More General Matters
452. A number of the matters discussed above caused us to investigate (although not, of course, as fully as possible without going outside our terms of reference) some more general matters on which we feel justified in making recommendations. These are the subject of this, our final, chapter.
Community care
453. We have indicated (in Paragraphs 350 to 351 above) certain difficulties which have arisen in connection with the need to find local authority hostel accommodation for patients who are suitable for this. And (in Paragraph 151 above) we have referred to the way in which at least one young patient came to be admitted to Ely, as a kind of holding centre while other authorities came to a decision about the way in which he should be accommodated. This suggested to us that the co-ordination of services for the sub-normal provided by different health authorities in the area of Ely left some room for improvement.
454. One possible reason for this appeared in the lack of clarity until recently in the definition of a catchment area for the hospital itself. This became apparent in the following way: —
(a) A document prepared by the RHB on 3rd May, 1966, containing a “Statement of Need concerning the development of Ely Hospital” (which is itself the basis of the first phase of the hospital’s development programme) noted that it was not possible to define exactly the catchment area for a hospital for the mentally sub-normal but had regard to a presumed catchment area that included:
Cardiff CB. 260,170 (population, 30th June, 1965) The whole or part of 8 ” second-tier ” authorities in Glamorgan 192,3677(population, 30th June, 1965)
Total 452,537
(b)The same document noted that by 1975 Ely was to be considered in relation to the District General Hospital Catchment Areas for Pontypridd, Bridgend and Neath (all in Glamorgan and with a 1981 population of 443,500); Cardiff District General Hospital Catchment Area was by that time to be linked to Hensol Castle.
(c) The Mental Health Services Committee of the RHB on 12th October, 1966, approved a catchment area for Ely as follows :
Cardiff CB 260,170
Merthyr CB 58,050
5 of the 8 Glamorgan authorities referred to in sub-paragraph (a) above 158,392
Total 476,612
(d)It is apparent that all the catchment areas link Ely in whole or in part with substantial areas of Glamorgan. Cardiff CB is identified in sub-paragraphs (a) and (c) as the source of a little over half of Ely’s patients; and in sub-paragraph (b) as the source of none of them. Glamorgan’s important role as a present—and probable future—source of many of Ely’s patients is confirmed by the fact that some 40 per cent of the hospital’s subnormality admissions in 1965 were resident within Glamorgan.
(e)In view of this obvious link between Ely and the County of Glamorgan it is noteworthy that the RHB’s 1966 statement on Ely’s future (see sub-paragraph (d) above), in its section dealing with “Relationship to community health services”, refers only to the future plans of Cardiff CB and not at all to those of Glamorgan. It is also significant that the information given in that document about the plans of Cardiff CB are attributed not to any direct communication between the RHB and Cardiff CB but to the 1964 Ministry publication, “Health and Welfare—The Development of Community Care”, Cmnd. 1973.
455.In these circumstances it is not altogether surprising that the difference of view (see Paragraph 350 above) between the Glamorgan County Council and Ely about responsibility for the care of adult subnormality patients had persisted at least until August, 1967. Yet the survival of this difficulty is not due to the absence of formal and personal links between the HMC and the Cardiff and Glamorgan local health authorities. The two Medical Officers of Health attend meetings of the HMC; and HMC members include the Chairmen of Cardiff’s Health and Welfare Committees and the Chairman of Glamorgan’s Children’s Committee. Consideration is being given to the joint employment by Cardiff CB and the Welsh Hospital Board of a medical officer to improve co-ordination. There is, moreover, a Mental Health Liaison Committee in Cardiff; but it meets, we were told, “only infrequently”—not more than once a year.
456. Our conclusion—which lacks any novelty by now—is that the present tripartite administrative structure of the health service has not, so far as Ely is concerned, done enough positively to encourage a more integrated service and pattern of care for the mentally sub-normal. Despite the best efforts of those concerned to interlock their activities, the gaps and the difficulties remain. A final solution will only be found within a new and more closely integrated administrative structure.
