- Email: [email protected]
THE DEVELOPMENT OF A PSYCHIATRIC REHABILITATION SERVICE
625 and attics had been restored by the kindness, cleanliness, food, light, and air of the asylum. A similar romantic fantasy has been heard over the past 30 years: touching tales relate the idle and hopeless years spent by asylum inmates who are now, happily knitting in group homes. The stories are true, and those who told them are honest. In both epochs the patients were undoubtedly happier in their improved circumstances. Those who had wrought the change could take justifiable pride in their achievement. Nevertheless, the enthusiasts tended to generalise from striking cases without looking dispassionately at standard conditions.
from
Mental Health THE DEVELOPMENT OF A PSYCHIATRIC REHABILITATION SERVICE
DAVID H. CLARK 33 Highsett, Hills
Road, Cambridge CB21 NY
SINCE 1961, when Mr Enoch Powell, then minister for health, announced’ that large mental hospitals would be defunct by 1975, successive UK governments have enthused the idea of community care for long-term mentally disordered people. In parts of the USA, the notion of community care has been seized on by politicians keen to cut State budgets and make a profit on sales of land. In San Francisco, San Jose, and Boston, for example, the sight of mentally disordered people roaming the streets and scouring the trash cans has provoked both compassion and fear-some citizens are demanding new, more secure institutions. In Italy, reformers have hailed Bassaglia’s radical experiments in Trieste and Venice; some psychiatrists, on the other hand, relate heart-rending tales of long-term patients driven from the security of their asylums. And in Australia, the Richmond report on the Sydney psychiatric service has produced the same split: pioneers describe the freedom of community care and others, whose career depends on the continued existence of asylums, speak of the suffering caused by rehabilitation. The life of people with long-term psychiatric disabilities in Britain has changed radically over the past 30 years. In the early ’50s, patients were locked in the back wards of county asylums. Now they live mostly in group homes, hostels, and half-way houses, attending day centres, psychiatric units in general hospitals, and sheltered workshops. Though there has been the occasional scandal, there can be no doubt that in comparison to the overcrowded and stinking back wards, life in the community is infinitely preferable. The professional debate, however, centres on two questions: whether there should be any people with long-term disabilities; and, if these people exist, how they should best be cared for. Kraepelin, in the 19th century, had divided lunatics into those suffering from manic depressive psychosis and those suffering from dementia praecox. The former group regained their health and left the asylum, but the latter required institutional care for the rest of their lives. Indeed, many authorities built specially designed hospitals for these chronic patients. But the tide of therapeutic enthusiasm that swept over psychiatry from 1930 to 1960, the introduction of physical methods of treatment (insulin coma therapy, ECT, and leucotomy), and the advent of the major and depot tranquillisers led many psychiatrists to believe that psychosis was conquered. All patients would recover permanentlythere need be no more long-term patients. It soon became clear that this was far from true. By the early ’70s, theorists could identify the "new chronic" as someone who remained in hospital despite active treatment, had a history of about 10 years’ contact with psychiatric services, including several admissions to acute units, and was semi-permanently impaired (thought disordered, dependent, and often socially over
deviant). The 19th century alienists had been sure that residence in the new, benign, public asylums was better for someone with a long-term mental disorder than living with uncaring relatives and hostile neighbours. The early superintendents often reported that lunatics and mental defectives released
.
