THE STORY OF A MENTAL HOSPITAL: FULBOURN, 1858-1983

by David H. Clark

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7 Rehabilitation

From the late 1970s Fulbourn’s interest in social therapy shifted to the people who were moving out of hospital – the people requiring rehabilitation. During the next decade a unique psychiatric rehabilitation service was developed in Cambridge making use of the skills, insights and attitudes that had been developed in years of ward social therapy with inpatients.

In the 1940s the word ‘rehabilitation’ was seldom heard in British psychiatry. The hope was that a person’s mental illness would be totally cured by medical skill and that he would then manage without future help. In those days ‘rehabilitation’ was a medical term reserved for those who worked with war wounded, helping them back to full function. Only gradually was the medical use of the word extended – in the 1950s to those with chronic physical diseases, such as asthma and stroke, and then in the 1960s to psychiatric disorders. By then, at Fulbourn we were just beginning to realise that the process of regaining social competence was far harder for long-term patients from mental hospitals than we had at first thought. It was not enough for us to provide freedom, activity and responsibility or work and opportunities to leave hospital. Many long-stay people were too crippled (either by their long incarceration or by their original psychotic disorders) to manage the transition on their own. It was at Winston House that I first became aware of the magnitude of the problem. For the first decade after its opening in 1958 ex-patients passed through rapidly – 360 in the first eight years – but then the flow slowed. Some people seemed unable to move further and stayed in Winston House for years. In the hospital, too, we found that long-stay people were coming back because they had found life outside too difficult.

Within the hospital the need for rehabilitation gradually emerged. Immediately after the war, all the long-stay patients – some 850 of them – had been housed in the main building, strictly divided into male and female wings. There was limited specialisation amongst these wards, apart from the two ‘sick wards’ (M4 and F4) and the two ‘disturbed wards’ (M5 and F5). Most of the long-stay patients were quietly living on wards with no specified function, which held a mixture of people at different levels of social capacity, from helpless people who had to be fed and cleaned to competent ‘ward workers’ who did most of the domestic work of the wards. The wards were locked and firmly controlled by nurses. Many of the patients worked in departments of the hospital – men on the Garden Gang; the Farm Gang, the Engineer’s digging gang, women in the kitchen, the vegetable preparation room, the laundry, the corridor scrubbing party. It was all low-grade work, indifferently and sloppily performed, ill-supervised and unchallenging – but at least it got them off the wards. A few elite patients had fairly skilled and responsible jobs – elite ward worker, hospital messenger, hospital librarian, assistant storekeeper, gardener to the resident doctors, or domestic maid for the Superintendent, the Matron or the doctors. All these activities were traditional in the asylum. They were justified as being necessary to keep the institution running at a low cost to the ratepayers. Their value as therapy or rehabilitation was seldom considered – some ward nurses were even quite open about ‘holding on to the key workers’ in order to get the housekeeping tasks done.

In the 1950s, we began to change the life of the patients, with the ‘Work for All’ programme, the open doors and the ‘Activity, Freedom and Responsibility’ ethos. The wards were opened, but few changes in their functions were made. It gradually became clear that wards with a mixture of patients were an obstacle to effective work programmes. When Kent House was opened in 1964 a major rearrangement of the long-term wards at last became possible. The medical responsibilities for the long-stay patients in the main building were rearranged several times during the 1960s, each time towards better-defined functions. When the Nursing Service was unified under Jack Long in 1966 it became possible to regroup the wards and we created the psychogeriatric, intensive nursing and rehabilitation areas. With a Nursing Officer in charge, each of these areas now had clear leadership, a Consultant and a Nursing Officer, for each area. All the nurses (especially the Charge Nurses) were answerable to them. Treatment teams were formed and examined their tasks with zest. This rearrangement tapped much therapeutic potential and Charge Nurses, who now worked in wards with clearly defined functions, began to develop their work energetically.

Oliver Hodgson’s Geriatric Area began to face the problems of the increasing number of very frail elderly and developed links with the other Geriatric Services in the City. My Intensive Nursing Area plunged into the excitement of Therapeutic Communities – on Hereward House, Mitchell Ward and others. Ross Mitchell threw himself into the tasks of the Rehabilitation Area and over the next three years started many new projects. The rehabilitation wards had been open for years. Some now became mixed-sex wards and promoted social activities. Others began to encourage their patients to go out to work. The number of patients on Ross Mitchell’s wards dropped sharply.

