The Story of a Mental Hospital: Fulbourn, 1858-1987
by David H.Clark.
| Contents | Foreword | Preface | Chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | Postscript | Acknowledgements | References | Index |
4 Managed Change: Towards Open Doors
The next few months were filled with adjustments – of myself to the hospital, of the hospital to me. I had resolved that I would make no major changes during the first year as I wanted to spend time getting to know the people and the job. In one sense I maintained that resolve, for I started no deliberate changes in the life of the hospital until the following summer. Nevertheless, some changes did occur of their own accord without my doing anything at all.
One of my first moves, during August, was to rearrange my working space. The ground floor of the central administration building contained three large rooms. To the left of the entrance was the ‘Board Room’ in which the Hospital Management Committee met; it was a handsome room with a marble fireplace surmounted by an elaborately carved oak overmantel, which framed a mirror. There was a fine view out over the drive and the front of the hospital; in the centre of the room stood a long table, covered in green baize and surrounded by comfortable chairs. On the walls hung maps of the hospital. This room stood empty most of the time. To the right of the entrance were two rooms. That to the rear was the Medical Superintendent’s office, a dark and dingy room. The windows were overshadowed by the nearby buildings and their small grimy panes obscured much of the light. The electric light had to be on most of the day even in summer. The other room at the front to the right of the door seemed to me to be empty all the time. It was a high, airy room with a fine view over the grounds, and another grand fireplace. I was told that it was the ‘Committee Dining Room’; that they lunched there at their monthly meetings. As the month of August passed, I saw no sign of anyone using it at all. It stood there, fine and empty while I worked in the grubby dark room behind.
I found these arrangements inefficient and inconvenient. All sorts of people came wandering into the office with messages, parcels, report books, and so on. Whenever the hospital switchboard operator (the porter on duty) had a call about which he was in doubt he plugged it through to me; I seemed to spend half my time putting enquirers in touch with the departments they really wanted. I felt that the situation was symptomatic of a larger problem from which Fulbourn suffered. The hospital had no medical heart, no centre. There was no place to which information and enquiries could flow or to which people could turn.
I, therefore, proposed that I should use the Committee Dining Room as my office, and that the medical secretaries should be brought together in the room next door. I discussed this with Mr Mitchell and Mr Merrin. There seemed no unsurmountable reasons against it. I arranged for an extension telephone, for some furniture and a new filing cabinet and moved in.
This new plan worked very well. The medical secretaries’ office became a medical centre for the hospital, where mail was sorted, messages left and where doctors could linger for a chat. The telephone was manned constantly, problems were sorted out and only those passed through to me which needed my personal attention. My office became an effective workplace for me, where I often stayed long into the evening. The room was excellent for small meetings, which gradually became more frequent. The fact that every other Friday all the furniture was changed around for the Committee’s lunch remained an irritant but not a major problem.
The rearrangement of the rooms, as far as I was concerned, worked well; for me, that was enough. It was not until many months later that I appreciated the significance of my action. The Committee Dining Room, in which a cheery fire was always maintained, had been a very pleasant club room for some of the members; in it they could sit and chat and smoke a pipe while other members were busy in the Board Room. It was pleasant for them too, to be served lunch there whenever they had occasion to be in the hospital. Now this had gone; a young upstart had moved himself in there and they could only get in by permission. At times, they had to hang about in the hall. In particular the Chairman of the Farm Committee, Alderman Street, who came up to the hospital at least twice a week and had long been accustomed to take his ease in the Dining Room after doing a round of the grounds, never ceased to resent my action.
To the staff of the hospital, too, this move was seen as a revolution and a portent. Dr Thomas had always been terrified of the Management Committee; he was an easily frightened man, and before 1948, as the Board of Visitors, they had had the power to raise or lower his salary. Everyone knew that the prospect of the Committee’s displeasure filled him with dismay, even terror. Here was the new Superintendent turning the Committee out of their dining room apparently without a qualm!
