- Email: [email protected]
PSYCHIATRIC HALFWAY HOSTEL
588
Special Articles PSYCHIATRIC HALFWAY HOSTEL A M.A.
Cambridge Experiment
Cantab.,
D. H. CLARK Edin., F.R.C.P.E., D.P.M.
M.B.
HONORARY CONSULTING PSYCHIATRIST
L. W. COOPER WARDEN
WINSTON
HOUSE, CAMBRIDGE
IN recent years there has been great interest in the rehabilitation of the mentally sick, especially those who have spent many years in mental hospitals. Day hospitals, night hospitals, hospital industries, industrial rehabilitation units have all contributed to this work, and " halfway houses ", or sheltered residential accommodation, have often been suggested as another possible means of helping these people to rejoin the community. In 1956 the Cambridgeshire Mental Welfare Association, a voluntary organisation founded in 1905, approached the Cambridgeshire County Council with a proposal to set up a halfway house in Cambridge; the project was accepted in principle but no funds were available. In 1958 the S.O.S. Society, a national philanthropic body specialising in the provision of hostel accommodation for the socially unfortunate and handicapped, offered a house in Cambridge, and Winston House was opened in October, 1958. The society have financed the experiment (with aid from the Association and the county council) and a local committee has guided the day-to-day management. THE RESIDENTS
Winston House has places for 12 men and 11 women and when it was opened it was expected that there would be considerable competition for places. At no time during the first year, however, has the house been full and the average number of residents has been 16. Selection Residents are selected by a small committee. original criteria of selection stated:
The
"
The age range of residents would be from twenty-five to sixty-five years, but it is expected that few over the age of fifty will be accepted; mental defectives will not be accepted, unless capable of social rehabilitation. All applicants should be in employment, or capable of obtaining it almost immediately."
In fact, of the 36 residents, 5 were under twenty-five, 2 were mental defectives (though they were both in employment when they entered the hostel), and several residents were admitted when not in employment. The criteria have broadened and at present can be fairly stated as follows: Residents should have had a mental or nervous illness and be in work or capable of finding employment within a month. They should be capable of rehabilitation-i.e., there should be a good chance of their achieving reasonably independent social life (in lodgings at least) within six months. In the first year there have been 41 admissions and 22 discharges, but as there were some readmissions the total number of people considered in this study is 36 (23 men and 13 women).
Background 26
came
direct from Fulbourn Mental Welfare
Cambridgeshire
Hospital, 3 came from the Association, 2 from the
Addenbrooke’s Hospital psychiatric outpatient department, 2 from a general practitioner in Cambridge, 1 on his own initiative, and 2 by arrangement from other hospitals. All but 3 had been for a long time in an institution, nearly all in mental hospitals. All the patients were completely discharged from their hospitals before they came to Winston House. Some were on chlorpromazine or other tranquillisers; often it was possible to cut this down, but some have had maintenance doses for months. Some receive regular sedation. The average length of previous hospital treatment was four years, nine months. 1 resident had been continuously in Fulbourn Hospital for nineteen years. 6 residents had been in hospital for more than ten years and altogether 16 residents had more than two years’ continuous residence in an institution. 19 had suffered from schizophrenia; 5 from depression; 2 from manic-depressive psychosis; 2 from epilepsy; 2 from mental defect with emotional instability, and 6 from other
disabilities-e.g., psychoneurosis, personality disorder, alcoholism. 15
men
and 11
separated, and
2 were divorced, 3 of the 36 had a spouse still
single;
women were
3 widowed.
Only 2
interested in them. The average age on admission was thirty-seven years. 3 residents were fifty-six and 1 was nineteen. 5 were over fifty; 9 between forty and fifty; 13 between thirty and forty; and 9 under thirty.
The average resident was thus an unattached man or in the middle thirties with a long history of mental hospital treatment. Most of them had been working outside hospital, but had failed to re-establish themselves in the community. When they first came to Winston House they were docile, passive, and obedient; they worked all day and came back and sat watching the television at night. As time went on, and they came to realise that they were free from the hospital organisation, they began to go out to the pictures and the pubs, to buy clothes and bicycles, and show signs of social initiative. After some months they would find lodgings or move off.
woman
Length of Stay No residents left immediately after arrival, though 4 who were accepted did not come in. 3 residents stayed for four weeks or less, but all 3 were satisfactory discharges who had benefited from their stay. The average period of residence was twenty-two weeks; the shortest stay was two weeks, and the longest stay was forty-five
weeks.