The building on the hill, the Occupational Therapy Department, became available for ward use in 1957. This building was named Ely Ward (because Ely Cathedral was visible from it on a clear day). In the early 1960s it had been used as a dormitory for male patients who were doing privileged work within the hospital and then as a hostel for the men going out to work in Cambridge by day. When Ross Mitchell took it over in 1966 he began to develop it as a Day Centre for ex-patients now living in Cambridge. They used it as a lunchtime canteen, a club and a place where they could spend a few nights if necessary. This gradually developed and it became known as the Ely Day Centre. In 1977 the Ely Day Centre and its treatment team moved to a church hall in Cambridge and operated from there. This ‘Day Clinic’ became a central part in the developing system of Day Care in Cambridge City. Ross Mitchell also started a Rehabilitation Clinic, where each week selected patients were reviewed by the Consultant, Nurses and the Disablement Resettlement Officer (DRO) of the Ministry of Labour. In those days of full employment they were often able to suggest appropriate work and then move the patient out to it.

In 1969, when Ross Mitchell took on other tasks, the remaining Rehabilitation Wards – Mitchell, Ferndale and Ely – were handed over to me, to form a new unit with the Intensive Nursing Wards. We decided to call this the ‘Social Therapy Area’ (STA). It became the centre of the Rehabilitation Programme at Fulbourn Hospital and my main clinical work for my last 14 years. I was fortunate in getting a succession of able and devoted Nursing Officers working with me over these years – Eric Raines, Maurice Fenn, Ruby Mungovan, John Wise, John Lambert, and others. We gradually became more specialised. In 1977 I gave up admission ward work and routine outpatient work to concentrate on the problems of the long-term patients. Gradually I recruited occupational therapists, psychologists and social workers who like me were interested in long-term patients and their rehabilitation and growth. As the focus of our work sharpened we became steadily more aware of the needs of this kind of patient and developed a pattern which became a model for similar rehabilitation services that developed elsewhere in the country during the 1980s.

The Social Therapy Area developed a special flavour and many staff who had been active in ward social therapy and therapeutic community work in Fulbourn Hospital gravitated there; lively and innovative nurses and creative therapists competed for the chance to work there. They were keen to maintain the tradition of egalitarian working together and the multi-disciplinary approach they had enjoyed in therapeutic community wards. They all accepted the need constantly to review and change the work we were doing, and to alter the social structure in which we worked. Every Thursday all the staff at the STA met for an hour in what became the ‘Parliament’ of the STA. At first I took the chair, but members pointed out the disadvantages of investing too much power in one person and so we elected a Chairman annually. Chairing a session was a challenging task for it was a turbulent meeting with many new ideas and an over-talkative Consultant! However, it worked very well and was a forum for innovations. It was here we developed our pattern of first acknowledging a problem and then investigating it fully before we took action. We began to survey and analyse our work and issue regular reports and papers.

We carefully examined our relationship with other parts of the hospital. In the first year or two we transferred a few elderly people to the Psychogeriatric Area but then decided that as long as our patients remained active and alert, however old they were, they should stay with us. The case of the hospital assistant storeman, George – who had been an inpatient for some 30 years – changed our view on this. George had always resisted any suggestion that he should ‘retire’ at 65. We allowed him to stay on one of the rehabilitation wards and he continued to go to the stores daily. He was thereby able to live an active and useful life until he succumbed to a brief pneumonia at the age of 83.

Some patients from the Admission Wards found their way into the Social Therapy Area. How and why this happened was not entirely clear. The belief of psychiatrists in the fifties and sixties had been that modern treatment would cure all acute episodes of mental illness and that therefore no one in future would need to become a long-stay patient. By the 1970s it was becoming clear that this was not the case and there was talk of ‘new long-stay’ patients. In 1972 Junichi Suzuki, one of our Senior Registrars, obtained a research grant to investigate the problem in Fulbourn. He soon showed that the hospital was recruiting about 17 new long-stay patients every year. He investigated their characteristics and made analyses of these. He came up with a most interesting finding – that most of these patients had been moved from the admission to the long-stay wards almost by accident. Often he could find nothing in the records to explain why the change had been made – or even that it has happened. There was nothing written down in the clinical notes as the move had often been done at a weekend to ‘ease overcrowding’. This finding forced the rehabilitation team to think hard about the process by which a ‘short-term patient’ became a ‘long-term resident’. We realised that it was a complex social event containing a lot of disappointment and despair for all parties concerned – for the short-term treatment staff, for the patient himself and for the family. We decided to bring some of this out into the open and set up an Assessment team. Their job was to interview and assess anyone whom admission wards proposed for a move to the Social Therapy Area and to investigate all alternatives before agreeing to the transfer.