457. There is one other matter of the same kind: the possibility of enlisting more help for Ely’s work from voluntary workers and organisations in the local community. Not very many practical links exist between the hospital and the community. Lectures on the management of the mentally sub-normal are given annually to eight different groups of external students, who visit the hospital. (This contrasts oddly with the absence of any comparable instruction for the nursing staff at Ely itself). Some school children have been brought on visits to the hospital (including last year a small group on a successful “Newsom project”, who attended regularly throughout a term). And the local Community Service Volunteers constructed the adventure playground which was opened at Ely in 1966; they have plans to erect a drinking fountain near the hospital school. There has also been some contact with the local Toc H and Spastics Society, who have taken patients for outings and to clubs.
458. Ely has not, however, got a League of Friends. And voluntary workers are not at present brought into the hospital to act, for example, as play leaders or to help in the feeding of patients or in the organisation of basic therapeutic activities, even in taking patients for a walk. There has been a fear that voluntary participation of this kind might lead to friction with the staff. And there has been a proposal for the appointment “in the more distant future when money becomes available ” of a full-time co-ordinator of voluntary workers.
459. In the circumstances of staff shortage which are likely to persist at Ely we are of the opinion that the HMC should now take active steps to secure, so far as possible, more substantial and effective participation in the work of the hospital by local volunteers and voluntary organisations. The formation of a League of Friends would certainly be desirable. Steps along these lines will not only improve the quality of care provided at Ely but will also help in the equally important task of improving the hospital’s public relations with the community and in the effective implementation of the whole concept of “Community Care”. Similar advantages will accrue from the preparation of a patients’/relatives’ booklet about the hospital, containing, amongst other things, a description of the hospital’s aims and purpose and an invitation to patients (or, more probably, their relatives) to comment upon the standard of service provided by the hospital. Ely is one of three hospitals within the Group which had no such booklet and it was decided, on 25th October, 1967, that one should be provided “as soon as possible”. Our perusal of the similar booklet already provided for Whitchurch Hospital suggests that those responsible for preparing the Ely booklet could with advantage study some examples of such booklets prepared in other Groups or Regions.
Standards of care: inspection?
460. Perhaps the most disquieting aspect of the matters which we have had to investigate has been the persistence of the low standards to which we have had to refer on many occasions—of medical and nursing care, nurse training, laundry arrangements and so on. The strong impression remains in our minds that if XY had not in fact approached the News of the World, then things at Ely, a closely knit and inward looking community, would have gone on very much as before. Yet this would not have been because of any real lack of concern on the part of those responsible. We were assured by all those who gave evidence before us, and we readily accept, that the very existence of our Inquiry and the recommendations that we may make will help them to do the best which they can for the hospital and their patients. The trouble has arisen not from any lack of good-will on their part but, more than anything else, from a lack of awareness of how far Ely has lagged behind what ought to have been, and can be, achieved.
461.It is plain that the Minister, with overall responsibility for the standard of service provided at Ely, as at other hospitals, cannot be satisfied with the persistence of such a gap between the standards attained and those suggested and amplified in many circulars and instructions. It is equally plain that the gap is not bridged by the distribution of such circulars. Complaints from patients or staff have not been effective to draw attention to deficiencies. And the hospital’s “customers” are, of course, seldom free to provide an unconscious, but automatic, value judgment by transferring their needs to another purveyor of hospital services. Standards of performance thus clearly need to be checked from time to time by somebody who is not responsible for day-to-day management of a hospital like Ely.
462. This function has not apparently been discharged within Wales by the RHB. It was explained to us that the Board’s officers did not regard themselves as entitled to perform any inspectorial role of the kind which we have in mind. This view is almost certainly founded upon a misunderstanding of the legal position: for the HMC controls and manages a hospital “on behalf of” the Board, who must in the circumstances be entitled to satisfy themselves as to the way in which their agents are performing their delegated duty. The explanation probably lies in the early suggestion (see Circular RHB(47)1) that the Minister wanted HMCs “to enjoy the maximum of autonomy”, to which the RHB have always attached much importance.