Discharges During the
year there
were
22
discharges.
4 residents had to go back to hospital. 1 alcoholic started to drink intermittently soon after his arrival. He remained in work for some weeks but the struggle steadily became more difficult for him until it was clear that the best thing for him was to return to the hospital. The 2 men with manic-depressive psychosis had to return to hospital. Both had a long history of remissions and relapses into hypomania. The fourth return to hospital was a forty-eight-year-old man with paranoid schizophrenia. The other 18 discharges were reasonably satisfactory. 2 patients went to their relatives; 6 went to lodgings which had been arranged for them with our approval, and 10 made their own arrangements, 1 slipping away without giving warning. THE
YEAR’S
RESULTS
Of the 36 people admitted during the year 17 were still in Winston House; 19 had gone elsewhere. The older residents had done less well than the younger. Of the 5 men over fifty, only 1 had been discharged; of the 9 residents under thirty, 7 had been discharged. When analysed by diagnosis some striking trends emerged.
589
and coughing, eczema scratching, fear of the dark with a Of the 19 residents with schizophrenic illnesses, 9 were still in Winston House (though 5 had been there less than three consequent desire for night lights, and early bathers. months), but 10 had been discharged satisfactorily. Of the SOME FIGURES 5 residents with depressive illnesses only 1 had been discharged, and 4 remained in Winston House (though 2 had been admitted During the first twelve months the running costs (food, within the past three months). The 2 men with maniclight, heat, staff salaries) were E4514. The average weekly depressive psychosis had both returned to hospital, but 1 had cost per resident (including all meals at weekends) was come back to Winston House. 2 residents with epilepsy had E6 13s. 7d. The residents actually paid E3 15s. per week both left and were in the community, though still having (for a few reductions were allowed). The loss on the year difficulties. The 2 mental defectives with behaviour disorders was S1784. left not been to an institution and had readmitted had also was to rather Of the their balance known be The deficit is partly due to the fact that the house was though precarious. 6 patients with psychoneurosis and personality disorders, building up numbers during the first five months and even later was never full. On the assumption of an overall average 3 were still in the house and the other 3 had left, though only of 21 residents the weekly cost per resident per week would be 1 had an entirely satisfactory discharge. E4 2s. 8d. A follow-up of the 19 discharges suggested that of the These costs make no allowance for the capital cost of the 13 residents who had been away from Winston House for for its repairs, or for the administrative service of the house, more than a month 6 would not have achieved this degree S.O.S. Society’s central office staff. of independence but for their stay.
1 had died; he made a satisfactory rehabilitation and slipped away from Winston House but he died two months later of heart failure in a lodging house in London. 2 were in Fulbourn Hospital. 7 were satisfactorily settled, 2 with relatives and 5 in lodgings in Cambridge. 9 were managing fairly well; 3 of these
had only been out of Winston House a few weeks but the other 6 were maintaining a reasonable balance either in their homes or in their lodgings. LIFE AT THE HOSTEL
The hostel is a large Victorian house in what was a residential road. The residents are in dormitories, 1 two-bed, 2 three-bed, 2 four-bed and 1 seven-bed; there is a common room and a dining-room. There is a staff of 4. The warden has tried to run the house as a place in which the residents could adjust their way of life to a more normal pattern and could learn to appreciate that they are discharged from hospital and living in communal lodgings. A " code of behaviour " rather than
a
" set of rules and
regulations " has been set up and an effort has been made to create an atmosphere of homeliness and relaxation. Attendance at Sunday morning family prayers has grown from 1 or 2 to 13 or 14. A reading and quiet room has been opened and a therapeutic social club was started in September, but has not so far attracted many residents. Attempts have been made to get the residents to help in running the hostel but meetings have been poorly attended. The staff join the residents for meals are taken at separate small tables. The very close connection of residents with each other and Fulbourn Hospital has tended to give the impression that residence in Winston House is an extension of their hospitalisation; and conversation centres around hospital life. All the staff have been asked to treat residents as normal people and to make no reference to the past. The atmosphere in the house has been reasonably good except for the first month or two. The first intake of residents included one or two who were unsuitable and who, by their difficult behaviour, caused some unrest and discontent. A few admissions from hospitals outside Cambridge have brought a new outlook.
which
The staff found at first a background of mistrust, suspicion and indifference among the residents, but by the end of the first year there seemed to be more trust and confidence in the staff and the hostel as a way back to normal life.
