population was involved in service industries and par-
Comment
We have been subjected to a considerable amount
of propaganda on the benefits that will accrue to the
National Health Service as a result of the projected
changes to come about on April 1, 1974.
The appointments made to date, however, suggest
no more than another round of play in the whist drive,
with a re-shuffle of the old pack, a change of trumps
and a more complicated set of rules than we had
before.
In subnormality more than in any other speciality,
we should by now have become accustomed to the
periodic announcement of a new deal for all. Although
our hopes have rarely been fulfilled, our fears have
come true with monotonous regularity. When the so
called “changes” are examined from the shop floor,
one cannot avoid wondering whether the ministerial
optimism expressed in Parliament is really justified.
In recent years, despite proclamations to the
contrary, hospital management committees, who
should more than any other body be aware of actual
need, have gradually had their freedom of action
reduced. For instance, the present ceiling of f1,000
which they can spend without reference to their
Regional Hospital Boards makes nonsense of any talk
of “freedom to manage their affairs”. In terms of
today’s costs, this is no more than the equivalent of a
five-year-old child’s pocket money.
We must assume that this has come about because
of a lack of confidence in the advisers and members
of the HMC’s by the powers higher up the scale. Yet
we are now informea that committees which will be
composed largely of the same members and advisers,
with some re-arrangement of their duties, will quite
spontaneously from April 1, 1974, become rejuvenated
into dynamic, imaginative groups. This change is
most unlikely unless there is a complete change of
heart from above, with a restoration of real power
and a relinquishing of a great deal of the time-wasting
and unnecessary bureaucratic control that exists
today.
NHS “a growth industry”
Sir Keith Joseph, the Secretary of State for Social
Services, must have aroused a warm response in his
audience at Coleshill Hall Hospital on his recent visit
there when he described the Health Service as a
growth industry of the future.
He looked ahead to the time when agriculture was
in the hands of a very small minority of the population,
manufacture in the hands of a larger but still small
minority, and the bulk of the nation’s working
2
ticularly in the field of leisure, education, health and
care.
Such a comment is likely to be particularly
welcomed by an audience involved in work for the
mentally handicapped. It has been grossly under-
financed in the past. It has been dogged by the
prejudices that always turn communities against those
who do not conform to the accepted patterns of
appearance or behaviour; and this rejection was
reinforced by the institutional philosophy which
became firmly established during the latter’ half of
the 19th-century when patients were incarcerated in
remote institutions which were often no more than
pleasantly situated prisons.
Even today there is a danger, emancipated from
institutionalism though we pride ourselves on being, of
thinking of “the mentally handicapped” as a collective
entity, a mass of people, rather than an assorted
group of individuals with distinct characteristics of
their own. Perspectives differ; some people climb the
Matterhorn, some Everest, but for John to learn to
dress and feed himself may actually be an achieve-
ment of a comparable order of magnitude.
We in Apex try to reflect this sort of personal
endeavour and accomplishment and perhaps we should
do more. Since we circulate to lay as well as
professional readers it is the means easiest to our
hands to project work in the field of mental handicap
as being far more than patient-minding. Certainly,
if more people are to be attracted to work in our
hospitals we have to show them that there are
profound rewards in human terms.
We also have to make sure that the material
rewards are at least fair and adequate, and here we
face a wider problem. Reassuring though it is to
hear a politician of Sir Keith’s eminence speaking so
firmly about the future role of service industries, we
cannot help recalling that it is less than eight years
since selective employment tax was introduced
specifically to restrain the growth of service industries
and to divert more people into manufacturing. At
that time service^' was so much a dirty word that
the original proposal, later withdrawn, was to impose
SET on charities as well as commercial undertakings.
If now there is to be the shift Sir Keith envisages
- and in the radical terms in which he clearly
envisages it - it implies making the service industries,
and particularly the Health Service, a field in which
the worker does not feel that he is making a financial
sacrifice if he enters it. Pay will have to be looked
at, so that it competes with manufacturing industry,
and there will need to be greater emphasis on initial
training for entry and also on the development of
in-service courses so that staff can have further
training, or even re-train for a different job altogether.