pigsties
LOCAL HISTORY
This paper charts the changes and excitements that have occurred in the Cambridge area. The Cambridge Psychiatric Rehabilitation Service looks after some 400 people with longterm mental disorder: 150 are resident on hospital wards; 100 live in sheltered accommodation; and 150 live in their own homes. Fulbourn Hospital originally opened in 1858 as the Cambridge and Isle of Ely Pauper Asylum. In 1948 its catchment area was Cambridgeshire, Huntingdonshire, the Isle of Ely, the Soke of Peter borough, and the Saffron Walden district. The population has since grown from 350 000 to about 510 000. Psychiatric units in the general hospitals in Wisbech, King’s Lynn, Bury St Edmunds-, and Peterborough have taken some of the pressure offFulbourn’s acute services, but there remains no other provision for longterm patients. When the hospital opened, it received 250 patients and for about a decade it was a place of hope and enthusiasm. Gradually it slumped into typically barren and nihilistic custodialism. In 1954 there were 950 patients, of whom about 100 in the admission villas were short-term, 100 were elderly patients near the end of their lives, and the rest had been there for many years, some since before 1900. In the ’50s, Fulbourn took an active part in the open-door movement sweeping British psychiatry. In 1951 the ward doors were all locked. By 1958 they were all open. Open doors were accompanied by the development of active therapy. A sports field was laid out, workshops were begun, and there was an increase in patient freedom. Fulbourn Industries was a sheltered workshop opened in 1956 that now accepts a variety of contracts with local manufacturers. In 1958, a national voluntary organisation made a hostel available in Cambridge for rehabilitating long-term patients. During the ’60s, several therapeutic communities were developed within the hospital, including one which joined the two disturbed wards into one
60-bed, mixed-sex, open-door community. Finally,
an
administrative reorganisation in 1969 grouped together demented patients into a psychogeriatric area, short-term patients into an admission area, and long-term patients into parts of the hospital designated as the social therapy area. A team led by one consultant and two nursing officers developed a system of discussion and administration that enabled experiments to take place and vigorous policies to emerge. In the early ’70s, a number of group homes became available and it soon became clear that as many patients were supported outside the hospital as inside. Unemployment hit our clients hard, and residents in Cambridge began to attend the hospital workshops regularly. Two day centres have evolved in Cambridge offering creative activities, psychotherapy, and long-term support. The Cambridge Mental Welfare Association has also been involved in the support of discharged patients and, by 1979, it had made available three group homes. A part-time social worker was appointed to develop these and new group homes.
626
PRINCIPLES OF REHABILITATION
I. The focus of rehabilitation is the life, how he or she lives and works.
quality
of a
patient’s
2. Commitment to clients is for as long as they want, maybe life-time. Our task is to help them make the most of the rest of their lives. 3. We concentrate on the abilities of the client and not the disabilities and try to find out what skills and what wishes the client has in order to build on them rather than drearily to discuss hallucinations. 4.
Challenges can be more valuable to the client than tender loving care and we must judge when reality confrontation will help more than either compassion or medication. 5. The approach must be multidisciplinary. No one profession has all the answers to rehabilitation and other patients can often be the individual’s most important source of strength. We have to work towards maxiniising the patient’s social support.
attempting to clarify shifting responsibilities. Attention must be paid to the larger organisations of which we are a part and to the community we 6. We constantly review organisation,
l
F -
serve.
7. We also undertake and
publish research on what we
are
doing. THE CAMBRIDGE PSYCHIATRIC REHABILITATION SERVICE
TODAY
In 1982 there were 3 fully staffed inpatient wards where intensive psychiatric work was carried out. Ward A acted as an admission unit, taking in new clients and readmissions, and taking in patients going through periods of disturbance from other parts of the hospital. Wards B and C took severely
psychiatrically or physically disabled patients requiring 24-hour nursing. 4 wards contained people living fairly independently, not requiring night staff but either not ready or too old to live out in the community. The eighth ward functioned mostly as a day ward for the support of people coming in from the community..People could sleep there during a period of crisis. Transitional accommodation consisted of 6 bedsitting rooms, 2 flats, and a cottage. Nurses visited regularly but there was no attempt at constant supervision. Clients lived independent lives, buying and preparing their own food. Six months of living together in the rehabilitation cottage
was
found
to
be
an
essential
preliminary to group home life. The group homes in the community were supervised by both the hospital and the Cambridge Mental Welfare Association. The homes ranged from long-settled, quiet establishments where a staff member called once a week to collect the rent to fragile, stormy homes where staff members visited regularly, even daily, to cope with the turmoils arising between residents. A hostel in which a few clients lived mostly received people from other hospitals and admission wards and another hostel for single homeless men provided some accommodation. Many clients lived in the homes from which they had entered hospital and which occasionally also housed parents or spouses, but the majority were, of course, single. Some had found private accommodation themselves, but in many cases the rehabilitation team had to help clients not only find but also furnish their housing. We have pursuaded housing associations to let flats to our clients with the agreement to visit them and be available should any difficulty arise.
