear: —

(a) There has been no pattern of visiting to ensure that all sections of the hospital are visited regularly, even by different visitors.

(b) The number of visits per member of the HMC has not enabled members to obtain a clear picture of the hospital.

(c) Only senior members of the nursing staff have apparently been drawn into discussion with visiting members of the HMC. Neither by visits nor in any other way have junior nurses or assistants been given the impression that their views are to be taken into account. Without the essential bond of confidence that should in such a way be created, it is not surprising that XY should have formed the view that he did. It is in such a setting that he came to feel (and again it is not surprising) that his anxieties could not be made known, and would not be heeded, within the system—and so decided to enlist the help of the Press.

(d) No effective inspection has been carried out. Such matters as the inactivity of patients on the wards have gone largely unremarked. And those that have been observed, and made the subject of adverse reports, have for the most part continued to remain without effective remedy.

438. It is thus imperative that a more positive and purposeful system of rota visiting should be established. It was in fact decided on 25th October, 1967, that each hospital in the Group should be visited by the same pair of members throughout a period of 12 months so that they could become more closely identified with patients and staff of their “adopted” hospitals. This again is a step in the right direction, though its relationship with the new pattern of house committees (see Paragraph 419 above) will need to be closely considered. And the effectiveness of each visit will have to be sufficient to deal with the matters to which we have referred. In particular, it must be appreciated that no pattern of visits will suffice unless the visitors are thoroughly well informed and conversant with a modern view of all aspects of patient care.

(E) Division of Responsibility between HMC and its Officers

439. We have already identified the way in which little pressure for modernisation and improvement appears to have been generated from within Ely itself. There were, of course, no members of the HMC with special responsibility for the hospital (see Paragraph 417(a) above). And such machinery as did exist to enable the hospital’s officers to press their case was insufficiently exploited. Why then did pressure for change not come from above, from Group level?

440.Quite apart from the deficiencies discussed in the immediately preceding paragraphs of this Report, there seems to have been some misunderstanding of the division of responsibility between the HMC and its own officers. The Chairman of the HMC told us that as far as his knowledge of the hospital was concerned he had to rely on his Group Secretary to keep him informed. And the matter was presented to us on behalf of the HMC (upon the basis, for example, of Paragraphs 17, 28, and 31 of the Ministry Handbook for Members of Hospital Management Committees (1966)) to the effect that the HMC was dependent upon the advice which it received from its officers and specialist advisory Committees and was responsible for management rather than initia­tion. “It is no part of the duties of the HMC”, we were told, “to try and do executive work themselves; they are not expected to go round ferretting things out unless something is brought to their attention”.

441. This attitude means that when, as here, the relevant Ministry Circulars are not brought to the attention of the HMC and the Medical Staff Advisory Committee initiates no advice upon those Circulars which it does consider (see, for example, HM(65)104 in Paragraph 426 above) and no external inspection of the hospital (see Paragraphs 460-467 below) effectively exists to alert the HMC to any shortcomings, the outcome will be, at best, a policy of “steady as she goes”.

442. This position is quite unacceptable. Yet it can apparently arise from a misunderstanding of the distinction of roles that is made in Paragraphs 28-31 of the Ministry Handbook, quoted in Paragraph 440 above. If the HMC and the officers look to each other to take initiatives and to “give a lead” and neither does so, then it appears easy for a hospital like Ely to continue sailing along a course on which it remains entirely outside the main stream of progress.

443.A substantial part of the responsibility for this state of affairs can, as was suggested to us on behalf of the HMC, be laid at the door of the system within which they work. It is plainly one which can allow responsibility for progress to be accepted by nobody.

444.But the majority of hospitals have not suffered in this way. This must be because their HMCs have been more aware of their responsibility (as suggested in the Ministry Handbook quoted) for “encouraging “, “stimulating ” and ” giving a lead ” towards the achievement of higher standards. We cannot, therefore, resist the conclusion that the HMC responsible for Ely has lacked the necessary enthusiasm or experience or awareness of what can and should be achieved and has failed to adopt a sufficiently dynamic approach to its task.