463. Whatever the precise explanation, the view of the RHB’s officers was clear. The doctor who had served for about three years (from 1964 to 1967) as the RHB’s Assistant Senior Medical Officer, with particular responsibility for mental hospitals, explained that it had never been incumbent upon him to prepare any report about the quality of service provided at Ely and that he had never been led to regard himself as having any inspectorial role as to the standards being attained there. (His own previous experience had been in general practice, the colonial service, hospital practice in obstetrics and orthopaedics; and his specialist qualification was in obstetrics and gynaecology.) He had, of course, submitted reports in support of particular capital projects (the proposed industrial therapy unit, for example). But, although he had visited Ely on 20 or 30 occasions in three years, he had never submitted any formal or informal report on the quality of service provided there. In this respect he did not differ from the eight other RHB officers who had visited the hospital in recent years. But they were all, of course, constrained by the view that the RHB was not entitled to undertake any inspectorial role.
464. Whatever may be the true view of this, the RHB cannot deny its responsibility for the unsatisfactory state of affairs at Ely. It is not without power. For instance, it is responsible for appointing the chairman and members of the HMC. Again, it allocates the money provided by the Ministry, and in doing so is able to exert a considerable influence on what is done by HMCs. Indeed, in practice, the allocation of money provides the RHB with many opportunities to find out what is being done, and what is not being done, by HMCs, and to make its dissatisfaction felt.
465 It was suggested to us that officers of the Ministry (or the Welsh Board of Health) were, by contrast entitled to perform this task. There seems, in law, no reason to distinguish their position from that of the RHB’s officers; for the HMC is discharging functions (see Paragraph 462 above) which are ultimately delegated from the Minister himself. Quite apart from the legal position, however, it was apparent from what we were told by Mrs. “Z” (an officer of the Welsh Board of Health) that she did not feel confident of her right to make the report that she did in any way that would secure its consideration by the HMC. And her report was not endowed with any particular, or inspectorial, authority. It was indeed an exceptional document for her to write, arising from her concern of what she found at Ely. But it is plain that no formal inspectorial role was regularly accepted by anyone on behalf of the Minister himself.
466. We were shown the last three reports on Ely by Commissioners or Inspectors of the old Board of Control (which ceased to operate, of course, in 1960, as a result of the Board’s abolition by the Mental Health Act, 1959). It is fair to record that these reports, relating to conditions at Ely at a time when the change of emphasis from custodial to community care was less advanced than it is today, are generally satisfactory. It is also significant that the reports themselves drew attention to matters which appeared to require attention (we instance, for example, the matter of pocket money, see Paragraph 320 above).
467. In the light of this consideration of the position revealed at the present time, we have concluded that there is a clear need, within the present structure of the health service, for some system of inspection of a hospital like Ely, which will ensure that those responsible for its management are made aware of what needs to be done to bring it up to the standards which the Minister aims to achieve. It would not, of course, be proper, or indeed possible, for us to conclude whether such inspection should be undertaken by officers of the RHB, by persons acting directly on behalf of the Minister or by some other independent inspectorate. But we are in no doubt that the conditions which we have found at Ely require some such system to ensure that the gap between aspiration and performance is not allowed to become or to remain too wide.
System of investigating incidents and complaints
468. We discussed in Chapter VII above the way in which complaints and incidents have in fact been handled at Ely hospital. In this section we fulfil the promise made in Paragraph 302 to consider the extent to which the difficulties there revealed are to any extent inherent in the present system of investigation.
469. An HMC (or other hospital authority) has in this respect several conflicting responsibilities. As the representative of the consumer it must see that complaints are brought forward and investigated. As an employer it must see that its staff are protected from unjust attack. As manager and purveyor of a service it must make appropriate management decisions in light of a complaint —and at the same time defend itself against unjust attack. And it must discharge, and appear to discharge, all these functions with a proper sense of justice.