Other cherished theories were also explored and challenged. In the 1950s we had a notion of a ‘ladder of rehabilitation’ by which people would pass from one rehabilitation task to another until they were ready for discharge. This idea was very popular in other hospitals’ Rehabilitation Programmes. An analysis by Eddie Oram in 1964 of discharges showed that this ‘ladder’ was a myth. Some people were discharged when quite low on the ladder, while patients in top-level jobs hardly ever seemed to leave. Eddie and I wrote a paper about this entitled ‘Working for the Hospital’ (Clark and Oram, 1966), in which we pointed out that gaining an elite job in the hospital seemed to be very prejudicial to one’s chances of discharge. As a result of our finding we actively encouraged discharges from all of our wards.

Later, we realised that discharged patients liked to keep in touch with their ward, their former friends, and the nurses they had known. Their relatives also valued a continuing contact with the ward staff. We therefore gradually developed in the late 1970s a system of community visiting by ward staff. These staff were allowed to go out to visit their former clients any time the ward could spare them. This was greatly valued by the patients and their relatives and often avoided a readmission. This policy, however, was anathema to tidy-minded administrators. Treasurers objected to paying travelling expenses to staff who were not ‘registered car users’. Central offices were much annoyed to ring a ward and have a patient tell them that ‘All the nurses are out on visits.’ Some social workers and qualified community psychiatric nurses felt they should be the only people to visit patients’ homes – ‘because we alone are competent to do this important work’. We were even criticised by a nurse administrator member of a Hospital Advisory Service team when she discovered that we did not require all outside visits to be programmed and authorised days ahead. All these criticisms we met and countered one by one. We showed how long-stay patients in the community benefited from an arrangement whereby they could be visited (at short notice if necessary) by a member of the ward team who knew them personally.

During the 1960s we had begun to explore the provision of Group Homes for long-term patients who could be released to live in the community. The Cambridgeshire Mental Welfare Association, which had helped to get Winston House started in 1958, took up this new idea of small homes for ex-patients. They opened their first Group Home in 1965 and provided a series of them over the years. As the idea succeeded other bodies helped – local authorities, the hospital and the Granta Housing Association. Whenever we found on a ward a group of congenial friends who were willing to move out, we would persuade a local authority to lease them a house. Initially, these were highly successful and several groups of steady patients moved out and kept going well. Later, when we tried this with more crippled people, difficulties arose. We soon found that many long-stay patients were woefully deficient in domestic skills; they did not know how to cook, to budget, or to shop in the supermarkets of the 1970s. Some had lost these skills; many had never had them. Many, after 20 or 30 years in the Institution, were appalled at the clamour, bustle and high prices in the shops. We therefore took over a former staff house in the grounds and made it into a ‘Rehabilitation Cottage’. We would move into it a group of people who seemed ready and willing to depart and over several months the occupational therapists would work with them, taking them out shopping, helping them to prepare meals and to look after the house. It was a useful testing ground; several patients decided that domestic life was too much for them and moved back to the wards. But any group who did finally move out were well-prepared for life outside.

Amongst those who benefited from the Group Homes was my old friend Jane who had been at the centre of the storms and fights in Hillview when I started the ward meetings in 1960. Over the years her hallucinations and violence had become less marked and she was now a cheerful, sturdy middle-aged woman. She was, however, still simple-minded and impulsive and could erupt in rage if thwarted. She lived on a quiet ward and worked in Fulbourn Industries on simple work. It seemed as if she would live out her days in the mental hospital. Then she expressed an interest in a Group Home. The first attempt was a disaster and she had to return after a fight in a village shop. We then proceeded more slowly; she had a long period in the Rehabilitation Cottage acquiring simple domestic skills and we then tried her in a Group Home in Fulbourn Village, with two other simple-minded, long-term people. This threesome seemed quiet and content, but then came complaints of their level of hygiene. I went to inspect and was appalled; the stove was thick with grease, the lavatory was blocked, cockroaches were everywhere. We had to help them. We arranged for regular visits from a Community Psychiatric Nurse, and weekly visits from a Home Help. The home became clean, tidy and welcoming. Jane lived there peacefully for years – but the team kept in touch.