Wrong answer
One can understand the discussion and, indeed,
the perturbation among nurses about the future of
their profession, and there is certainly cause for great
pleasure in the animated discussion which went on in
the day conference arranged by the Institute to discuss
the future of the subnormality trained nurse. And
yet . . . .
A total of 285 nurses of all grades attended. During
the meeting, they were given voting forms so as to
ascertain Zheir views about the future of the
profession. Only 124 people voted: the figures are
given in the article by D. G. McCullagh. Seven of
the 124 voted for mainstream Briggs and 75 - that
is 60 per cent of those voting wanted an independent
service staffed and controlled by nurses with responsi-
bility to central Government.
Now it is surely depressing, first that so few
troubled to vote at all. They were, after all, virtually
a captive audience faced with none of the minor
irritations involved in putting forms in envelopes and
posting them off which often account for low
responses to questionnaires.
It is also depressing, however, that so many of them
should have plumped for such a thoroughly unrealistic
system. At a time when the emphasis is so heavily,
and pro,uerly, on closer integration, when the concept
of administration by teams of officers is now built
into the Health Service, the majority option was for
a scheme which in political terms and in the context
of the needs of the National Health Service is
impracticable.
A service as fundamental as nursing simply cannot
hive itself off into a separate category without doing
grave harm to the whole system and to itself as well.
Separatism is not an answer: the general practitioner
service is about the nearest parallel to what these
nurses would like to see, and no one can be happy
about the responsiveness of many general practitioners
to the evolving needs of the Health Service.
Nursing belongs in the mainstream of health
activity. Its problems cannot be solved by jiggling
about with the organisational framework. They will
be solved as nurses progressively develop a greater
sense of their own professional standing and their
own involvement with the service at so many points.
In mental handicap, which has for so long been a
backwater of the service, nurses have had an especially
unsatisfying time. One sympathises; and one wel-
comes the militancy and the determination to be on
the move that were such a marked feature of the
conference. The spirit is right: the objective, as
expressed in the response to the questionnaire.
misconceived.
Aims and dependency
The reduction of overcrowding described by Dr.
Spencer is very significant for the future of all
establishments dealing with the mentally handicapped.
Dr. Spencer refers to the variation in staff attitudes -
from cautious and pessimistic on the one hand to
over-enthusiastic expectation on the other. The view
expressed by staff that a reduction in establishments
might follow a reduction in the number of patients is,
of course, a very real fear, but it needs to be set in
perspective.
In most subnormality hospitals at least 20 per cent
of the adult population could be dicharged with a
minimum of effort. Dr. Spencer has achieved a
reduction of one-quarter of the total number in just
under five years. It is true to say that the first 20
per cent need the least effort while the next 10 per
cent will prove more difficult and, as one goes further
down the scale, the effort required in treatment,
training and management will be considerably greater.
The moral is clear. Staff freed by the discharge of
patients will be immediately absorbed again by the
imperative need to improve standards of care and
training for the patients left behind. And that leaves
out of consideration altogether the mentally handi-
capped in the community who should be in hospital
now but for whom there is no room.
Hospital authorities should aim at providing
sufficient staff to enable them to become involved with
ongoing improvement and not simply containment.
Under these circumstances it is clear that staff ratios
must increase for many years to come if a proper
service which must include getting patients to a
dischargeable level is to be increased and maintained.
Staff attitudes
This journal has frequently referred to staff
attitudes. Results at Meanwood Park speak for
themselves; of one group of 77 discharged only 6
returned over a period of three years. This surely
makes nonsense of any arguments put forward by the
pessimists.
Protagonists of the view that patients should not
be discharged, frequently put forward reasons such as:
“the patient’s best interests, happiness, contentment,
etc.”. One finds that these are no more than
assumptions based on their own convictions and the
outcome of the paternalistic role they have played for
years and are loth to abandon. How many of the
anti-discharge lobby have ever given their clients a
free choice in the matter? How many have lifted
totally the restrictions of thirty years ago? What sort
of life and existence do their clients lead in the anti-
discharge establishment which is assumed to be better
for them? Whenever and wherever the answers have
been sought the results indicate that life in such
establishments is dull, dreary, stereotyped and lacks
any freedom for the individual when compared with
others aiming at re-training, sociaiising and ultimately
discharging their patients.