The year’s experience suggests that single rooms for all residents would be an advantage. There have been complaints of nocturnal strolling, heavy asthmatical breathing
DISCUSSION "
It is difficult to answer the question: What did these people get from their stay in Winston House ? ", for this varied for different people. Many long-stay hospital patients said that it was a great pleasure to live again in a home. They enjoyed the privacy of the small rooms and the freedom to come and go. For others, the security of the house was important, and during their stay they were able to make progress in their psychotherapeutic treatment Some of course resented the or personal development. tolerance with which criticism was but the regime, and the in which it was met by pointing out way accepted the needs of the other residents was at times therapeutic and educative. The people who gained most were undoubtedly the long-stay schizophrenics who had no home or interested relatives. Without Winston House they would have stayed forever in mental hospitals. With it some of them managed to achieve an independent life. The work has been exacting and at times perplexing. Residents have become disturbed in a psychotic manner and have even wandered round hallucinated in the middle of the night. The lack of response from the residents and their disinclination to form any group or relationships with one another has been striking. A clinic has been held in the house every week at which residents were seen, especially for adjustments of medication. Though no formal psychotherapy has been carried out at these evening clinics, they have had considerable supportive value. The consultant psychiatrist, or a deputy, has always been available for consultation. In future it is hoped to hold these clinics at a nearby hospital outpatient clinic. Some of the original expectations with which the house It was known that was set up have not been justified. there were enough patients working out from Fulbourn Hospital to fill such a half-way hostel, but the criterion that they should be capable of rehabilitation proved limiting. In the months before the opening of Winston House there was an average of 25 patients going out to work from Fulbourn Hospital every day. Some of these were moved to Winston House during the autumn of 1958 and the number of working patients fell, but there have never been less than 10 patients going out to work every day from Fulbourn, and during the summer of 1959 the average was about 15, yet none of these was judged suitable for the vacancies at Winston House. Some were short-stay patients, working outside the hospital before returning to their homes. Others were long-stay patients for whom there was no prospect of rehabilitation.
590 The preliminary phase of build-up ended during February, 1959, and since then there has been an average of 16 residents or more. A mental hospital serving a catchment area of 360,000 population will probably only have about 16 patients at any one time suitable for and in need of a halfway hostel. Since August, 1958, we have tried to interest other hospitals in the venture, but so far the number of applicants has been small. This may be because even though recovering patients have no homes, they have roots in their native community and, however keen they may be to leave hospital for a halfway house, they hesitate to go to a distant city and an unknown part of the country. CONCLUSIONS
A
halfway house for psychiatric patients capable of paid employment is of value for a limited group of people. The patient who gains most seems to be the schizophrenic between 30 and 45 whose illness has passed the acute stage, who has lived for a number of years in a mental hospital, and who is capable of regular work in the community but not able to achieve an independent social life, either because he lacks interested relatives or initiative. COMMITTEE ON ACCIDENT SERVICES IN a memorandum published a few months ago1 the British Orthopxdic Association set out the present deficiencies of hospital accident services in this country and made a number of recommendations. A further step towards improving this part of the work of the National Health Service was announced this week. On the initiative of Mr. H. J. Seddon a conference on accident services was held in January at the Royal College of Surgeons of England; and it set up a committee which is to examine the situation and make proposals. The chairman of the new committee is Mr. H. Osmond-Clarke, and the sponsoring bodies are the Royal College of Surgeons of England, Edinburgh, and Ireland, the Royal College of Physicians of London, the College of General Practitioners, the British Medical Association, the British Orthopaedic Association, the Society of British Neurological Surgeons, the Society of Thoracic Surgeons of Great Britain and Ireland, and the British Association of Plastic Surgeons. The committee’srecommendations are in due course to be passed to the Joint Consultants Committee for discussion with the Ministry of Health. MEDICAL LIBRARY FOR AUCKLAND FROM OUR NEW ZEALAND CORRESPONDENT
Sir Ernest Davis, of Auckland, has given 5::36,000 to build and partly maintain a medical library and meetingrooms for professional purposes in the precincts of the Auckland Hospital. This will replace the central medical library at present housed and almost wholly maintained by the Auckland Hospital Board, the nucleus having been formed many years ago by the late Dr. T. M. Philson, a former medical superintendent. Sir Ernest’s gift is particularly welcome at the present time. Medical research has begun in Auckland in the last few years, and at some time in the future a medical school will be developed. The Committee on Universities, under the chairmanship of Sir David Hughes Parry, lately suggested that the plan for the second medical school and the proposed veterinary school should be shelved for ten years in view of the enormous arrears to in the be made up in buildings, staffing conditions, &c., But in institutions. difficulties university persistent the at the more and other staffing hospitals junior levels, factors, may bring about a more urgent view. 1. Summarised in The
Lancet, 1959, ii, 78.