The work in the hospital industrial unit in 1982 was mostly fairly simple-packing manufactured items into cardboard boxes, assembling and packing goods in plastic bags, stamping NHS forms, and so on-but there were several small units where more challenging work was available. In the carpentry workshops furniture was made and repaired. A gardening group ran a successful allotment. The bicycle repair shop repaired bicycles and assembled new ones out of derelict parts. Employment at the sheltered workshop in Cambridge was more sophisticated-the assembly of birdnesting boxes, electrical appliances, and so on. The range of creative activities was considerable. A drama therapist, a music therapist, and two art therapists showed great ingenuity in developing activities that would stimulate people stultified by long-term hospital residence. In 1982 a creative writing group produced a magazine and a drama group put on several shows. One important question remains. When should people move from a highly-staffed to a less-well-staffed ward, from a bedsitter within hospital grounds to a bedsitter in Cambridge? Our aim was always to wait until the client felt ready for the move, had asked for it, and was seen to be ready to face the challenge. Clients would usually request a move and we would discuss it with them and arrange trial periods to test their fitness to move on. The opinion of other residents was often one of the best guides to a person’s suitability. We liked to let people try moving, and if the move was unsuccessful, we would let the client realise this for him or herself and request a more sheltered facility. All units developed their own assessment procedures and, when it was suggested that a client move, a team from the new unit would visit the client to discuss the proposal. We tried to maintain this system even within the hospital, aiming always to keep the initiative with the client. If a long-term client arrived weeping at the hospital and requested a bed, the person on
had authority to arrange an overnight stay as a guest, rather than using the formal admission procedure. When clients understood that they could always return to hospital, they were more prepared to carry on outside. When compulsion was necessary, our objective was for outside authorities to take the initiative so that compulsion was clearly related to the disturbance, in the hope that either then or later the client would learn what would and what would not be tolerated. This policy, of course, involved us at times in protracted and occasionally acrimonious discussions with social workers, general practitioners, and the police. Provided there was no danger, we wanted always to learn as much as possible from the experience. The NHS paid the full-time salary equivalent of 65 nurses, 3 doctors, 112 a clinical psychologist, and 9 creative therapists to serve these 400 patients. 78 staff formed a ratio of approximately 1 staff member to 5 clients-with many other people involved, including social workers,. voluntary workers, and general practitioners. The medical staff included 1 full-time consultant, 1 full-time registrar, 1 parttime clinical assistant, and 1 clinical assistant for one session a week. The psychologist worked part-time and many of the creative therapists also served other parts of the hospital. The nurses included 1 nursing officer, 12 charge nurses, 18 staff nurses, and student nurses or nursing assistants. Economy in the use of staff was achieved by concentrating nurses in the fully staffed wards and not attempting to provide night cover for the other parts of the Rehabilitation Service. Visitors from comparable units in Britain concluded that staffing levels were low, but that staff were notable for their enthusiasm and involvement.
duty
627 CONCLUSIONS
The success of supporting people with long-term disabilities cannot easily be measured. There are no "cures" and few "failures". In 1970, however, there were 267 long-term patients in Fulbourn Hospital. In 1982, despite regular recruitment of about 20 clients a year, there were only 163. With a catchment population of about half a million, this figure is well below the national average. After 30 years of working with the long-term mentally ill and 13 years of running a specialist rehabilitation team, we have drawn the following conclusions. 1. Despite the advances in the treatment of short-term breakdowns and psychotic episodes, there is still a group of people coming out of the acute psychiatric services with longterm disabilities. Among them are people with long-term schizophrenic disabilities who, after 5 or 6 admissions and a decade of psychiatric handling, are crippled and require continuing support. There are also a number of people with other disabilities and with combined disabilities (such as a depressed feeble-minded person with a moderate degree of hemiplegia), people similar to those who were held permanently in the long-stay wards of the old asylums. Their numbers may not be so great but they exist and continue to be produced as a byproduct of the active treatment programmes. 2. Many of these people will require lifelong support. The number of these people in the Cambridge area, out of a population in the region of 400 000, is about 400. The recruitment rate is 10-15 people a year, and there is no evidence of any falling-off in these numbers. 