We set aside some rooms in the hospital as flats where people could live independently for a time before going out. They received Social Security money, paid rent to the hospital and bought and cooked all their own food. This again was an excellent testing area for people’s domestic skills.

We began to publish what we were doing in our Social Therapy Area, and to welcome visitors. The first publicity came for Westerlands in the early 1970s, after a visiting Hospital Advisory Service team in 1971 wrote in their report ‘this is psychiatric nursing at its best’. Later John Wise and John Lambert, Charge Nurses of Westerlands, put on a one-day conference on ‘Nursing the Disturbed Patient’ which was attended by staff from many other hospitals. Many visitors came to see our service, particularly parties from Japan (following the trip I made there in 1967–68). In 1981 a BBC team from the Everyman series spent several weeks in the hospital. After reviewing all the work being done at Fulbourn they decided to concentrate on Burnet House (as Westerlands was now called). They produced the outstanding and moving programme entitled The Way Back (BBC TV, 1982).

During the early 1970s we made a Case Register of people who had passed through the Social Therapy Area and reviewed regularly how all the patients were getting on. In 1979 we made a count and discovered that we had 137 clients in the community and only 176 patients within the hospital. We realised that we were not so much running an ‘Area’ within the hospital as providing a service for people with long-term mental disability in both the community and the hospital. We therefore changed our name to the ‘Cambridge Psychiatric Rehabilitation Service’. At that time, too, we reviewed our work and set out a number of principles for our service for the mentally disabled.

We rejected the medical concepts of ‘cure’ and of ‘discharge’. We accepted that our clients were disabled and that this disability would probably not go away. We said that we intended to concentrate on their strengths and residual skills rather than endlessly re-examining their disabilities and weaknesses (as doctors usually did). We accepted that we would probably never ‘discharge’ them and we accepted a commitment to help them for the rest of their lives. We declared that we had no simple goal which could be applied to all patients – certainly not the former one of discharge from hospital. We believed that all our clients were capable of some growth – but that the degree of that growth would be different for each one. For some it might be moving from a group home to independent living; for some moving from hospital to a Group Home; for some moving from the disturbing environment of Burnet House to a settled, productive life on a quieter ward.

By the early 1980s we had a well-established team with good morale and high effectiveness, which was nationally recognised as a ‘Demonstration Project’ in 1985.

In 1971 my post of Medical Superintendent was formally abolished, though it had been withering away for years. When I first arrived at Fulbourn in 1953 I had accepted the role of Medical Superintendent with its nineteenth-century functions, and also the real power to start change. I used it as a base from which to pull the whole asylum forward and get it functioning as a lively, up-to-date mental hospital, with full employment for the patients, open doors and a high staff morale. In the years after my return from California in 1963, I was active in developing Social Therapy – in promoting and operating therapeutic communities and devolving authority to the patients and staff. While I was involved in doing this the role of the Medical Superintendent was gradually disappearing. There were a number of factors helping this process, some general in England and others specific to Fulbourn.

The Mental Health Act 1959 made consultants in mental hospitals into Responsible Medical Officers, answerable for the treatment and legal detention of their own patients. There was, therefore, no longer any legal need for a Medical Superintendent. In many English mental hospitals this change was welcomed because it freed young consultants from the irritating interference of elderly, anxious Superintendents.

Throughout the National Health Service, the quality of administrative officers was rising and more competent men were being appointed. In Fulbourn there was a marked change after Charles Mitchell retired in 1962 from the post of Group Secretary. Charles was an excellent and charming man with a very sound judgement of people, but he had lived all his life on asylum premises and had spent most of it as a servant of the Committee of Visitors under the direct authority of Medical Superintendents. He did not want more responsibility in the last years of his working life and was happy to leave the leadership of the hospital to me. After he retired we had a succession of able men, several of whom insisted (quite rightly) that they should take the leadership in non-medical matters. I went along with this. Thus my activities in non-medical spheres of the hospital – building plans, sports fields, annual reports – gradually ceased.