470. The objectives which Solomon would have to set for himself in this context can be more fully defined:
(a) “As the body representing the consumer the Committee will wish to satisfy itself that complaints about any of the Hospitals’ services are handled fairly, promptly and with courtesy”. ( Handbook for Members of HMCs, Ministry of Health, 1966.) And, it should be added, the consumer needs to be demonstrably satisfied that this has been done.
(b) From the point of view of management it is important for deficiencies of organisation or personality to be identified and corrected as soon as possible.
(c) Any employee who is exposed to criticism and to the risk of disciplinary proceedings needs to be assured of justice in the handling of a complaint against him. There is little doubt that this can be assured by compliance with the appropriate circulars (HM(61)112 and RHB(51)80). This is particularly important for an employee who faces a semi-monopolistic employer and for whom dismissal can sometimes involve the effective termination of a professional career.
(d) There must be all-round confidence that complaints which arise from within ” the system ” will be fairly handled. This means the complete absence of any fear or belief in the possibility of victimisation. In the absence of this confidence the complainant may feel obliged—as XY did—to resort to the Press, whose important role as a “long stop” in any system can hardly be denied. In the last resort, an anonymous letter may be brought into play—as it was by somebody in the “T”/”U” incident at Ely (see Paragraph 168 above).
471. It is clear from what we have said in Chapter VII above that there have been several occasions at Ely when one or more of these objectives has not been achieved. Much can be done to avoid a recurrence of such failure at Ely by: —
(a) A greater awareness on the part of senior officers at the hospital of the second and fourth objectives listed above and a more alert attitude towards complaints and incidents which could be symptomatic of more serious faults;
(b) Similarly increased awareness, on the part of the HMC, of the way in which complaints can signify a trend or state of affairs within the hospital which calls for fuller investigation;
(c) A more determined effort on the part of the HMC and its senior officers to create bonds of loyalty between themselves and every member of the hospital staff, so that they may be recognised and identified by even the most humble nurse as the people to whom he may convey his anxieties, in the confidence that they will receive firm and sympathetic consideration.
472. It is right to add, in fairness to the HMC, that these are aspects of their responsibility that have not been emphasised, in the guidance which they have received from above, as much as the judicial aspect of their duty to ensure fairness to any member of the staff against whom a complaint has been made. And it is doubtful whether the present system takes sufficient account of the fact that ” it is a natural reaction to resist complaints which are made against an organisation such as a hospital ” (The Work of the Management Committee Member. 2nd Edition I.H.A. 1960.) It may be doubted whether any system that does not assure, in the last resort, the existence of some truly independent investigating body can be relied upon to reconcile all the objectives set out in Paragraph 470 above.
473. In this context, what of the part which we have been required to play? As our work has proceeded we have become increasingly aware of an ambiguity in our role, which it has been almost impossible to resolve. We think it right to draw attention to this.
474. The duty laid upon us by our terms of reference was that of investigating certain allegations as well as the existing state of affairs at Ely and of making recommendations. It was thus an essential part of our task to ascertain exactly what had been happening and what were present conditions in certain parts of the hospital. Such an investigation necessarily implies an inquisitorial function. For it to be completely effective for its purpose the persons conducting such an investigation need to have the unfettered freedom of police officers to ferret around and to gather evidence from every kind of source in complete confidence. In this kind of search for pointers towards the truth, for “clues”, considerations of justice to particular individuals are necessarily secondary. The only objective would be to produce a series of prima facie conclusions, checked as carefully as possible, from which two kinds of decision might follow: —
(a) particular management decisions to the effect that this or that state of affairs needs particular action in order that it may be put right;
(b) decisions to institute disciplinary action against particular individuals, who would then have a chance to defend themselves against known charges and, in that context, to establish the truth.