3. The majority can live independently and do not need to spend all their lives in hospital. They can live in the community provided that a sophisticated, well-staffed, and vigorous support service is available. We do find, however, that a back-up inpatient facility for periods of stress is necessary. This support is best provided by a closely knit, well-directed professional team containing social workers, occupational therapists, psychiatric and communitypsychiatric nurses, psychiatrists, and physicians. Since clients require long-term support, the team should be relatively stable. Members should stay for some years and make commitments to individual clients. Clearly, professionals in training and students must be attached to the team to gain experience, but they cannot contribute effectively to the long-term support required. 4. The work, though exciting and rewarding, is challenging and at times very difficult. Junior doctors and nurses are called upon to make decisions about disturbed and disturbing people. Back-up support is vital and risk-taking must be accepted as an essential part of rehabilitation work. 5. The employing authorities, particularly district management teams, must be made to realise that community workers must be well supported. The usual management pattern of neglect and parsimony interspersed with sudden punitive inquiries rapidly produces a second-rate service. Our service developed from a well-staffed psychiatric hospital, but there is no reason why a rehabilitation team should not be based in the community or attached to a general hospital, provided that extra staff were made available. 6. The message to our political masters is clear. There are, always have been, and always will be a substantial number of people in any district suffering from long-term psychiatric disability. A compassionate society must decide where it will care for them. During the 19th century they were herded into asylums and kept there in relative safety but in stultifying and often degrading conditions. In the ’80s it is possible for most
to be maintained in the community -but this is not a A substantial team of well-trained and wellalternative. cheap staff must be provided. Despite saving the NHS supported the cost of feeding and housing long-term patients, maintaining the long-term mentally disordered will continue to be a considerable charge to the community as a whole.
of them
REFERENCE 1.
Anonymous. Everybody’s business. Lancet 1961;
i: 608-09.
Round the World From
our
Correspondents
United States THE HOSPITAL STRIKE IN NEW YORK
WE have become used
to the steady increase in hospital costs, by third-party insurers or by Federal or State governments. So the usual ending to a real or tentative strike of hospital employees has been an award met by increased grants from these third parties and then paid for in higher health care premiums or taxes. But now all these parties, the insurers, the administrations, and industry are baulking. All, in one way or another, are determined to cut health costs. An increasingly bitter strike of hospital employees in New York City has involved some 45 hospitals or medical institutions and 50 000 employees, and it has affected about 17 000 patients. Non-striking staff, volunteers, and family members have given their services to try to maintain care for patients. Temporary employees have been taken on. Heavy fines are being placed on unions whose members have defied their contract terms in striking without adequate notification. The usual accompaniments of strikes have been seen-picketing, sporadic violence, tyre slashing, and sabotage. Hospitals have threatened to fire all striking employees. The staff on strike are members of the Retail, Wholesale and Department Store Workers’ Union, and they include nurses, social workers, technical and laboratory workers, maintenance workers, and other service personnel. They are asking for a 9%
largely
met
increase in pay for each year of a two-year contract. Meanwhile, outpatient and special clinics have been closed, renal dialysis units have been shut down or restricted, and many hospitals have limited admissions to emergency cases. The situation is being carefully watched by the State authorities to ensure that adequate care is being provided for patients, none of whom, it is said, have been adversely affected. From nursing homes, patients have been sent back to the families. The strike is also restricting some of the largest and most prestigious of the city’s hospitals, and it is now reported that many of the volunteer and administrative staff, not to say the physicians and medical students who have pitched in, are reported to be very tired. The union leaders have not succeeded in getting any satisfactory response from the bargaining hospital negotiators and the two sides are still far apart. The union delegates-take issue over the large salaries and yearly increases granted to hospital administrative staff at the expense, they claim, of the lower-paid workers. The institutions concerned boldly state that they cannot afford such increases in hospital workers’ pay, let alone the costs of meeting a whole series of other demands, unless they have increased support from elsewhere. Where? That is the question. The hospitals are even now facing the effects of cuts in financial aid, the new regulations on diagnosis-related groups, and changes in Medicaid and Medicare payments. They do not see the public, or industry, or the insurers making up the deficits which have led some hospitals to declare bankruptcy. The Reagan administration is in deep financial waters, so both sides have turned on the State. Here, there is something new and decisive. The Governor, Mr Mario Cuomo, a determined man, has bluntly stated that New York State will not intervene and will provide no more money than it has previously decided to provide, a 6 -5% inflation factor this year and 6 2% next year. We thus have an impasse and so the strike goes on, and it will have to be settled between the contestants, with the State providing its good offices but no cash.