Occasional
Survey
FLUORIDATION: THE PRESENT POSITION THE new year began with a reawakening of the conDr. troversy over the fluoridation of water-supplies. Norman Parfit, medical officer of health for Abingdon, says in his annual report that any further delay in fluoridation is " quite inexcusable" 1; and he adds that although the next two years should bring more positive evidence (the fluoridation tests in Watford, Anglesey, and Kilmarnock end in 1961) " previous investigations have amply demonstrated the good effects of fluoridation." Dr. Wynne Griffith, county medical officer for Anglesey, has also advocated the general adoption of fluoridation, saying that " decay advances so fast that the child is already a dental cripple when the school dental surgeon first sees him ",2 and that "fluoridation costs about 6d. a head of the population for about a year. A very small price to pay for reducing the amount of decay by a third."3 Now we read that the States of Jersey have rejected by a large majority a bill for the compulsory fluoridation of water-supplies.4 These pronouncements coincide with the appearance of a critical analysis by Sutton5 of the results of five of the recent fluoridation trials in Canada and North America. His discussion relates mainly to the statistical conduct of the trials, but a brief recapitulation of the story of the connection between fluorides, enamel dysplasias, and resistance to caries is necessary to provide the background against which his work must be judged. As long ago as 1874, a Dr. Erhardt, of Emmerdingen, described an experiment in which a dog’s molar tooth was extracted, after which the dog was given small doses of potassium fluoride for four months. The opposite molar was then removed and was found to be harder and denser. Dr. Erhardt recommended the sucking of one fluoride pastille a day for the protection of the teeth against caries; according, to him such a practice had been known in England for several years, but no reference can be found in contemporary medical literature before 1892.6 In that year Sir James Crichton-Browne stated that a supply of fluoride was necessary when teeth were
developing.7 The effects of excessive fluoride intake on dental enamel first noticed nearly sixty years ago among the inhabitants of Naples, and, at about the same time but independently, by dentists in Colorado Springs. In 1908, the Colorado Springs Dental Society began a study of the " Colorado brown stain ". Much of the initial work was carried out by Black and McKay, whose first report was published in 1916.8 They did not comment on any reduction in caries incidence, for their concern was with the pathology of mottled enamel. After Black’s death, his work was continued by McKay, who reported in 1929 that children with mottled enamel were less susceptible to caries than those with normal teeth.9 A similar observation had been made by Bunting in 1928 10 The connection with fluorine was not appreciated, however, until 1931 when Churchill analysed the water of certain districts where mottled enamel was were
1. Sunday Times, Jan. 10, 1960. 2. Liverpool Daily Post, Jan. 28, 1960. 3. Sunday Times, Jan. 17, 1960. 4. Times, Feb. 10, 1960. 5. Fluoridation: Errors and Omissions in Experimental Trials. By PHILIP R. N. SUTTON, D.D.SC. London: Cambridge University Press. Melbourne: Melbourne University Press. 1959. Pp. 83. 8s. 6d. 6. Banus, J. Penguin Science News, 1955, 38, 27. 7. Crichton-Browne, J. Lancet, 1892, ii, 6. 8. Black, G. V., McKay, F. S. Dental Cosmos, 1916, 58, 129, 477, 627, 781, 894. 9. McKay, F. S. ibid. 1929, 71, 747. 10. Bunting, R. ibid. 1928, 70, 1002.