Composition of HMC

445. In light of the view expressed in the preceding paragraph and of some of the evidence given to us, we feel obliged to undertake some consideration of the composition of the HMC. We do so with some hesitation since we did not, of course, have the opportunity of meeting all its members. And we are very conscious of the fact that they have all accepted an invitation to perform an important public service without reward and without having put themselves forward in any form of election. We do not in the least underestimate their sense of civic responsibility.

446. The facts about the composition of the HMC as at 31st March, 1968 (when there were two vacancies due to death and resignation), are as follows:

Age : Half the membership of the HMC was more than 60 and one quarter more than 70 years old; 3 were in their forties; the average age was 60 years old.

Length of Service :

20 years …………………..1

More than 15 years………2

„ „ 10 „ ……………………4

,, 5 ,, ……………………..3

Less „ 5 „ ………………..6

447. Membership was more or less equally divided between lay and professional members. Five members were, or had been, local authority members (four of the seven oldest members were in this category). The Glamorgan and Cardiff Executive Councils had one “representative ” apiece. There were three “representatives ” of senior medical staff (including two of the three members under 50 years old). Other organisations represented included :

British Dental Association.

Royal College of Nursing.

British Red Cross.

St. John’s Ambulance.

Welsh Hospital & Health Services Association.

Staff Associations.

448. The Staff Association’s representative was the retired Secretary of Hensol Castle sub-normality hospital. He appears to have been the only professional member of the HMC with extensive knowledge of sub-normality, having given long service in what must now be regarded as the old era of “custodial care”. The medical member of the HMC whom we were invited to interview was plainly first-class in his own specialty of mental illness but acknowledged that he had never visited any hospital or training centre for the sub-normal apart from Ely. The Chairman of the HMC, 66 years old, is a former member of Cardiff CB Council, a Justice of the Peace, and concerned inter alia with the government of the National Museum of Wales and the control of civil defence in Cardiff.

449. It will be apparent from what we have to say in Paragraph 455 below that the inclusion of senior local authority representatives on the HMC has not been effective to secure co-ordination between the different branches of the health services for the sub-normal. (This is, as we demonstrate, largely due to the fragmented organisation of the service). But it has meant that many members of the HMC are exceptionally busy people, with many other public commitments. It will also be apparent from all that we have said above that the HMC does not appear to have been dominated by any well informed or single minded enthusiasm for improving the standard of care for the mentally sub­normal in particular. The recent transition from the idea of custodial to that of community care means that a lively awareness of the modern approach is more than ever essential in an HMC that has responsibility for a large group of mixed hospitals.

450. In these circumstances we consider that the RHB should give con­sideration to: —

(a) The organisation of a course or series of conferences designed to ensure that HMC members have a more specialized knowledge of the needs of mentally sub-normal patients and that full account is taken of the guidance regularly available from the Ministry and elsewhere.

(b) Extension of their list of “other organisations” to be consulted when making nominations to the HMC. More account might well be taken of the university and other educational institutions in the locality, and of voluntary organisations with a special interest in sub-normality, with a view to introducing different kinds of expertise to the HMC.

(c) A reduction in the apparent emphasis, when nominating HMC members, upon age and experience. Although we do not go all the way with one witness who suggested that most HMC members had largely “shot their bolt” after two terms of office, there is, in our judgment, much to be said in favour of a deliberate attempt to recruit to the HMC a number of younger members, who are less burdened with other public responsibilities and, with the right guid­ance, could do much to promote a more modern approach. It is often too easily assumed that such people are not available.

451. We have not regarded it as part of our duty to consider more fundamental questions, which were raised before us, about the entire basis upon which HMCs are appointed : their difficulty in combining the role of “consumer representatives” with that of management; the extent to which, if at all, professional members should regard themselves as the “watch dogs” of special interests; and the possibility of replacing the present large HMC, composed of part-time, unpaid members with a more compact, semi-professional body. These suggestions will, no doubt, be considered elsewhere, in the light of our other conclusions.