During September, there were other important meetings as people came back from their holidays and the routine of Health Service business took up again. My consultant colleagues returned and took over the patients I had been looking after. I made it clear how inconsiderate I felt they had been in leaving so much to me without notifying me in advance; I think they were surprised at my vehemence. Each explained in his different way that it was his custom to depart on holiday when he wished and that there had never been trouble before. I suggested that if we were all to work together, we should have to think more of the needs of others. This seemed obvious; yet as time went on, I realised that it was really a revolutionary idea for Fulbourn and even more for Addenbrooke’s, where they never before cooperated over holiday arrangements.
The senior psychiatrist at Addenbrooke’s, Ralph Noble, had worked there for over 20 years, during most of which time he had no psychiatrist colleagues. Always a headstrong, choleric man, it did not occur to him to consult with the youngsters now coming on the scene. He told me of his great plans for the development of what he grandly called the ‘Psychiatric Department’ of Addenbrooke’s – of which I was now the junior member. Derek Russell Davis was Reader in Psychopathology in the University with honorary appointments at Addenbrooke’s and Fulbourn. He told me that he was primarily a university teacher, not greatly concerned in the web of Health Service responsibilities. He took some time to tell me of local affairs, emphasising how much had already been done and indicating the role he saw me fulfilling. He was very kind personally to me and the family in our move down from London. Edward Beresford Davies, who was emerging as the leading clinician, was an able, shrewd, intuitive man who had been appointed a few years earlier and had managed to build up a most successful private practice in the City. He showed a warm interest in the plans I was beginning to develop for the division of work among the doctors and welcomed my plans to improve the doctors’ training.
Beresford Davies and Russell Davis told me of the troubles of recent years. They said that neither Dr Noble at Addenbrooke’s nor Dr Thomas at Fulbourn had realised that, as Consultants, they were entitled to facilities to enable them to treat their patients properly. They told how Dr Thomas, full of anxieties about his position as Medical Superintendent and still clinging to the pre-1948 position when the Medical Superintendent was personally responsible for the treatment of every patient in the hospital, had interfered unwarrantably again and again in their clinical practice, changing medication they had ordered, holding back their letters or moving their patients from ward to ward without consultation.
The pattern of medical action and responsibility for the treatment of patients was at this time changing within Fulbourn Hospital – as it was in all the mental hospitals in the NHS. Before 1948 the Medical Superintendent had been responsible, legally and personally, for all treatment of all patients. Although all Medical Superintendents had to delegate much day-to-day work to the Assistant Medical Officers, they still remained responsible and often altered treatment plans and medication. The NHS Act had created new medical grades of which the top was the ‘Consultant’. He was personally responsible for the treatment of his named patients. Some of the more senior asylum doctors were appointed Consultants. In many hospitals there were tussles between the newly created Consultants and Superintendents still operating on the old pattern. At Fulbourn in 1953, Leslie Buttle was a Consultant, as were Beresford Davies and Russell Davis. Dr Thomas had regarded them as upstart boys and had often altered their treatment prescriptions. This had caused great rows in 1952 and speeded Dr Thomas’ desire to retire. This issue gave me no trouble. It never occurred to me to interfere with another Consultant’s treatment for his patients, even if I disagreed with it.
I knew the Consultants were responsible at law and could do what they saw fit. Furthermore, they were all older than me, more experienced and probably wiser. It would have been an impertinence for me to interfere – as well as being bad for the patients. All I wished to do was to define responsibilities, so that we each knew who our patients were and to try and promote a spirit of cooperation rather than the backbiting, mistrust and intrigue which seemed to have prevailed before. It had always seemed to me obvious that if a group of people had to do a job together, the sensible thing was to assemble, discuss the task, work out what everyone had to do, and then let them get on with it. It never occurred to me to proceed otherwise at Fulbourn; whenever there was a problem, I assembled those involved and discussed it with them.