The overall demand for places remains high,
especially for the multiply handicapped, and a policy
of stagnation in one hospital must inevitably place a
greater load on others in the neighbourhood. The
White Paper Better Services for the Mentally Handi-
cupped published in 1971 has clearly defined the
policy to be followed both in hospitals and in the
community. Conservatism or prejudice should not
be permitted to retard its implementation. We are
well aware of the problems posed by institutionalised
patients. What is to be done about institutionalised
staff?
‘Roles’ in mental subnormality
Hardly a week goes by without some official or
professional body somewhere issuing a document on
the role of its members in the speciality of mental
subnormality. Dr. Michael Craft describes in this
journal the history, management and treatment, and
its outcome, of a 15-year-old girl. Major roles were
played by doctor, nurse and various members of the
community and general hospital services in putting
to rights a child’s tragic life. When confronted with
problems such as this, the defence or belittling of some
roles as opposed to others, which frequently takes
place at symposia, detached from reality, appears
squalid and pointless.
Discussion on the roles of the nurse, doctor,
teacher, psychologist and all the other people involved
with the mentally handicapped should be related to
the needs of the patient and it should not disintegrate
into demarcation disputes which so frequently
happens. The needs of the patient or client, not the
needs of those appointed to help him, should determine
the pattern of help and the personnel involved. If
there were a more practical approach to the problem
along these lines, if the various disciplines would
more readily admit their need for each other, there
could be far more constructive and useful discussion
on the method of application of the respective skills
of the workers involved.
“Hand” to hand
An interesting venture is under way in Totnes.
Devon, signalised by the arrival of the first issue of
Hand, the duplicated journal of the Totnes Action
Group for Handicapped Children.
The group was formed to counter opposition to
proposals to build a new special school in Dartington
and its attitude, to judge by Hand, is both blunt and
inquiring. An editorial says:
“We believe that there is an almost passive accept-
ance on behalf of the caring professions of the status
quo and that as individuals they are not nearly active
enough in demanding more resources to help the
handicapped cope with dignity. At the same time
there are probably all sorts of reasons for this which
we as parents are only dimly aware of. Thus we
extend an invitation to doctors, teachers, social
workers, and other officials to write about some of
the difficulties which they meet in their day-to-day
work in response to what the parents have to say in
the pages of this journal.”
Hand has articles about difficulties faced by parents.
and records events and new developments in local
authority and voluntary services for all handicapped
children, whether the handicap be physical or mental.
It costs lop (postage extra) from Mrs. Rod Ballard.
Robins Court, Orchard Way, Totnes, Devon.
“Sir .... .99
In our last issue there were three letters from
readers, in this issue one, and that from Dr. D. A.
Spencer, Physician Superintendent of Meanwood Par!;
Hospital, Leeds, who takes up a point raised by Miss
Sheila Hodgetts, social worker at St. Margaret’s
Hospital, Great Barr, Birmingham, and, incidentally,
elaborates on his own article in this issue.
We are not altogether happy about this sparse
correspondence from readers (who, incidentally, are
steadily increasing in number). Apex is a forum
open to many, not a pulpit reserved for the select
few. If the journal is to realise its fun potential as a
meeting ground of members of all disciplines, as a
point of contact between laymen interested in mental
subnormality and professionals, then its correspon-
dence column has a vital role to play. It is important
to us, too, since it is the best way of all of learning
what concerns our readers.
True, we are a quarterly, and that means a letter-
writer may have to wait quite a long time for reaction
to what he has said. But we publish a great deal
more frequently than some of the learned journals
which come out annually or even every other year
and which oblige a correspondent to wait agonisingly
until he can carry on the debate.
We reserve the right to shorten letters if they
become excessively prolix, though it is not a right we
expect to have to exercise very often. It is easier to
get a letter into Apex than into the Times and,
touching a respectful forelock to Printing House
Square, we would say that our columns give you by
far the more selective and the more discriminating
audience. It is yours for the asking.