475. Along these lines our task would have been defined as one of pure investigation. And we could have undertaken it, without feeling the need for any assistance from anyone else to conduct a preliminary investigation and to “present the case”.
476. Apparently, however, there has been a feeling that such a procedure could lead to the expression of more or less definitive conclusions about the “guilt” or “innocence” of individuals, and so affect their reputations. Hence the decision has been taken to introduce some aspects of legal procedure. Along the lines suggested in Circular HM(66)15, we were provided with a lawyer for a chairman and instructed by the Minister to ensure that “serious allegations” against named individuals were made in their presence, with opportunity afforded for legal representation and cross-examination.
477. In the result—and for the reasons referred to in Paragraph 6 above— this has not been effectively possible. Without a solicitor to investigate the evidence in advance and without anyone to formulate “charges” and present the case, we have ourselves been unaware, on many occasions, of the nature of “serious allegations” until they have actually been made. It has proved impossible—unless we had been prepared to break off and resume our proceedings on numerous occasions, so as to secure the presence of individuals unexpectedly accused—to give every individual affected the chance of defending himself or even notice of the accusations. Such a procedure is a far cry from that recommended, for example, in the Report of the Royal Commission on Tribunals of Inquiry (1966, Cmnd. 3121)—which represents an ideal at which to aim.
564.There is, in the circumstances, a risk that the result will satisfy nobody. Persons “accused”— sometimes brought in by a side-wind and without sufficient notice—will feel that they have had an inadequate opportunity of defending themselves. We ourselves, conducting the investigation, have been conscious of obscurity about the burden of proof to be applied and constantly aware of the risk of coming to unjust conclusions. Any British lawyer, in particular, is unhappy in attempting to combine the roles of judge and prosecutor.
565.For much the same reasons there is a risk that our conclusions will fall short of what is necessary from the point of view of good management. There are matters on which, if we had not been clad in legal form, we would have felt sufficiently sure that a potentially serious incident had occurred for us to recommend remedial action. Yet, within a legal framework designed (theoretically at least) to secure justice, we have felt obliged, by reason of imperfections in our procedure, to stop short of a clear conclusion. For such a conclusion, although necessary and important for good management, might have involved the risk of injustice to a particular individual. We can only claim to have done our best, within the limitations of the procedure laid down, to steer a middle course.
566.As a result of our experience in the conduct of this Inquiry we have concluded that there is a clear need for re-consideration of the procedures that are intended to secure the effective achievement of all the objectives listed in Paragraph 470 above. If it should be considered that the task of inspecting the hospital service can properly be entrusted to an independent inspectorate, then there is much to be said for giving to the same body the investigatory function which we have tried to perform. Consideration should also be given to the establishment of an independent body (on the lines, as has been suggested in several quarters recently, of the Parliamentary Commissioner)—who could, in the last resort, undertake consideration of complaints and disciplinary matters, which had not been satisfactorily handled in some other way.
Conclusions
481. In our report we have of course paid particular attention to the quality of the service provided for the patients at Ely. It would be appropriate, we think, to end with a further brief reference to other considerations. We developed during the course of our inquiry a personal respect and liking for the staff of the Hospital, whatever criticisms we have made of them in particular respects. They have very difficult and exacting jobs to do, which at times places great strain on them. It is no easy thing to look after, with one or two colleagues, a large number of patients, some of whom make ceaseless demands on skill, intelligence, patience and good humour. We were on many occasions impressed by the real concern shown by the staff for the well-being of even the most difficult of their patients.
482. Good management has another function to perform. This is to provide for staff conditions in which they can work well with pride and confidence. To create these conditions is the responsibility of the Ministry, the RHB and the HMC. The Royal Colleges, the professional associations and the trade unions have important parts to play. If the conditions are good, and professional pride is encouraged, the chances of ill-treatment will be greatly reduced. Discussion of our findings should give full weight to this more positive approach.