from
Mental Health THE DEVELOPMENT OF A PSYCHIATRIC REHABILITATION SERVICE
DAVID H. CLARK 33 Highsett, Hills
Road, Cambridge CB21 NY
SINCE 1961, when Mr Enoch Powell, then minister for health, announced’ that large mental hospitals would be defunct by 1975, successive UK governments have enthused the idea of community care for long-term mentally disordered people. In parts of the USA, the notion of community care has been seized on by politicians keen to cut State budgets and make a profit on sales of land. In San Francisco, San Jose, and Boston, for example, the sight of mentally disordered people roaming the streets and scouring the trash cans has provoked both compassion and fear-some citizens are demanding new, more secure institutions. In Italy, reformers have hailed Bassaglia’s radical experiments in Trieste and Venice; some psychiatrists, on the other hand, relate heart-rending tales of long-term patients driven from the security of their asylums. And in Australia, the Richmond report on the Sydney psychiatric service has produced the same split: pioneers describe the freedom of community care and others, whose career depends on the continued existence of asylums, speak of the suffering caused by rehabilitation. The life of people with long-term psychiatric disabilities in Britain has changed radically over the past 30 years. In the early ’50s, patients were locked in the back wards of county asylums. Now they live mostly in group homes, hostels, and half-way houses, attending day centres, psychiatric units in general hospitals, and sheltered workshops. Though there has been the occasional scandal, there can be no doubt that in comparison to the overcrowded and stinking back wards, life in the community is infinitely preferable. The professional debate, however, centres on two questions: whether there should be any people with long-term disabilities; and, if these people exist, how they should best be cared for. Kraepelin, in the 19th century, had divided lunatics into those suffering from manic depressive psychosis and those suffering from dementia praecox. The former group regained their health and left the asylum, but the latter required institutional care for the rest of their lives. Indeed, many authorities built specially designed hospitals for these chronic patients. But the tide of therapeutic enthusiasm that swept over psychiatry from 1930 to 1960, the introduction of physical methods of treatment (insulin coma therapy, ECT, and leucotomy), and the advent of the major and depot tranquillisers led many psychiatrists to believe that psychosis was conquered. All patients would recover permanentlythere need be no more long-term patients. It soon became clear that this was far from true. By the early ’70s, theorists could identify the "new chronic" as someone who remained in hospital despite active treatment, had a history of about 10 years’ contact with psychiatric services, including several admissions to acute units, and was semi-permanently impaired (thought disordered, dependent, and often socially over
deviant). The 19th century alienists had been sure that residence in the new, benign, public asylums was better for someone with a long-term mental disorder than living with uncaring relatives and hostile neighbours. The early superintendents often reported that lunatics and mental defectives released
.