During these early months of my appointment I learned that the Minister of Health was planning to spend a million pounds on English Mental Hospitals – ‘the Mental Million’, and that if we hurried a plan for Fulbourn Hospital up to the Ministry it might be selected. We decided to ask for a 40-bed Villa for women patients to relieve the current congestion.
The sketch plans began to come from the Regional Board, so I asked the Consultants to come and see them. They were delighted, interested and had a number of suggestions. It soon emerged that on previous occasions, Dr Thomas had not told them anything until after all the plans were decided. We had a lively discussion; it went on all morning and we began to air our ideas on the future development of the hospital. I realised that these men had very valuable ideas about how we could best serve the patients. I suggested that perhaps we should meet again, and a date was fixed. Soon, these meetings became a regular monthly fixture. We hammered out the differences and problems that arose between us, planned the recruitment and training of the junior doctors and discussed problems at the hospital as they emerged.
Every morning the Matron, the Chief Male Nurse and the junior doctors used to come in and see me individually. Each of them would discuss problems and often spend a good deal of time insinuating that the trouble was due to someone else I was to see later in the day. The Matron spoke of the grave difficulty she had in getting the doctors to see patients who became suddenly ill; the doctors complained that the nurses – especially the Matron – would move patients suddenly without telling them. Another problem arose because the porters deposited all hospital mail on my desk each morning; I had to open it and go through it. Most of the enquiries would relate to patients I did not know, and I would then have to put them aside until I found someone who knew about it. Sometimes the doctors did not come up for a day or two and letters would lie until it was too late to do anything about them.
I was sure things could be improved. Then, an incident one evening in September forced a crisis. As I was walking down a corridor late one evening, I met a nurse carrying a bundle of clothing, followed by a bedraggled woman in a shapeless nightgown, who wept bitterly as she stumbled barefoot over the cold flagstones. I enquired what was amiss; I was told that she was being moved to another ward and it had been necessary to wake her up and get her out of bed to make the move. This seemed unnecessarily barbaric, so I started making enquiries the following morning.
It emerged that one of the doctors had sent up a new patient for admission that afternoon from the outpatient department at Addenbrooke’s. No one had been told and the patient arrived in the evening to a full admission ward. A patient was hurriedly moved to the sick ward, from which someone had to be displaced. The task had been left to the Matron, who was thus forced to turn people out of bed to make the necessary moves, thus finally producing the sad spectacle that I had seen. As I elicited each part of this sorry tale, there was a flood of recriminations and accusations: the nurses said the doctors never told them about impending admissions; the doctors said the nurses moved patients without consultation.
I called a meeting of everyone concerned and suggested we discuss what had happened and how we might improve things. After a period of polite fencing, they began to express openly the bitterness that they had revealed privately to me. Miss Brock and one of the women doctors became particularly angry with one another. I hurried to interpose, to point out that we were all trying to help the patients, that everyone was anxious to give of their best, that we all appreciated one another’s difficulties, and other emollient platitudes. The tension declined, but the problem remained.
Finally, I suggested that we had better meet more frequently. This was welcomed and daily meetings were agreed. I extended it to include the Chief Male Nurse and the doctors working on the male side, and said that I would deal with the correspondence at that time each day. Thus the ‘morning meeting’ started, which was to endure for a number of years. At the beginning, the concern was with transfers. A rule was made that there should be no transfers until they had been discussed at the meeting, except for emergencies. This was agreed and then broken. It soon fell to me to reprimand Miss Brock in front of the junior doctors, for moving a patient without consultation. She took this very badly. Fortunately, the next day, I was able to reprimand the woman doctor who had been most critical of Miss Brock for just the same sort of inconsiderate behaviour. I demonstrated in each case how the patient had suffered because of their failure to work together.