Special Articles PSYCHIATRIC HALFWAY HOSTEL A M.A.
Cambridge Experiment
Cantab.,
D. H. CLARK Edin., F.R.C.P.E., D.P.M.
M.B.
HONORARY CONSULTING PSYCHIATRIST
L. W. COOPER WARDEN
WINSTON
HOUSE, CAMBRIDGE
IN recent years there has been great interest in the rehabilitation of the mentally sick, especially those who have spent many years in mental hospitals. Day hospitals, night hospitals, hospital industries, industrial rehabilitation units have all contributed to this work, and " halfway houses ", or sheltered residential accommodation, have often been suggested as another possible means of helping these people to rejoin the community. In 1956 the Cambridgeshire Mental Welfare Association, a voluntary organisation founded in 1905, approached the Cambridgeshire County Council with a proposal to set up a halfway house in Cambridge; the project was accepted in principle but no funds were available. In 1958 the S.O.S. Society, a national philanthropic body specialising in the provision of hostel accommodation for the socially unfortunate and handicapped, offered a house in Cambridge, and Winston House was opened in October, 1958. The society have financed the experiment (with aid from the Association and the county council) and a local committee has guided the day-to-day management. THE RESIDENTS
Winston House has places for 12 men and 11 women and when it was opened it was expected that there would be considerable competition for places. At no time during the first year, however, has the house been full and the average number of residents has been 16. Selection Residents are selected by a small committee. original criteria of selection stated:
The
"
The age range of residents would be from twenty-five to sixty-five years, but it is expected that few over the age of fifty will be accepted; mental defectives will not be accepted, unless capable of social rehabilitation. All applicants should be in employment, or capable of obtaining it almost immediately."
In fact, of the 36 residents, 5 were under twenty-five, 2 were mental defectives (though they were both in employment when they entered the hostel), and several residents were admitted when not in employment. The criteria have broadened and at present can be fairly stated as follows: Residents should have had a mental or nervous illness and be in work or capable of finding employment within a month. They should be capable of rehabilitation-i.e., there should be a good chance of their achieving reasonably independent social life (in lodgings at least) within six months. In the first year there have been 41 admissions and 22 discharges, but as there were some readmissions the total number of people considered in this study is 36 (23 men and 13 women).
Background 26
came
direct from Fulbourn Mental Welfare
Cambridgeshire
Hospital, 3 came from the Association, 2 from the
Addenbrooke’s Hospital psychiatric outpatient department, 2 from a general practitioner in Cambridge, 1 on his own initiative, and 2 by arrangement from other hospitals. All but 3 had been for a long time in an institution, nearly all in mental hospitals. All the patients were completely discharged from their hospitals before they came to Winston House. Some were on chlorpromazine or other tranquillisers; often it was possible to cut this down, but some have had maintenance doses for months. Some receive regular sedation. The average length of previous hospital treatment was four years, nine months. 1 resident had been continuously in Fulbourn Hospital for nineteen years. 6 residents had been in hospital for more than ten years and altogether 16 residents had more than two years’ continuous residence in an institution. 19 had suffered from schizophrenia; 5 from depression; 2 from manic-depressive psychosis; 2 from epilepsy; 2 from mental defect with emotional instability, and 6 from other
disabilities-e.g., psychoneurosis, personality disorder, alcoholism. 15
men
and 11
separated, and
2 were divorced, 3 of the 36 had a spouse still
single;
women were
3 widowed.
Only 2
interested in them. The average age on admission was thirty-seven years. 3 residents were fifty-six and 1 was nineteen. 5 were over fifty; 9 between forty and fifty; 13 between thirty and forty; and 9 under thirty.
The average resident was thus an unattached man or in the middle thirties with a long history of mental hospital treatment. Most of them had been working outside hospital, but had failed to re-establish themselves in the community. When they first came to Winston House they were docile, passive, and obedient; they worked all day and came back and sat watching the television at night. As time went on, and they came to realise that they were free from the hospital organisation, they began to go out to the pictures and the pubs, to buy clothes and bicycles, and show signs of social initiative. After some months they would find lodgings or move off.
woman
Length of Stay No residents left immediately after arrival, though 4 who were accepted did not come in. 3 residents stayed for four weeks or less, but all 3 were satisfactory discharges who had benefited from their stay. The average period of residence was twenty-two weeks; the shortest stay was two weeks, and the longest stay was forty-five
weeks.
