- Email: [email protected]
THE HEALTH SERVICE IN 1957
415 supper. He draws them together each and hot milk, and often provides more at his own expense. After months of persistent effort the Junior Supper Club now assembles fairly spontaneously, and some of its members now help to make the toast, wash up, and begin to show a very little social feeling.
pool their money for evening, makes them
toast
Staff and Patients The great stress laid on maximum communication between patients, nurses, relatives, and doctors makes it possible to foster and recognise-as well as tolerate-the first stirrings of initiative. Great skill and patience are needed on the part of the nurses to guide the reviving
patient into socially acceptable modes of expression. This means that the ward offers an exceptionally good trainingground for the student nurses who come to us for up to three months at a time. Their curiosity and receptivity very valuable to the unit, and we ask them to make a careful study of particular patients. They then present their observations to the ward staff meeting, and in this way patients are reassessed, and plans for treatment are made by the meeting as a whole. This means that the long-stay patients with great folders full of forgotten notes are considered again as though they were new problems, and this often produces a new approach which is helpful to the patient. Of the 24 founder members, 5 have had to be transferred to other wards; 2 because they ran away repeatedly,1 became intolerably aggressive, 1 impulsive, and 1 negativistic enough to be a bad influence. 2 others did not return from leave and had to be left at home with our blessing if not our approval. There is a steady flow of discharges of short-stay patients, and the first 3 long-stay patients have now started work at a nearby factory, while continuing to live in the unit for the time being. A 4th (the organiser of the Junior Supper Club) has just joined an Anglican monastery as a resident lay worker. This partial withdrawal of 4 of the best-preserved and most active long-stay patients has stimulated initiative in some of those who were content to be organised by them. New leaders, though of rather inferior calibre, have begun to appear and take their work as committee members very seriously. 3 or 4 patients show no improvement, do not cooperate, and try to avoid their share of communal chores. They are much resented by the others and are often publicly criticised, but so far the community continues to tolerate them. are
Discussion
Living
in
a self-governing community and working as socially useful projects has had a marked effect on the patients, which is commented on spontaneously by all who know them, especially their relatives. " Even the goldfish are more active in this ward is our most precious testimonial. The patients themselves say that life is much more enjoyable now, and many comment on feeling fitter and more confident. They look smarter and brisker, talk more spontaneously, and are altogether more responsive. With a high proportion of those who have been severely damaged by their illness, this may well be all that can be achieved. We hope, however, to return the others to the community. It is difficult to quantify the improvements observed or to assign cause and effect accurately; but there seems to be little doubt that we have established not only a happy ward but also one with therapeutic powers. These therapeutic powers seem to depend to a very cónsiderable extent on having the same nurses on the unit long enough
a
group
on
"
!
i
í
: :
establish a real relationship, and on having enough of them. Sometimes, when the hospital has been short of
to
we have had frequent changes, with nurses coming These times have been for short periods as reliefs. marked by a sagging ward morale with a tendency to return to aimless drifting, and a failure to cultivate the patients’ initiative. A nurse doing this kind of work needs the same sort of patience as a mother who lets her 3-yearold do up his own buttons. Many of the chronic patients who have improved so much in bearing, work, and apparent social adjustment, retain intact their delusions and disordered modes of thought. The King of the Incas, while retaining his imperial status, now works quite well, joins in the discussion, and looks neat and relatively brisk, compared with his former slouching idleness only relieved by occasionally toying with a little basket-work. This suggests that much of the typical " chronic patient " appearance and behaviour is due to hospital conditioning, and is not necessarily an inescapable consequence of the primary illness. The long-stay mental-hospital patient is all too likely to lose his human dignity through giving up his own responsibility for himself, and in our unit we are trying to prevent this happening.
staff,
Summary
,
experience in starting a new schizophrenic unit on community lines is described. We have tried to improve certain aspects of the care of long-stay patients in a hospital where (if we may say this, being only short-stay doctors) the standard of such care is already high. The essential principles involved are (1) an attempt to reproduce normal stresses by introducing compulsory work and democratic social organisation, (2) bringing the families into the treatment situation, (3) maximum communication, (4) selective mixing of acute and chronic cases for mutual benefit. The preliminary planning and the mechanism of opening the ward are described,followed by a general account of how things have worked out during the first year. We are indebted to Dr. G. Somerville, physician superintendent, and Dr. J. E. McA. Glancy, consultant psychiatrist, for their help and encouragement as well as to Miss J. Stapleton, clinical psychologist, Miss Abley and Miss S. MacNulty, psychiatric social workers, and Miss M. D. Beldam, head occupational therapist, for Our
their valuable assistance.