The formal business of the morning meeting was the distribution of the mail which had come addressed to the Medical Superintendent, the consideration of the night report and the major happenings of the previous 24 hours – as well as anything else anyone wanted to bring up. For a long time, it was my main instrument for keeping in touch with the activities of the hospital and for disseminating information and trying out new ideas. In it, I learned many lessons. The atmosphere varied from that of the celebration supper of a victorious team to the bitterness of a shareholders’ meeting of a bankrupt company. I was aware that I tended to talk too much and I tried to limit this by keeping my own business until last and calling on the doctors, the most junior first, for their items. There were, however, times when I felt hostility welling out at me or the enduring personal antipathies rising to the surface again.
One major cause of problems at Fulbourn arose over staff working hours – the ‘shift system’ of the day and night duties. In the early fifties there were several different arrangements. On the women’s wards the nurses worked a two-shift, ‘long day’ system. The night staff were on permanent night duty and were never seen on the wards during the day. There was little communication between day and night staff. The men’s wards had a three-shift system, with a separate Charge Nurse in the morning and in the afternoon. Inevitably there were clashes between different approaches and attitudes – and much ‘losing’ of messages between shifts. Student nurses during their three years did most of their training on day duty, but had to do two much-disliked periods of night duty. The doctors were required to share night duties between them. Depending on the number of doctors available it came round once or twice a week. As we began to change ward routines, the gap between the shifts caused many problems.
Early during the first autumn I set up a meeting with the male charge nurses because I knew that these senior men were the backbone of the hospital. It was a most successful meeting. I found a group of twelve middle-aged men, speaking most of the dialects of Britain – Welsh, Geordie, Scots and Cockney – but predominantly, the flat local dialect. At first, they were slow to speak up in the presence of the Chief Male Nurse and the Medical Superintendent, but they gradually got talking. I asked for their views on what needed to be done and many things came forward: their difficulty in keeping their wards tidy and in getting good worker patients; the lack of good recruits to nursing (young men nowadays were not what they used to be); their lack of professional status (they had to wear the same sort of short white jackets as untrained orderlies, why could they not have distinctive uniforms?); the poor repute of the hospital in the district (could it not be changed to something better – like St Ethelburga’s?).
To all these points, I responded as best I could. I told them I believed we could make this a good hospital if we worked together. I tried to still some of their anxieties about changes. I agreed to take up various remediable material problems. To the suggestion of changing the name of the hospital, I told them of two bad hospitals I knew which had changed their titles without affecting their (deservedly) bad reputations. What we must do, I said, was to change the nature of the hospital, not its name! The meeting closed on a gratifying note. The oldest charge nurse rose and thanked me humbly for calling them together. It was the first time, he said, that anyone at Fulbourn had ever asked for the charge nurses’ opinions. He felt sure that we would achieve much together.
Encouraged by this I then called a meeting of the ward sisters; however, this did not go so well. A group of weary, irritable elderly women assembled and poured forth floods of complaint. They had not enough staff – they could not get the work done; the student nurses were useless – too much was expected of them; the doctors were discourteous; the duty lists were unreasonable; the administrative office did not understand their problems. Much of this could have seemed to be implied criticism of Miss Brock and she immediately took it that way, launching into fierce personal attacks on the sisters and their competence. Before I knew what was happening, I had three or four angry women all talking at once. Many of the sister’s remarks began ‘in Miss Fossey’s time …’ (referring to the Matron’s revered and beloved predecessor). Many of Miss Brock’s began ‘As long as I am Matron here …’. At times, I had the feeling that many present thought and even hoped, that this might not be for long!