pigsties
LOCAL HISTORY
This paper charts the changes and excitements that have occurred in the Cambridge area. The Cambridge Psychiatric Rehabilitation Service looks after some 400 people with longterm mental disorder: 150 are resident on hospital wards; 100 live in sheltered accommodation; and 150 live in their own homes. Fulbourn Hospital originally opened in 1858 as the Cambridge and Isle of Ely Pauper Asylum. In 1948 its catchment area was Cambridgeshire, Huntingdonshire, the Isle of Ely, the Soke of Peter borough, and the Saffron Walden district. The population has since grown from 350 000 to about 510 000. Psychiatric units in the general hospitals in Wisbech, King’s Lynn, Bury St Edmunds-, and Peterborough have taken some of the pressure offFulbourn’s acute services, but there remains no other provision for longterm patients. When the hospital opened, it received 250 patients and for about a decade it was a place of hope and enthusiasm. Gradually it slumped into typically barren and nihilistic custodialism. In 1954 there were 950 patients, of whom about 100 in the admission villas were short-term, 100 were elderly patients near the end of their lives, and the rest had been there for many years, some since before 1900. In the ’50s, Fulbourn took an active part in the open-door movement sweeping British psychiatry. In 1951 the ward doors were all locked. By 1958 they were all open. Open doors were accompanied by the development of active therapy. A sports field was laid out, workshops were begun, and there was an increase in patient freedom. Fulbourn Industries was a sheltered workshop opened in 1956 that now accepts a variety of contracts with local manufacturers. In 1958, a national voluntary organisation made a hostel available in Cambridge for rehabilitating long-term patients. During the ’60s, several therapeutic communities were developed within the hospital, including one which joined the two disturbed wards into one
60-bed, mixed-sex, open-door community. Finally,
an
administrative reorganisation in 1969 grouped together demented patients into a psychogeriatric area, short-term patients into an admission area, and long-term patients into parts of the hospital designated as the social therapy area. A team led by one consultant and two nursing officers developed a system of discussion and administration that enabled experiments to take place and vigorous policies to emerge. In the early ’70s, a number of group homes became available and it soon became clear that as many patients were supported outside the hospital as inside. Unemployment hit our clients hard, and residents in Cambridge began to attend the hospital workshops regularly. Two day centres have evolved in Cambridge offering creative activities, psychotherapy, and long-term support. The Cambridge Mental Welfare Association has also been involved in the support of discharged patients and, by 1979, it had made available three group homes. A part-time social worker was appointed to develop these and new group homes.
626
PRINCIPLES OF REHABILITATION
I. The focus of rehabilitation is the life, how he or she lives and works.
quality
of a
patient’s
2. Commitment to clients is for as long as they want, maybe life-time. Our task is to help them make the most of the rest of their lives. 3. We concentrate on the abilities of the client and not the disabilities and try to find out what skills and what wishes the client has in order to build on them rather than drearily to discuss hallucinations. 4.
Challenges can be more valuable to the client than tender loving care and we must judge when reality confrontation will help more than either compassion or medication. 5. The approach must be multidisciplinary. No one profession has all the answers to rehabilitation and other patients can often be the individual’s most important source of strength. We have to work towards maxiniising the patient’s social support.
attempting to clarify shifting responsibilities. Attention must be paid to the larger organisations of which we are a part and to the community we 6. We constantly review organisation,
l
F -
serve.
7. We also undertake and
publish research on what we
are
doing. THE CAMBRIDGE PSYCHIATRIC REHABILITATION SERVICE
TODAY
In 1982 there were 3 fully staffed inpatient wards where intensive psychiatric work was carried out. Ward A acted as an admission unit, taking in new clients and readmissions, and taking in patients going through periods of disturbance from other parts of the hospital. Wards B and C took severely
psychiatrically or physically disabled patients requiring 24-hour nursing. 4 wards contained people living fairly independently, not requiring night staff but either not ready or too old to live out in the community. The eighth ward functioned mostly as a day ward for the support of people coming in from the community..People could sleep there during a period of crisis. Transitional accommodation consisted of 6 bedsitting rooms, 2 flats, and a cottage. Nurses visited regularly but there was no attempt at constant supervision. Clients lived independent lives, buying and preparing their own food. Six months of living together in the rehabilitation cottage
was
found
to
be
an
essential
preliminary to group home life. The group homes in the community were supervised by both the hospital and the Cambridge Mental Welfare Association. The homes ranged from long-settled, quiet establishments where a staff member called once a week to collect the rent to fragile, stormy homes where staff members visited regularly, even daily, to cope with the turmoils arising between residents. A hostel in which a few clients lived mostly received people from other hospitals and admission wards and another hostel for single homeless men provided some accommodation. Many clients lived in the homes from which they had entered hospital and which occasionally also housed parents or spouses, but the majority were, of course, single. Some had found private accommodation themselves, but in many cases the rehabilitation team had to help clients not only find but also furnish their housing. We have pursuaded housing associations to let flats to our clients with the agreement to visit them and be available should any difficulty arise.