Discharges During the
year there
were
22
discharges.
4 residents had to go back to hospital. 1 alcoholic started to drink intermittently soon after his arrival. He remained in work for some weeks but the struggle steadily became more difficult for him until it was clear that the best thing for him was to return to the hospital. The 2 men with manic-depressive psychosis had to return to hospital. Both had a long history of remissions and relapses into hypomania. The fourth return to hospital was a forty-eight-year-old man with paranoid schizophrenia. The other 18 discharges were reasonably satisfactory. 2 patients went to their relatives; 6 went to lodgings which had been arranged for them with our approval, and 10 made their own arrangements, 1 slipping away without giving warning. THE
YEAR’S
RESULTS
Of the 36 people admitted during the year 17 were still in Winston House; 19 had gone elsewhere. The older residents had done less well than the younger. Of the 5 men over fifty, only 1 had been discharged; of the 9 residents under thirty, 7 had been discharged. When analysed by diagnosis some striking trends emerged.
589
and coughing, eczema scratching, fear of the dark with a Of the 19 residents with schizophrenic illnesses, 9 were still in Winston House (though 5 had been there less than three consequent desire for night lights, and early bathers. months), but 10 had been discharged satisfactorily. Of the SOME FIGURES 5 residents with depressive illnesses only 1 had been discharged, and 4 remained in Winston House (though 2 had been admitted During the first twelve months the running costs (food, within the past three months). The 2 men with maniclight, heat, staff salaries) were E4514. The average weekly depressive psychosis had both returned to hospital, but 1 had cost per resident (including all meals at weekends) was come back to Winston House. 2 residents with epilepsy had E6 13s. 7d. The residents actually paid E3 15s. per week both left and were in the community, though still having (for a few reductions were allowed). The loss on the year difficulties. The 2 mental defectives with behaviour disorders was S1784. left not been to an institution and had readmitted had also was to rather Of the their balance known be The deficit is partly due to the fact that the house was though precarious. 6 patients with psychoneurosis and personality disorders, building up numbers during the first five months and even later was never full. On the assumption of an overall average 3 were still in the house and the other 3 had left, though only of 21 residents the weekly cost per resident per week would be 1 had an entirely satisfactory discharge. E4 2s. 8d. A follow-up of the 19 discharges suggested that of the These costs make no allowance for the capital cost of the 13 residents who had been away from Winston House for for its repairs, or for the administrative service of the house, more than a month 6 would not have achieved this degree S.O.S. Society’s central office staff. of independence but for their stay.
1 had died; he made a satisfactory rehabilitation and slipped away from Winston House but he died two months later of heart failure in a lodging house in London. 2 were in Fulbourn Hospital. 7 were satisfactorily settled, 2 with relatives and 5 in lodgings in Cambridge. 9 were managing fairly well; 3 of these
had only been out of Winston House a few weeks but the other 6 were maintaining a reasonable balance either in their homes or in their lodgings. LIFE AT THE HOSTEL
The hostel is a large Victorian house in what was a residential road. The residents are in dormitories, 1 two-bed, 2 three-bed, 2 four-bed and 1 seven-bed; there is a common room and a dining-room. There is a staff of 4. The warden has tried to run the house as a place in which the residents could adjust their way of life to a more normal pattern and could learn to appreciate that they are discharged from hospital and living in communal lodgings. A " code of behaviour " rather than
a
" set of rules and
regulations " has been set up and an effort has been made to create an atmosphere of homeliness and relaxation. Attendance at Sunday morning family prayers has grown from 1 or 2 to 13 or 14. A reading and quiet room has been opened and a therapeutic social club was started in September, but has not so far attracted many residents. Attempts have been made to get the residents to help in running the hostel but meetings have been poorly attended. The staff join the residents for meals are taken at separate small tables. The very close connection of residents with each other and Fulbourn Hospital has tended to give the impression that residence in Winston House is an extension of their hospitalisation; and conversation centres around hospital life. All the staff have been asked to treat residents as normal people and to make no reference to the past. The atmosphere in the house has been reasonably good except for the first month or two. The first intake of residents included one or two who were unsuitable and who, by their difficult behaviour, caused some unrest and discontent. A few admissions from hospitals outside Cambridge have brought a new outlook.
which
The staff found at first a background of mistrust, suspicion and indifference among the residents, but by the end of the first year there seemed to be more trust and confidence in the staff and the hostel as a way back to normal life.