The rearrangement of consultant responsibilities in the 1960s suited me very well. As far as I was concerned it meant relief from a number of irritating and unnecessary activities and allowed me to concentrate on the patients in whom I was most interested, the most disturbed long-stay people. It did, however, also mean that I went less often on to those wards for which I was no longer personally responsible. My Medical Superintendency was becoming nominal – though it was still my task to attend the Hospital Management Committee meetings and to speak for the doctors when necessary. In 1971 this, too, changed. As part of the reorganisation of medical representation within the National Health Service a ‘Division of Psychiatry’ was formed in Cambridge. All Consultants were members and it encompassed mental illness, child psychiatry and mental handicap. I was elected the first Chairman, Gwyn Roberts of the Ida Darwin the first Secretary and our Superintendencies were abolished. We continued to attend the HMC of our hospitals until the HMC was abolished in the NHS reorganisation of 1974. In 1975 I came to the end of my period as Chairman, and from that time onward I no longer held any position in the management structure of Fulbourn Hospital, or the District Health Authority which after 1974 ruled our affairs. I was, however, still a Consultant Psychiatrist. I was Responsible Medical Officer for all the long-stay non-geriatric patients in the hospital (about 400 in 1970) and I ran the Social Therapy Area, later the Cambridge Psychiatric Rehabilitation Service.

My role in the hospital was not the only area of my life which was changing at this time. After my year in the USA I was still primarily centred on the hospital and the therapeutic communities, but I developed other activities. I wrote and published two books and a number of articles on aspects of Social Psychiatry. I took part in national activities; I headed a Ministry of Health Working Party that produced a Report ‘Psychiatric Nursing; Today and Tomorrow’ in 1968 (Ministry of Health, 1968). As well as lecture tours (such as the one in 1961), I was asked to do international consulting work.

The World Health Organisation began to use me, first on a Working Party in Geneva in 1965 and then in Japan for four months in 1967–68, advising the Japanese Government on their mental hospital system. I lectured up and down that country; my books were translated into Japanese and circulated widely; in the 1970s and 1980s I went back to Japan several times. As a result we had a flow of Japanese visitors to look at Fulbourn and a steady trickle of Japanese doctors, social workers and others to join the staff at Fulbourn for a year or two. Some of them, notably Junichi Suzuki (1970–73), made most valuable contributions to the Social Therapy of the hospital. The British Council sent me to Peru and Argentina in 1968. In 1974 WHO sent me to Poland for three weeks. Some of the appalling wards and hospitals I saw on these trips showed me how truly awful some psychiatric institutions still were. I also travelled to the USA in 1966, 1968 and 1971 lecturing and consulting. I sat on Committees of the Royal Medico-Psychological Association, and took an active part in its reshaping as the Royal College of Psychiatrists in 1971. For six exciting years, 1966–72, I was Vice-Chairman of the National Association for Mental Health (now MIND) chairing conferences, meeting Ministers, MPs and Princesses. It was all heady and exciting – but also very exhausting.

My personal situation radically changed in the mid-1970s. In 1974 I was offered a full-time post at the WHO in Geneva which was withdrawn at the last moment. The intensity of my disappointment forced me to realise how wearisome both my work and my personal life had become. The children had left home and my wife and I had drifted apart. Even my garden had ceased to be a joy and had become a burden.

My wife and I separated, the home broke up and in January 1976 I went to live on my own in a small flat. I applied for a job in Australia, was offered it and almost took it. However, I decided to stay in Cambridge, but live differently. I took up yoga and meditation. I gradually became calmer and more insightful and pleasure began to return to my life. The Rehabilitation Service and the long-term patients were a great joy to me during those troubled years and I worked hard to develop new methods of psychiatric rehabilitation. I was particularly fortunate that Geoffrey Shepherd, a clinical psychologist and a distinguished rehabilitator, joined me in 1981 and gradually took over the leadership of the unit.

Around 1980 my life took a turn for the better. I remarried and began to look to the future. I was getting near to the time for my retirement. I decided to set an exact time limit to my service to Fulbourn, and I retired on 31 July 1983, exactly 30 years from the evening when I first knocked on the front door of the locked asylum. I was given a fine send-off, parties and presentations from my colleagues, and best of all a great party in the main hall attended by all the patients of the CPRS. I then went off round the world on a lecture tour.