THE HEALTH SERVICE IN 1957 LAST year, perhaps the most important event bearing on the National Health Service was the publication of the report of the Royal Commission on the Law relating to Mental Illness and Mental Deficiency.1 One of the Commission’s recommendations-that mentally defective patients should be compulsorily detained in hospital only when this is positively necessary for the patient’s own welfare or for the protection of others-has already been acted on.2 In his introduction to the Ministry of Health’s report on the year,3 Mr. Derek Walker-Smith, the Minister, says that he looks forward to new legislation " as soon as the difficulties and complexities of the subject permit". DEMANDS ON HOSPITALS
The annual report shows the year to have been one of solid endeavour. The hospitals of England and Wales treated some 55,000 more inpatients than in the previous Report of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency. H.M. Stationery Office, 1957. See Lancet, 1957, i, 1187. 2. Circular H.M.(58)5. 3. Report of the Ministry of Health for the year ended Dec. 31, 1957. Part 1. 1: The National Health Service. 2: Welfare, Food and Drugs, Civil Defence. Cmd. 495. H.M. Stationery Office. 1958. Pp. 254. 1.
12s.
416 i
year, the total
being 3,794,000; but waiting-lists, which had been falling in previous years, increased by about 9000 *
to
440,000. Last year
some
29%
more
patients
1949, though the number of beds
were was
treated than in
only about 6%
end of the year, compared with 639,319 a year earlier. The number of donations rose from 803,522 in 1956 to 846,202 in 1957. The attendance-rate of general-public donors invited to give blood remained unchanged at an average of
51-8%.
greater than at the start of the service. CONSULTANTS At the end of the year patients awaiting admission to Consultants in the National Health Service, including general-surgery departments numbered 131,000, and those those employed by the Board of Control and in the Public awaiting admission to ear, nose, and throat departments Health Laboratory Service, numbered 6902 at the end of numbered 104,000; these two departments thus accounted last year, compared with 6739 at the end of 1956 and 5649 for more than half of the total waiting-lists. The extent at the end of 1950. The numbers receiving distinction of waiting-lists differed greatly between England and awards were as follows: A (E2500 per annum), 276; Wales and between regions in England. In Wales, only in B 690; C (E500), 1377. (E1500), traumatic and orthopaedic surgery and in other " departGENERAL MEDICAL SERVICES ments were there increased waiting-lists. In England, the During the year the number of doctors admitted to I demand for admissions to hospitals in the Oxford region councils’ lists was 936 and the number deleted executive in the overall continued to increase; contrast, position 694. Of those admitted, 601 entered into partnership, was in the Manchester and Liverpool improved somewhat 310 assistants who joined their former principals, including in regions, and waiting-lists increased less than average total number of doctors practising as principals and The East Anglia. unrestricted general medical services in England providing In general, both the London and provincial teaching at 1 Wales increased from 19,082 in 1956 to and July hospitals have much larger waiting-lists in relation to in The number of single-handed practitioners 1957. 19,343 their resources of staffed beds than the non-teaching those with continued to declineassistants) (including hospitals. 6568 in 1956 to 6381 in 1957. The number of from Compared with the non-teaching hospitals, about three times assistants (excluding trainee general practitioners) at July 1, as many patients were awaiting admission to the general 1957, was 1465, compared with 1546 in 1956. The general medical departments of London teaching hospitals, and three decrease in assistants which seemed to have been arrested and a half times as many to the same departments of the For provincial teaching hospitals. general-surgery departments in 1955 and 1956 has now been resumed. the difference between the London teaching and non-teaching There was a further decrease in the number of patients ! hospitals was not so great; but at the provincial teaching living in under-doctored areas from 9,500,000 in 1956 to hospitals the waiting-lists per 100 staffed beds were about 8,500,000 in 1957. The average number of patients per two-fifths greater than at the non-teaching hospitals. doctor remained virtually the same-2273, compared with At the non-teaching hospitals most major departments 2272 in 1956. except ear, nose, and throat, and at the teaching hospitals GENERAL DENTAL SERVICES most departments except ear, nose, and throat and onwards the volume of treatment given under gynxcology, treated more patients per available bed than in theFrom 1952dental services increased at the rate of 8-900 general 1956. This was due in nearly every instance to reduced a year, but in 1957 the increase over the previous year was stay in hospital, and not to reduced interval between only 5-2%. This was nevertheless appreciably more than occupation of beds. The number of inpatients admitted to designated mental the increase in the number of dentists in the service (2’3°o) were on the Dentists hospitals was 88,943, of whom 73,499 (82-6%) were volun- At the end of the year 16,113 dentists at the end of 1956. with 16,007 Register, compared tary patients, 1318 (1-5%) temporary, and 14,126 (15-9%) certified. The total in 1956 was 83,994, of whom 65,637 EFFECTS OF RADIATION (78-2%) were voluntary, 1453 (1-7%) temporary, and "
,
M.R.C. Committee’s Comments
16.904 r20-l°/certified.