I was appalled by the outcome of this meeting and I searched for some way in which to draw it to a close but the subject then moved on to uniforms. The sisters did not care for their traditional uniforms (which looked rather like that of an Edwardian parlourmaid), Miss Brock also wanted to change them. This gave me a chance to lead them into an amicable discussion of different forms of bonnets. I then suggested that this was an important matter, requiring further extended consideration at another meeting, and thus drew the meeting to a close. Only years later did I realise why I had touched off such a volcano of feeling. Appointed only a year earlier, after a contested appointment that had made her feel bitterly insecure, Miss Brock had thrown all her prodigious energy into whipping a lethargic and inadequate staff to higher standards. Smarting under her reproofs, frustrated by all their shortages, resentful of the pressures on them, my assembling them together provided a much-needed chance to let off steam. Unfortunately after this meeting I committed a faux pas which made things worse. I had made notes on these meetings in which I had noted the Matron’s ‘aggressive outbursts’, one sister’s ‘sulky reply’ and that another ‘seems stupid’. I put these notes in a file, from which they dropped in the corridor. A few days later, Miss Brock returned them to me suggesting that it might be better to keep them more securely! It was clear that she and several of the sisters named had read the notes and disliked my comments. Her understanding tolerance was almost harder to bear than her indignation!
Though these meetings varied in their effectiveness, this method of coordination seemed the obvious one to me. I only gradually realised how radical it all seemed to Fulbourn where there had apparently hardly ever been meetings before. All information was given out individually, all projects were pushed through surreptitiously. One doctor said that he had been there a year, and never seen all the medical staff together in one place. Dr Thomas, they told me, never liked to see more than one person at once; it worried him to have too many people in the room. Gradually, it emerged that he had maintained himself by a variant of the ‘divide and rule’ system. Three different doctors told me how Dr Thomas had confided in them personally how irritated he was by the behaviour of some other doctor. Another favourite tale told how Dr Thomas had confided consecutively to two social workers how appalling the other social worker was. Unfortunately, they had met going down the drive, compared notes and found that he had criticised each of them, to the other, in identical terms! I began to see why Fulbourn seemed a disunited, unhappy hospital, where everyone was only concerned for himself and hardly anyone considered the needs of the patients.
What started as an instinctive way of operating became a method. I tried to make it a principle always to reach decisions in open meetings, with everyone present who was legitimately interested. I tried as far as I could to refuse to make decisions when a person captured me alone. At times I found this difficult; it was easier to say that I would decide later than to give my reasons in an open meeting, but I came to believe that this might eventually influence the way in which the important decisions about the patients were reached.
During the first autumn, I also gradually met those who held power or authority over me. The full complexity of the Hospital Management Committee’s operations gradually unfolded. Once a month on a Friday afternoon, there was the full meeting, which went on for several hours. But there were many subcommittees, almost one a week, all of which I had to attend. Some were well run and relevant, such as the Finance Committee, and the Stock Losses Enquiry. Others were ill-managed and seemed concerned with irrelevancies. The Farm Committee spent much of its time considering lists of minor supplies, and querying whether two or three balls of binder twine would be enough for the harvest. One curious committee, the Staff Liaison Subcommittee, contained ‘representatives of the staff of the hospital’. I could see little virtue in it, but was told that ‘the Union’ had demanded it, and that the Ministry insisted on such meetings. A Nursing Committee, consisting of lady members of the Management Committee, met with Matron. These meetings were of great length and were usually bogged down in endless discussions of suitable uniforms for student nurses. The fact that we had practically no student nurses was not felt relevant, nor did anyone suggest that the young women who were to wear the uniforms might have something to say!
As time went on, however, I began to get to know individual members of the Committee and to realise that they were an able group of people who were honestly attempting to improve the hospital and the lot of the patients in it. Baffled and frustrated by the incompetence and deviousness of the hospital staff, the constant complaints of the patients and their relatives and the apparent indifference of the Regional Hospital Board and the Ministry, their standard response to a problem was to set up yet another subcommittee of their own members.