After my return I continued to live in Cambridge, but took no active part in the work of the hospital. I continued to see my friends, my former colleagues and, more important, my former patients about the city, in the shops and libraries and swimming pools. I worked in the University of the Third Age, but spent much of my time writing this book, attempting to record the story of our exciting times at Fulbourn and trying to make sense of what we did, what succeeded and what failed and why.

CAMBRIDGE PSYCHIATRY CHANGES

During the 1970s and 1980s the Psychiatric Services in Cambridge expanded greatly and Fulbourn Hospital gradually diminished in importance. From the opening of Fulbourn Asylum in 1858 until the founding of the National Health Service in 1948, there was no other psychiatric institution for the people of Cambridgeshire and there were practically no other psychiatric services. Then things began to change. Outpatient clinics were set up; the psychiatrists at Addenbrooke’s gained a detached outpatient department and began to provide psychotherapy; a Child Psychiatric service was set up in 1954 and gradually extended. However, until the 1960s Fulbourn Hospital was still the centre of the psychiatric services in Cambridgeshire. It was there that new buildings were put up (Adrian Ward in 1956, Kent House in 1964) and much money went into upgrading the ancient main building. In the 1950s the policy-makers of the Ministry of Health saw building at mental hospitals as the solution to problems of mental health.

In the 1960s ideas altered. After proposing essential changes in the Mental Illness Laws, the Royal Commission in their 1957 Report went on to say that what was needed were developments in ‘Community Mental Health Services’. In 1961, in his ‘water tower’ speech Enoch Powell, then Minister of Health, announced that the Government would not spend any more money on mental hospitals which, he said, were going to become redundant.

In Cambridge other facilities began to develop. Winston House was opened in 1958. In 1965 the Cambridgeshire Mental Welfare Association opened its first group home and in 1969 the St Columba Day Centre was started. The Duly Authorised Officers of the Counties became Mental Welfare Officers in 1959 and steadily developed and extended preventive and supportive services for the mentally ill throughout the district. The opening of the Ida Darwin Hospital in 1965 led to the development of an effective service for the mentally-handicapped people of Cambridgeshire. For a time Fulbourn Hospital carried on as if it was providing the major service in the area, but gradually activities in the community became more important.

A major change came in 1971 when Social Service Departments were set up in every local authority, centralising and professionalising the work of various groups of Social Workers. In Cambridgeshire after several difficult years, the department began to develop and improve the facilities for the mentally disordered in the community.

The psychiatric outpatient department of Addenbrooke’s had been in its own building at 2 Bene’t Place since 1953 and grew steadily in size, importance and sophistication during the 1960s and 1970s. It developed a more active psychotherapy service under Malcolm Heron and then Bernard Zeitlyn. A Student Mental Health Service was developed by Brian Davy and Ruth Young. The department responded to Society’s new demands on psychiatry by developing clinics for advice on Termination of Pregnancy, a Drug Containment Unit, an Alcoholism Service and a Consultation Service for patients who had taken suicidal overdoses. During the same period voluntary efforts in the mental health field expanded and diversified – the Samaritans, Alcoholics Anonymous, Cruse, the National Schizophrenia Fellowship – all started groups in Cambridge.

In the early 1970s, things appeared to be going well in the field of mental health care in Cambridge. Fulbourn Hospital had been transformed and many patients had moved out. Other mental health services were developing. Cooperation was good and money available for new projects. We did not realise then that this would soon change as the money began to run out.

The world-wide oil crisis in 1974 and the start of an economic recession in Britain began to affect us. Government funds for mental health care became short during the later seventies and the squeeze began to be felt. New developments requiring money were refused. No new building projects were started. The Alcoholism Unit (1974) was the last new building at Fulbourn Hospital. Maintenance money became limited; each year the budget was scrutinised more severely; even small developments were stopped. Projects which merely needed a few extra staff – which would have been granted easily in the 1960s – were refused or postponed for years. The administrative atmosphere of the NHS became one of shortages, refusals, wrangling and discouragement, with constant pressures for economy. Instead of looking at new ideas, senior staff spent much of their time defending established services and trying to avert cuts.