The year’s experience suggests that single rooms for all residents would be an advantage. There have been complaints of nocturnal strolling, heavy asthmatical breathing
DISCUSSION "
It is difficult to answer the question: What did these people get from their stay in Winston House ? ", for this varied for different people. Many long-stay hospital patients said that it was a great pleasure to live again in a home. They enjoyed the privacy of the small rooms and the freedom to come and go. For others, the security of the house was important, and during their stay they were able to make progress in their psychotherapeutic treatment Some of course resented the or personal development. tolerance with which criticism was but the regime, and the in which it was met by pointing out way accepted the needs of the other residents was at times therapeutic and educative. The people who gained most were undoubtedly the long-stay schizophrenics who had no home or interested relatives. Without Winston House they would have stayed forever in mental hospitals. With it some of them managed to achieve an independent life. The work has been exacting and at times perplexing. Residents have become disturbed in a psychotic manner and have even wandered round hallucinated in the middle of the night. The lack of response from the residents and their disinclination to form any group or relationships with one another has been striking. A clinic has been held in the house every week at which residents were seen, especially for adjustments of medication. Though no formal psychotherapy has been carried out at these evening clinics, they have had considerable supportive value. The consultant psychiatrist, or a deputy, has always been available for consultation. In future it is hoped to hold these clinics at a nearby hospital outpatient clinic. Some of the original expectations with which the house It was known that was set up have not been justified. there were enough patients working out from Fulbourn Hospital to fill such a half-way hostel, but the criterion that they should be capable of rehabilitation proved limiting. In the months before the opening of Winston House there was an average of 25 patients going out to work from Fulbourn Hospital every day. Some of these were moved to Winston House during the autumn of 1958 and the number of working patients fell, but there have never been less than 10 patients going out to work every day from Fulbourn, and during the summer of 1959 the average was about 15, yet none of these was judged suitable for the vacancies at Winston House. Some were short-stay patients, working outside the hospital before returning to their homes. Others were long-stay patients for whom there was no prospect of rehabilitation.
590 The preliminary phase of build-up ended during February, 1959, and since then there has been an average of 16 residents or more. A mental hospital serving a catchment area of 360,000 population will probably only have about 16 patients at any one time suitable for and in need of a halfway hostel. Since August, 1958, we have tried to interest other hospitals in the venture, but so far the number of applicants has been small. This may be because even though recovering patients have no homes, they have roots in their native community and, however keen they may be to leave hospital for a halfway house, they hesitate to go to a distant city and an unknown part of the country. CONCLUSIONS
A
halfway house for psychiatric patients capable of paid employment is of value for a limited group of people. The patient who gains most seems to be the schizophrenic between 30 and 45 whose illness has passed the acute stage, who has lived for a number of years in a mental hospital, and who is capable of regular work in the community but not able to achieve an independent social life, either because he lacks interested relatives or initiative. COMMITTEE ON ACCIDENT SERVICES IN a memorandum published a few months ago1 the British Orthopxdic Association set out the present deficiencies of hospital accident services in this country and made a number of recommendations. A further step towards improving this part of the work of the National Health Service was announced this week. On the initiative of Mr. H. J. Seddon a conference on accident services was held in January at the Royal College of Surgeons of England; and it set up a committee which is to examine the situation and make proposals. The chairman of the new committee is Mr. H. Osmond-Clarke, and the sponsoring bodies are the Royal College of Surgeons of England, Edinburgh, and Ireland, the Royal College of Physicians of London, the College of General Practitioners, the British Medical Association, the British Orthopaedic Association, the Society of British Neurological Surgeons, the Society of Thoracic Surgeons of Great Britain and Ireland, and the British Association of Plastic Surgeons. The committee’srecommendations are in due course to be passed to the Joint Consultants Committee for discussion with the Ministry of Health. MEDICAL LIBRARY FOR AUCKLAND FROM OUR NEW ZEALAND CORRESPONDENT
Sir Ernest Davis, of Auckland, has given 5::36,000 to build and partly maintain a medical library and meetingrooms for professional purposes in the precincts of the Auckland Hospital. This will replace the central medical library at present housed and almost wholly maintained by the Auckland Hospital Board, the nucleus having been formed many years ago by the late Dr. T. M. Philson, a former medical superintendent. Sir Ernest’s gift is particularly welcome at the present time. Medical research has begun in Auckland in the last few years, and at some time in the future a medical school will be developed. The Committee on Universities, under the chairmanship of Sir David Hughes Parry, lately suggested that the plan for the second medical school and the proposed veterinary school should be shelved for ten years in view of the enormous arrears to in the be made up in buildings, staffing conditions, &c., But in institutions. difficulties university persistent the at the more and other staffing hospitals junior levels, factors, may bring about a more urgent view. 1. Summarised in The
Lancet, 1959, ii, 78.