The work in the hospital industrial unit in 1982 was mostly fairly simple-packing manufactured items into cardboard boxes, assembling and packing goods in plastic bags, stamping NHS forms, and so on-but there were several small units where more challenging work was available. In the carpentry workshops furniture was made and repaired. A gardening group ran a successful allotment. The bicycle repair shop repaired bicycles and assembled new ones out of derelict parts. Employment at the sheltered workshop in Cambridge was more sophisticated-the assembly of birdnesting boxes, electrical appliances, and so on. The range of creative activities was considerable. A drama therapist, a music therapist, and two art therapists showed great ingenuity in developing activities that would stimulate people stultified by long-term hospital residence. In 1982 a creative writing group produced a magazine and a drama group put on several shows. One important question remains. When should people move from a highly-staffed to a less-well-staffed ward, from a bedsitter within hospital grounds to a bedsitter in Cambridge? Our aim was always to wait until the client felt ready for the move, had asked for it, and was seen to be ready to face the challenge. Clients would usually request a move and we would discuss it with them and arrange trial periods to test their fitness to move on. The opinion of other residents was often one of the best guides to a person’s suitability. We liked to let people try moving, and if the move was unsuccessful, we would let the client realise this for him or herself and request a more sheltered facility. All units developed their own assessment procedures and, when it was suggested that a client move, a team from the new unit would visit the client to discuss the proposal. We tried to maintain this system even within the hospital, aiming always to keep the initiative with the client. If a long-term client arrived weeping at the hospital and requested a bed, the person on
had authority to arrange an overnight stay as a guest, rather than using the formal admission procedure. When clients understood that they could always return to hospital, they were more prepared to carry on outside. When compulsion was necessary, our objective was for outside authorities to take the initiative so that compulsion was clearly related to the disturbance, in the hope that either then or later the client would learn what would and what would not be tolerated. This policy, of course, involved us at times in protracted and occasionally acrimonious discussions with social workers, general practitioners, and the police. Provided there was no danger, we wanted always to learn as much as possible from the experience. The NHS paid the full-time salary equivalent of 65 nurses, 3 doctors, 112 a clinical psychologist, and 9 creative therapists to serve these 400 patients. 78 staff formed a ratio of approximately 1 staff member to 5 clients-with many other people involved, including social workers,. voluntary workers, and general practitioners. The medical staff included 1 full-time consultant, 1 full-time registrar, 1 parttime clinical assistant, and 1 clinical assistant for one session a week. The psychologist worked part-time and many of the creative therapists also served other parts of the hospital. The nurses included 1 nursing officer, 12 charge nurses, 18 staff nurses, and student nurses or nursing assistants. Economy in the use of staff was achieved by concentrating nurses in the fully staffed wards and not attempting to provide night cover for the other parts of the Rehabilitation Service. Visitors from comparable units in Britain concluded that staffing levels were low, but that staff were notable for their enthusiasm and involvement.
duty
627 CONCLUSIONS
The success of supporting people with long-term disabilities cannot easily be measured. There are no "cures" and few "failures". In 1970, however, there were 267 long-term patients in Fulbourn Hospital. In 1982, despite regular recruitment of about 20 clients a year, there were only 163. With a catchment population of about half a million, this figure is well below the national average. After 30 years of working with the long-term mentally ill and 13 years of running a specialist rehabilitation team, we have drawn the following conclusions. 1. Despite the advances in the treatment of short-term breakdowns and psychotic episodes, there is still a group of people coming out of the acute psychiatric services with longterm disabilities. Among them are people with long-term schizophrenic disabilities who, after 5 or 6 admissions and a decade of psychiatric handling, are crippled and require continuing support. There are also a number of people with other disabilities and with combined disabilities (such as a depressed feeble-minded person with a moderate degree of hemiplegia), people similar to those who were held permanently in the long-stay wards of the old asylums. Their numbers may not be so great but they exist and continue to be produced as a byproduct of the active treatment programmes. 2. Many of these people will require lifelong support. The number of these people in the Cambridge area, out of a population in the region of 400 000, is about 400. The recruitment rate is 10-15 people a year, and there is no evidence of any falling-off in these numbers. 