There were also other difficulties. In 1974, after many years of discussion, an administrative reorganisation of the National Health Service was carried out, to coincide with a reshaping of the ancient counties and local authorities of Britain. The reorganisation had been debated for years, and had many admirable aims, but somehow, in the event, it did not work out well. The reorganisation was originally proposed by a Labour Government but was finally implemented by a Conservative one. They hired American organisational advisers who offered suggestions which, when turned into British bureaucratic regulations, produced a structure of Byzantine complexity where many people and groups had the power to prevent change and hardly anyone had the authority to make decisions or to force effective action. It may be that the reorganisation would have done better if its introduction had not coincided with the economic crisis. As it was, there was never enough money to do what the planners intended, or even to hire the staff to carry out their plans.

The 1974 reorganisation abolished Hospital Management Committees. For Fulbourn Hospital this was a great loss. For 116 years, since 1858, the final responsibility for the government of the hospital had been in the hands of concerned local people: in the 1850s squires and parsons; after 1890 elected representatives from county and borough councils; after 1948 selected concerned people representing many local interests. This body of sagacious, experienced citizens – mayors, councillors, professors and others – had been most valuable to the hospital throughout the century but particularly during the postwar years. Led, in succession, by Lady Adrian, Alderman Mallett, Sir Henry Willinck and Mrs Pauline Burnet, they were a continual source of wise counsel to me and the other officers. They told the Cambridge public about the hospital and its changes; they told us what the local public wanted, and also what it would not stand. The Committee provided a forum where disputes between officers or departments could be firmly resolved. After 1974 this was no longer available to us.

In 1974 all the hospitals in Cambridge were brought into one organisation. This seemed an admirable step forward, and there was certainly greater cooperation between Addenbrooke’s and Fulbourn at all levels. The snag, however, was once again the shortage of money. In 1974 Addenbrooke’s was in the middle of a protracted 20-year move from their old eighteenth-century building in the centre of Cambridge to a modern site in the south of the City. The original planning in the 1960s had not allowed enough funds and budgets were fixed too low. As the New Addenbrooke’s Hospital opened up in the 1970s the budget was regularly overrun and there were cries for economy. Any money for local development in Cambridge hospitals had to be poured into Addenbrooke’s – with the result that there was little money for Fulbourn. There was even a tendency to look for savings at Fulbourn to help out with Addenbrooke’s difficulties.

From 1974 to 1982 an Area Health Authority was responsible for all medical services in an enlarged Cambridgeshire. This proved most unwieldy and the people in charge at Area level – officers and committee members – floundered in increasing despair over the eight years. Pauline Burnet became steadily more central in Mental Health in Cambridgeshire. When Lady Adrian died unexpectedly in 1968, Pauline took over the Chairmanship of the Cambridgeshire Mental Welfare Association. When in 1969 Sir Henry Willinck had to give up the Chairmanship of the Fulbourn Hospital Management Committee because of increasing ill health, she became Chairman and led it with aplomb until it was abolished in 1974. She was Chairman of the Cambridgeshire Area Health Authority during its difficult existence from 1974 to 1982. She was active, cheerful and compassionate; she helped many of those who worked for her, and took social casualties into her own home. I got to know her well and developed great admiration for her compassion, devotion and personal courage in times of difficulty.

The 1974 reorganisation turned out to be so unsatisfactory that there was another national reorganisation in 1982 which abolished Area Health Authorities and shifted power to District Health Authorities. A new Cambridge District Health Authority became responsible for all hospital and medical services in the Cambridge District. This and other reorganisations in the 1980s swept away the last vestiges of voluntary or representative local involvement in the NHS. By 1990 all management and authority was vested in paid officers answerable to and under control of Central Government.

Another development in Cambridge psychiatry in the 1970s was the establishment of an Academic Department of Psychiatry. Ever since the asylum was founded in 1858 there had been hopes that links could develop between it and Cambridge University and that university study of mental disorder might develop. Although personal links with the university and the asylum sprang up in every generation, and university people contributed much to the welfare of the patients, attempts at formal links foundered. Not until the government accepted the Todd Commission’s recommendations in 1968 did the University of Cambridge reluctantly accept that it would have to have a Clinical Medical School. After the economic and educational expansion of Britain in the 1960s everyone believed that the university and the National Health Service would have ample funds to support steady development and expansion of new teaching departments.