The Regional Hospital Board and its powers and functions gradually became clear to me. It was they and not the Hospital Management Committee who were my employers and it was they who sent me my monthly cheque. I realised that the Senior Administrative Medical Officer was my particular ‘boss’, but it was not clear how the Board itself affected the hospital. Soon enough, however, I learned that finance was the key to virtually every issue in the hospital. Nearly every time I pointed to something necessary, from new beds for the patients to a coat of paint on the front door, I was referred to the current Government policy of limiting Health Service expenditure and told of some ruling of the Minister, of the Auditors, or of the Regional Board which made action impossible. Particularly outspoken in these matters was the Finance Officer who constantly exhorted the Committee to ‘Remember the Interests of the Ratepayer’. In time, I came to appreciate that all these people, and particularly the Regional Board Officers, were trying to share out inadequate funds fairly and to develop a comprehensive service for the area. But in those early days, I could only see indifference to our crying needs and an inexhaustible ability to think of different ways of saying ‘no’.
During the early months, I also addressed myself to the training of the doctors. In the past, medical staff appointed at Fulbourn had trained themselves in the specialism of psychiatry as best they could. Only recently had there been any significant number of young doctors working at Fulbourn, or any official recognition of their need for training. A Registrar who was leaving poured out to me a mass of dissatisfactions – no library, no clinical meetings, no seminars, no classes, no adequate supervision. I had just come from a teaching hospital and could see how this could be put right. I started clinical meetings and ran a series of seminars. I tried to make the morning meetings into teaching occasions as well. I organised ward rounds, going regularly round with the doctors, answering their queries, stimulating them with questions and teaching on suitable problems. I asked the other Consultants to do the same. I put my own psychiatric library in my office and made it available to all the doctors. I persuaded the Committee to give a small grant and bought new medical textbooks for the doctors. I found some junior doctors complaining of lack of interesting work, so I took them down to Addenbrooke’s with me on outpatient days so that they could sit in on my clinics. I worked out a plan by which all the junior posts could be regraded as training ones. This was well received by the Consultants and to my surprise, accepted by Addenbrooke’s and the Regional Hospital Board without demur.
The group of doctors began to change. The last months of Dr Thomas’ regime and the interregnum had been trying times. When I arrived, two of the doctors had found jobs elsewhere. During the coming months, three others decided to move on. A number of new people came, unspoilt by the sour dispirited former atmosphere of bickering. By the spring of 1954 only two of the original group of junior doctors remained and the new group was working together well.
For the first two months of my appointment I lived in a room in the nurses’ home during the week and went back to London each weekend. Then the flat on the top floor of the administrative building became vacant and my wife and family joined me in early October 1953. We lived there for five months. We were very crowded, and all prams and shopping had to be carried up two flights of stairs, but we were at least together again. The work on the Superintendent’s house went on, though slowly. There were difficulties with the new central heating, our alterations and the painting and paperhanging, which was done by the hospital’s workmen. However, finally, in February 1954, we were able to move in and were well pleased with our new home. We had a housewarming party and felt at home at last. I was absorbed in my work, to which I walked every morning through the hospital grounds. We gradually got to know people in Cambridge.
My professional work began to settle. Apart from my major concern, the running of the hospital, I was expected to do a good deal of clinical work. I took a substantial proportion of the new admissions and followed them through. I held outpatient clinics at Huntingdon County Hospital and also at Addenbrooke’s seeing a number of new patients and taking on a few for psychotherapy.
During my first two months at Fulbourn Hospital – August and September 1953 – I had very little contact with Cambridge. This was partly because I rushed off to London each weekend, partly because most things closed down in Cambridge during these months of university vacation and town holidays. I made contact with my College, King’s, where to my pleasure the Head Porter recognised me immediately. The University Library, the bookshops, the cinemas, the University Swimming Sheds (for 1953 was a hot summer), all seemed much the same as when I was a student 15 years earlier. A few people asked me out to dinner. Several general practitioners asked me to do home visits to patients and I had some requests for second opinions on inpatients on the wards of Addenbrooke’s from physicians and surgeons. These came partly because all the other psychiatric consultants were out of town on holiday, but I think some were attempts to put the new man through his paces to see if he was any good.