3. The majority can live independently and do not need to spend all their lives in hospital. They can live in the community provided that a sophisticated, well-staffed, and vigorous support service is available. We do find, however, that a back-up inpatient facility for periods of stress is necessary. This support is best provided by a closely knit, well-directed professional team containing social workers, occupational therapists, psychiatric and communitypsychiatric nurses, psychiatrists, and physicians. Since clients require long-term support, the team should be relatively stable. Members should stay for some years and make commitments to individual clients. Clearly, professionals in training and students must be attached to the team to gain experience, but they cannot contribute effectively to the long-term support required. 4. The work, though exciting and rewarding, is challenging and at times very difficult. Junior doctors and nurses are called upon to make decisions about disturbed and disturbing people. Back-up support is vital and risk-taking must be accepted as an essential part of rehabilitation work. 5. The employing authorities, particularly district management teams, must be made to realise that community workers must be well supported. The usual management pattern of neglect and parsimony interspersed with sudden punitive inquiries rapidly produces a second-rate service. Our service developed from a well-staffed psychiatric hospital, but there is no reason why a rehabilitation team should not be based in the community or attached to a general hospital, provided that extra staff were made available. 6. The message to our political masters is clear. There are, always have been, and always will be a substantial number of people in any district suffering from long-term psychiatric disability. A compassionate society must decide where it will care for them. During the 19th century they were herded into asylums and kept there in relative safety but in stultifying and often degrading conditions. In the ’80s it is possible for most
to be maintained in the community -but this is not a A substantial team of well-trained and wellalternative. cheap staff must be provided. Despite saving the NHS supported the cost of feeding and housing long-term patients, maintaining the long-term mentally disordered will continue to be a considerable charge to the community as a whole.
of them
REFERENCE 1.
Anonymous. Everybody’s business. Lancet 1961;
i: 608-09.
Round the World From
our
Correspondents
United States THE HOSPITAL STRIKE IN NEW YORK
WE have become used
to the steady increase in hospital costs, by third-party insurers or by Federal or State governments. So the usual ending to a real or tentative strike of hospital employees has been an award met by increased grants from these third parties and then paid for in higher health care premiums or taxes. But now all these parties, the insurers, the administrations, and industry are baulking. All, in one way or another, are determined to cut health costs. An increasingly bitter strike of hospital employees in New York City has involved some 45 hospitals or medical institutions and 50 000 employees, and it has affected about 17 000 patients. Non-striking staff, volunteers, and family members have given their services to try to maintain care for patients. Temporary employees have been taken on. Heavy fines are being placed on unions whose members have defied their contract terms in striking without adequate notification. The usual accompaniments of strikes have been seen-picketing, sporadic violence, tyre slashing, and sabotage. Hospitals have threatened to fire all striking employees. The staff on strike are members of the Retail, Wholesale and Department Store Workers’ Union, and they include nurses, social workers, technical and laboratory workers, maintenance workers, and other service personnel. They are asking for a 9%
largely
met
increase in pay for each year of a two-year contract. Meanwhile, outpatient and special clinics have been closed, renal dialysis units have been shut down or restricted, and many hospitals have limited admissions to emergency cases. The situation is being carefully watched by the State authorities to ensure that adequate care is being provided for patients, none of whom, it is said, have been adversely affected. From nursing homes, patients have been sent back to the families. The strike is also restricting some of the largest and most prestigious of the city’s hospitals, and it is now reported that many of the volunteer and administrative staff, not to say the physicians and medical students who have pitched in, are reported to be very tired. The union leaders have not succeeded in getting any satisfactory response from the bargaining hospital negotiators and the two sides are still far apart. The union delegates-take issue over the large salaries and yearly increases granted to hospital administrative staff at the expense, they claim, of the lower-paid workers. The institutions concerned boldly state that they cannot afford such increases in hospital workers’ pay, let alone the costs of meeting a whole series of other demands, unless they have increased support from elsewhere. Where? That is the question. The hospitals are even now facing the effects of cuts in financial aid, the new regulations on diagnosis-related groups, and changes in Medicaid and Medicare payments. They do not see the public, or industry, or the insurers making up the deficits which have led some hospitals to declare bankruptcy. The Reagan administration is in deep financial waters, so both sides have turned on the State. Here, there is something new and decisive. The Governor, Mr Mario Cuomo, a determined man, has bluntly stated that New York State will not intervene and will provide no more money than it has previously decided to provide, a 6 -5% inflation factor this year and 6 2% next year. We thus have an impasse and so the strike goes on, and it will have to be settled between the contestants, with the State providing its good offices but no cash.