In 1976 the university appointed a Professor of Psychiatry. They chose Professor Sir Martin Roth of Newcastle, first President of the Royal College of Psychiatrists, a senior figure famous for his encyclopaedic knowledge and notable academic achievements. Sir Martin came to Cambridge expecting generous funding, plentiful staff and ample hospital facilities. Unfortunately he could not have come at a worse time. The Clinical School had been planned in the euphoria of the late sixties. It was assumed that the University Grants Committee would fund professorships, that the Medical Research Council would fund research projects and that the National Health Service would provide the extra wards, beds, nurses and other staff to house the academic clinical units. Alas, people forgot that all of these bodies were funded from the same national purse! After the 1974 oil crisis, the Government cut funds all round. As a consequence there was little money available for Cambridge’s struggling Clinical School and none for the Department of Psychiatry. Sir Martin had constantly to battle for funds, facilities and services. Since these could only come from someone else’s budget he faced constant opposition and many disappointing struggles. He had hoped to develop a professorial inpatient psychiatric unit within Addenbrooke’s – but was unable to do so. He had hoped to attract teachers and research workers – but could barely get funds for secretaries. His manifest dissatisfaction brought constant tensions within the psychiatric group.

Further, Sir Martin found much that he disliked about psychiatry in Cambridge – and he made his distaste apparent. He found the culture of open discussion which we had developed at Fulbourn quite unacceptable. The fact that junior doctors, social workers and nurses argued and challenged the views and instructions of consultants – and even his opinions – appalled him. He could see no value in the therapeutic community approach.

Gradually a sour atmosphere developed amongst Cambridge psychiatrists, erupting in rows on Committees and struggles over resources. A polarisation began amongst the doctors; academic psychiatry began to be seen as preferable to social psychiatry; the Friday morning doctors’ meeting with its egalitarian culture gradually declined and withered. I withdrew into my work in the Rehabilitation Service. The nurses, social workers and occupational therapists in Fulbourn who enjoyed therapeutic community work gradually moved there to work with me and we became an isolated bastion of social therapy.

At first the changes outside did not much affect the work within the hospital. The work of treating acute psychiatric admissions on Street, Friends and Adrian Wards improved, flourished and expanded through the late 1960s and the 1970s. The flourishing of Social Therapy for the long-term patients has already been described, and the Rehabilitation Service moved more and more people out to sheltered accommodation. Numbers of inpatients fell steadily. Only on the geriatric wards did pressure increase. After we created a defined Psychogeriatric Area in 1966, the service for a time improved. During the 1970s, however, the increasing pressure to take in elderly and demented people overloaded the service and standards and morale fell. The appointment of Peter Brook as Consultant in Psychogeriatrics in 1979, however, started a steady rise in the quality of the service afforded to the confused elderly and their carers, both in the community and within the hospital.

By the early 1980s Fulbourn Hospital had become very different, both in appearance and function. Active work was still going on in the admission units, Kent House and Adrian, and in various outlying buildings. The main building was becoming empty. Wards were being closed down as the physically active long-term population left hospital. Only the ground floor wards were actively filled with the confused elderly. But most of the work of the psychiatrists was being done elsewhere, in Addenbrooke’s, in the outpatient clinics and in the many special units being developed throughout Cambridge.

I retired from the National Health Service in 1983 and ended my involvement with Fulbourn Hospital. This tale might have ended at that point but, of course, the work goes on. The Cambridge Psychiatric Rehabilitation Service won national recognition under Graham Petrie (who succeeded me) and Geoffrey Shepherd, and visitors continued to come (especially from Japan) to observe the work.

I retired from Fulbourn in 1983, just 30 years to the day since I went there – green, naive, enthusiastic, determined to do something for those packed into the squalid, brutal back wards. I left well satisfied; we had indeed released the people from the back wards, and in the process abolished the back wards themselves. In Cambridge, at least, they were a memory, now being forgotten, a memory of padded cells, brutality and the asylum stink of urine, paraldehyde, carbolic soap and boiled cabbage.

In the process of opening the wards and freeing the people, we had discovered and demonstrated Social Therapy and established the basis of a better kind of psychiatric nursing – a nursing of caring, counselling and helping rather than a nursing of control, coercion and occasional brutality.

Some of our more exciting experiments had proved transient – the therapeutic communities, the Fulbourn culture of growth, the doctors’ sensitivity meetings – but much remained, especially the advanced psychiatric nursing and the model Rehabilitation Service.


The Human Nature Review
Ian Pitchford and Robert M. Young - Last updated: 28 May, 2005 02:29 PM

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