The number of patients admitted to mental hospitals has been rising steadily for many years-the number increased by some 5000 in 1957-but the number of patients resident has begun to fall, owing to the rehabilitation and discharge of patients who have been in hospital for many years, and the shorter stay of newly admitted patients. In 1957 the national average of overcrowding, which had been 14% in 1956, fell to 11-9%. HEARING-AIDS
During the year 52,166 new patients were fitted with hearing-aids, bringing the total fitted with aids since 1948 to over 580,000. Following field trials orders were placed for the first batch ofMedresco ’ transistor hearing-aids. These aids, which weigh just under 3 oz. complete with battery, compared with 241/2 oz. with battery case for the original model issued in 1948, are intended in the first instance for children and will until 1959.
not
be available
to
adults
BLOOD-TRANSFUSION
The strength of the civilian donor panel in the National Blood Transfusion Service amounted to 674,117 at the
on
U.N.
Report
THE committee appointed by the Medical Research Council to report on the hazards to man of nuclear and allied radiations has prepared a statement1 on the United Nations report published last week.2 In general the U.N. report follows the same linesai the reports of the M.R.C. committee and the Unitej States National Academy of Sciences, both of which were " We have derived considerable published in 1956. the M.R.C. committee say, " from IIh: reassurance", fact that, in a field of science that is so difficult and,;, yet, relatively little developed, the three major report on this subject are so substantially in agreement with each other ". In the past two years much addition:.. information has been collected, but it has led to no ma’ revisions of opinion: " rather it has strengthened acamplified the tentative conclusions and predictions in the two earlier reports ". Both the 1956 reports confined attention to conditions in technologically well-develop 1. Statement on the Report of the United Nations Scientific Committee the Effects of Atomic Radiation. H.M. Stationery Office. Cmd Pp. 15. 1s. 2. See Lancet, Aug. 16, 1958, p. 360.
pool their money for evening, makes them
toast
Staff and Patients The great stress laid on maximum communication between patients, nurses, relatives, and doctors makes it possible to foster and recognise-as well as tolerate-the first stirrings of initiative. Great skill and patience are needed on the part of the nurses to guide the reviving
patient into socially acceptable modes of expression. This means that the ward offers an exceptionally good trainingground for the student nurses who come to us for up to three months at a time. Their curiosity and receptivity very valuable to the unit, and we ask them to make a careful study of particular patients. They then present their observations to the ward staff meeting, and in this way patients are reassessed, and plans for treatment are made by the meeting as a whole. This means that the long-stay patients with great folders full of forgotten notes are considered again as though they were new problems, and this often produces a new approach which is helpful to the patient. Of the 24 founder members, 5 have had to be transferred to other wards; 2 because they ran away repeatedly,1 became intolerably aggressive, 1 impulsive, and 1 negativistic enough to be a bad influence. 2 others did not return from leave and had to be left at home with our blessing if not our approval. There is a steady flow of discharges of short-stay patients, and the first 3 long-stay patients have now started work at a nearby factory, while continuing to live in the unit for the time being. A 4th (the organiser of the Junior Supper Club) has just joined an Anglican monastery as a resident lay worker. This partial withdrawal of 4 of the best-preserved and most active long-stay patients has stimulated initiative in some of those who were content to be organised by them. New leaders, though of rather inferior calibre, have begun to appear and take their work as committee members very seriously. 3 or 4 patients show no improvement, do not cooperate, and try to avoid their share of communal chores. They are much resented by the others and are often publicly criticised, but so far the community continues to tolerate them. are
Discussion
Living
in
a self-governing community and working as socially useful projects has had a marked effect on the patients, which is commented on spontaneously by all who know them, especially their relatives. " Even the goldfish are more active in this ward is our most precious testimonial. The patients themselves say that life is much more enjoyable now, and many comment on feeling fitter and more confident. They look smarter and brisker, talk more spontaneously, and are altogether more responsive. With a high proportion of those who have been severely damaged by their illness, this may well be all that can be achieved. We hope, however, to return the others to the community. It is difficult to quantify the improvements observed or to assign cause and effect accurately; but there seems to be little doubt that we have established not only a happy ward but also one with therapeutic powers. These therapeutic powers seem to depend to a very cónsiderable extent on having the same nurses on the unit long enough
a
group
on
"
!