Occasional
Survey
FLUORIDATION: THE PRESENT POSITION THE new year began with a reawakening of the conDr. troversy over the fluoridation of water-supplies. Norman Parfit, medical officer of health for Abingdon, says in his annual report that any further delay in fluoridation is " quite inexcusable" 1; and he adds that although the next two years should bring more positive evidence (the fluoridation tests in Watford, Anglesey, and Kilmarnock end in 1961) " previous investigations have amply demonstrated the good effects of fluoridation." Dr. Wynne Griffith, county medical officer for Anglesey, has also advocated the general adoption of fluoridation, saying that " decay advances so fast that the child is already a dental cripple when the school dental surgeon first sees him ",2 and that "fluoridation costs about 6d. a head of the population for about a year. A very small price to pay for reducing the amount of decay by a third."3 Now we read that the States of Jersey have rejected by a large majority a bill for the compulsory fluoridation of water-supplies.4 These pronouncements coincide with the appearance of a critical analysis by Sutton5 of the results of five of the recent fluoridation trials in Canada and North America. His discussion relates mainly to the statistical conduct of the trials, but a brief recapitulation of the story of the connection between fluorides, enamel dysplasias, and resistance to caries is necessary to provide the background against which his work must be judged. As long ago as 1874, a Dr. Erhardt, of Emmerdingen, described an experiment in which a dog’s molar tooth was extracted, after which the dog was given small doses of potassium fluoride for four months. The opposite molar was then removed and was found to be harder and denser. Dr. Erhardt recommended the sucking of one fluoride pastille a day for the protection of the teeth against caries; according, to him such a practice had been known in England for several years, but no reference can be found in contemporary medical literature before 1892.6 In that year Sir James Crichton-Browne stated that a supply of fluoride was necessary when teeth were
developing.7 The effects of excessive fluoride intake on dental enamel first noticed nearly sixty years ago among the inhabitants of Naples, and, at about the same time but independently, by dentists in Colorado Springs. In 1908, the Colorado Springs Dental Society began a study of the " Colorado brown stain ". Much of the initial work was carried out by Black and McKay, whose first report was published in 1916.8 They did not comment on any reduction in caries incidence, for their concern was with the pathology of mottled enamel. After Black’s death, his work was continued by McKay, who reported in 1929 that children with mottled enamel were less susceptible to caries than those with normal teeth.9 A similar observation had been made by Bunting in 1928 10 The connection with fluorine was not appreciated, however, until 1931 when Churchill analysed the water of certain districts where mottled enamel was were
1. Sunday Times, Jan. 10, 1960. 2. Liverpool Daily Post, Jan. 28, 1960. 3. Sunday Times, Jan. 17, 1960. 4. Times, Feb. 10, 1960. 5. Fluoridation: Errors and Omissions in Experimental Trials. By PHILIP R. N. SUTTON, D.D.SC. London: Cambridge University Press. Melbourne: Melbourne University Press. 1959. Pp. 83. 8s. 6d. 6. Banus, J. Penguin Science News, 1955, 38, 27. 7. Crichton-Browne, J. Lancet, 1892, ii, 6. 8. Black, G. V., McKay, F. S. Dental Cosmos, 1916, 58, 129, 477, 627, 781, 894. 9. McKay, F. S. ibid. 1929, 71, 747. 10. Bunting, R. ibid. 1928, 70, 1002.