i
í
: :
establish a real relationship, and on having enough of them. Sometimes, when the hospital has been short of
to
we have had frequent changes, with nurses coming These times have been for short periods as reliefs. marked by a sagging ward morale with a tendency to return to aimless drifting, and a failure to cultivate the patients’ initiative. A nurse doing this kind of work needs the same sort of patience as a mother who lets her 3-yearold do up his own buttons. Many of the chronic patients who have improved so much in bearing, work, and apparent social adjustment, retain intact their delusions and disordered modes of thought. The King of the Incas, while retaining his imperial status, now works quite well, joins in the discussion, and looks neat and relatively brisk, compared with his former slouching idleness only relieved by occasionally toying with a little basket-work. This suggests that much of the typical " chronic patient " appearance and behaviour is due to hospital conditioning, and is not necessarily an inescapable consequence of the primary illness. The long-stay mental-hospital patient is all too likely to lose his human dignity through giving up his own responsibility for himself, and in our unit we are trying to prevent this happening.
staff,
Summary
,
experience in starting a new schizophrenic unit on community lines is described. We have tried to improve certain aspects of the care of long-stay patients in a hospital where (if we may say this, being only short-stay doctors) the standard of such care is already high. The essential principles involved are (1) an attempt to reproduce normal stresses by introducing compulsory work and democratic social organisation, (2) bringing the families into the treatment situation, (3) maximum communication, (4) selective mixing of acute and chronic cases for mutual benefit. The preliminary planning and the mechanism of opening the ward are described,followed by a general account of how things have worked out during the first year. We are indebted to Dr. G. Somerville, physician superintendent, and Dr. J. E. McA. Glancy, consultant psychiatrist, for their help and encouragement as well as to Miss J. Stapleton, clinical psychologist, Miss Abley and Miss S. MacNulty, psychiatric social workers, and Miss M. D. Beldam, head occupational therapist, for Our
their valuable assistance.
THE HEALTH SERVICE IN 1957 LAST year, perhaps the most important event bearing on the National Health Service was the publication of the report of the Royal Commission on the Law relating to Mental Illness and Mental Deficiency.1 One of the Commission’s recommendations-that mentally defective patients should be compulsorily detained in hospital only when this is positively necessary for the patient’s own welfare or for the protection of others-has already been acted on.2 In his introduction to the Ministry of Health’s report on the year,3 Mr. Derek Walker-Smith, the Minister, says that he looks forward to new legislation " as soon as the difficulties and complexities of the subject permit". DEMANDS ON HOSPITALS
The annual report shows the year to have been one of solid endeavour. The hospitals of England and Wales treated some 55,000 more inpatients than in the previous Report of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency. H.M. Stationery Office, 1957. See Lancet, 1957, i, 1187. 2. Circular H.M.(58)5. 3. Report of the Ministry of Health for the year ended Dec. 31, 1957. Part 1. 1: The National Health Service. 2: Welfare, Food and Drugs, Civil Defence. Cmd. 495. H.M. Stationery Office. 1958. Pp. 254. 1.
12s.
416 i
year, the total
being 3,794,000; but waiting-lists, which had been falling in previous years, increased by about 9000 *
to
440,000. Last year
some
29%
more
patients
1949, though the number of beds
were was
treated than in
only about 6%
end of the year, compared with 639,319 a year earlier. The number of donations rose from 803,522 in 1956 to 846,202 in 1957. The attendance-rate of general-public donors invited to give blood remained unchanged at an average of
51-8%.
greater than at the start of the service. CONSULTANTS At the end of the year patients awaiting admission to Consultants in the National Health Service, including general-surgery departments numbered 131,000, and those those employed by the Board of Control and in the Public awaiting admission to ear, nose, and throat departments Health Laboratory Service, numbered 6902 at the end of numbered 104,000; these two departments thus accounted last year, compared with 6739 at the end of 1956 and 5649 for more than half of the total waiting-lists. The extent at the end of 1950. The numbers receiving distinction of waiting-lists differed greatly between England and awards were as follows: A (E2500 per annum), 276; Wales and between regions in England. In Wales, only in B 690; C (E500), 1377. (E1500), traumatic and orthopaedic surgery and in other " departGENERAL MEDICAL SERVICES ments were there increased waiting-lists. In England, the During the year the number of doctors admitted to I demand for admissions to hospitals in the Oxford region councils’ lists was 936 and the number deleted executive in the overall continued to increase; contrast, position 694. Of those admitted, 601 entered into partnership, was in the Manchester and Liverpool improved somewhat 310 assistants who joined their former principals, including in regions, and waiting-lists increased less than average total number of doctors practising as principals and The East Anglia. unrestricted general medical services in England providing In general, both the London and provincial teaching at 1 Wales increased from 19,082 in 1956 to and July hospitals have much larger waiting-lists in relation to in The number of single-handed practitioners 1957. 19,343 their resources of staffed beds than the non-teaching those with continued to declineassistants) (including hospitals. 6568 in 1956 to 6381 in 1957. The number of from Compared with the non-teaching hospitals, about three times assistants (excluding trainee general practitioners) at July 1, as many patients were awaiting admission to the general 1957, was 1465, compared with 1546 in 1956. The general medical departments of London teaching hospitals, and three decrease in assistants which seemed to have been arrested and a half times as many to the same departments of the For provincial teaching hospitals. general-surgery departments in 1955 and 1956 has now been resumed. the difference between the London teaching and non-teaching There was a further decrease in the number of patients ! hospitals was not so great; but at the provincial teaching living in under-doctored areas from 9,500,000 in 1956 to hospitals the waiting-lists per 100 staffed beds were about 8,500,000 in 1957. The average number of patients per two-fifths greater than at the non-teaching hospitals. doctor remained virtually the same-2273, compared with At the non-teaching hospitals most major departments 2272 in 1956. except ear, nose, and throat, and at the teaching hospitals GENERAL DENTAL SERVICES most departments except ear, nose, and throat and onwards the volume of treatment given under gynxcology, treated more patients per available bed than in theFrom 1952dental services increased at the rate of 8-900 general 1956. This was due in nearly every instance to reduced a year, but in 1957 the increase over the previous year was stay in hospital, and not to reduced interval between only 5-2%. This was nevertheless appreciably more than occupation of beds. The number of inpatients admitted to designated mental the increase in the number of dentists in the service (2’3°o) were on the Dentists hospitals was 88,943, of whom 73,499 (82-6%) were volun- At the end of the year 16,113 dentists at the end of 1956. with 16,007 Register, compared tary patients, 1318 (1-5%) temporary, and 14,126 (15-9%) certified. The total in 1956 was 83,994, of whom 65,637 EFFECTS OF RADIATION (78-2%) were voluntary, 1453 (1-7%) temporary, and "
,
M.R.C. Committee’s Comments
16.904 r20-l°/certified.
The number of patients admitted to mental hospitals has been rising steadily for many years-the number increased by some 5000 in 1957-but the number of patients resident has begun to fall, owing to the rehabilitation and discharge of patients who have been in hospital for many years, and the shorter stay of newly admitted patients. In 1957 the national average of overcrowding, which had been 14% in 1956, fell to 11-9%. HEARING-AIDS
During the year 52,166 new patients were fitted with hearing-aids, bringing the total fitted with aids since 1948 to over 580,000. Following field trials orders were placed for the first batch ofMedresco ’ transistor hearing-aids. These aids, which weigh just under 3 oz. complete with battery, compared with 241/2 oz. with battery case for the original model issued in 1948, are intended in the first instance for children and will until 1959.
not
be available
to
adults
BLOOD-TRANSFUSION
The strength of the civilian donor panel in the National Blood Transfusion Service amounted to 674,117 at the
on
U.N.
Report
THE committee appointed by the Medical Research Council to report on the hazards to man of nuclear and allied radiations has prepared a statement1 on the United Nations report published last week.2 In general the U.N. report follows the same linesai the reports of the M.R.C. committee and the Unitej States National Academy of Sciences, both of which were " We have derived considerable published in 1956. the M.R.C. committee say, " from IIh: reassurance", fact that, in a field of science that is so difficult and,;, yet, relatively little developed, the three major report on this subject are so substantially in agreement with each other ". In the past two years much addition:.. information has been collected, but it has led to no ma’ revisions of opinion: " rather it has strengthened acamplified the tentative conclusions and predictions in the two earlier reports ". Both the 1956 reports confined attention to conditions in technologically well-develop 1. Statement on the Report of the United Nations Scientific Committee the Effects of Atomic Radiation. H.M. Stationery Office. Cmd Pp. 15. 1s. 2. See Lancet, Aug. 16, 1958, p. 360.