Once my family joined me in September we became more involved in Cambridge life. My elder daughter went to the Fulbourn Village School. My wife began shopping in Fulbourn and in Cherryhinton and got to know our neighbours. Gradually we began meeting colleagues and making friends. I was welcomed to his department, colleagues and excellent library by Oliver Zangwill, recently appointed Professor of Experimental Psychology. I got to know some of the social scientists then working in Cambridge, particularly Meyer Fortes, Professor of Social Anthropology, who as a former clinical psychologist showed great interest in some of my developing ideas about Social Therapy. I began to frequent my College more often.
I held to my intention of doing nothing new for the first year and started no major projects for many months. However, as I later came to realise, the very way in which I dealt with people in my first year caused shifts in the hospital. Prior to my arrival the basic premise of Fulbourn had been the traditional humane custodialism of British asylum management: look after patients kindly until they die, or perhaps, by chance, recover. Their illnesses were viewed as being hereditary with a natural relapsing course and therefore it was felt that such people were probably better off in hospital. If a doctor or nurse had enthusiasm or drive, it was probably better turned away from trying to help such patients into other fields – outpatient psychiatry, short-stay patients, the football club, the Union or professional advancement. My view was that chronic patients could be actively helped toward recovery and that furthermore the way to do this was to change the way they lived within the asylum. The fact that I treated a patient’s remarks as being of equal importance to those of a nurse caused some surprise; traditionally, patients were considered insane until proved otherwise, and any comments they made disregarded if they clashed with the views of a staff member.
Even without planned initiatives on my part, projects kept emerging and to each I could give either support or discouragement. I used this as a way of gradually redefining policy. Over every idea that came forward, I asked myself – how does it help the patients? Then I determined, more or less consciously, the support I would give to it. The clamour for differential uniforms seemed to me nonsense, so I gave it no support and it made slow progress. A plan to recruit French girls as assistant nurses seemed to me most valuable and I gave it much support. Miss Brock had heard of foreign recruitment producing recruits for other hospitals and had then met a cheerful advertising man who promised to plan the campaign. Miss Brock and I worked hard together on this project, drafting advertisements for the French press, scrutinising the scores of applications that poured in, filling out forms, corresponding with parents. After Christmas 1953 the first of them started arriving; by Easter 1954, we had a dozen on the staff and had incurred a reprimand from the Regional Board for overspending our allowance for nursing staff.
I remained ashamed of the shabbiness of the grounds and was impatient to get things smartened up. The front gate hung lopsided, shabby and dilapidated. Mr Merrin said he was not allowed to repaint or repair it. I had a squad of patients lift it off the hinges and throw it into the shrubbery. The male nurses drew my attention to the cricket pavilion, originally a black and white building which now looked horribly shabby. Half its paint was off and its timbers were bleached and bare. Mr Merrin said there was no need to worry; it was western Red Cedar and weatherproof. I grumbled to the Commissioners of the Board of Control, who put a sour little comment in their report. The Committee picked this up and at my prompting, Mrs Adrian instructed Mr Merrin to get the pavilion painted.
The work on the Staff Recreation Hut was going very slowly; the nurses said cynically that Mr Merrin, who had made his distaste for the project known, would see it was never finished. I worried at it like a terrier , bringing it up at every Committee meeting, taking all official visitors there, talking about it constantly. The work was finished just before Christmas and there was an opening ceremony. I invited the Press and Mrs Adrian was persuaded to pour the first drink. Mr Allen and the staff were delighted and held a number of Christmas parties there.
As time passed, however, I began to see another side to Mr Merrin. I would meet him on Sunday mornings prowling round the works in progress. One morning, he seemed rather tired and I heard he had been up all night driving an iron lung 50 miles across the county to a desperately ill child. When a patient broke her arm on a Sunday, he came up and X-rayed it for us there and then, producing a picture of professional standard. When we sounded the fire alarm, he was on site before the first of the fire fighters, and when the boilers broke down one weekend, he spent all night inside the boiler until the heating restarted. I realised that for all his surface cynicism, he was a highly skilled man with exacting professional standards, who was devoted to maintaining the hospital in sound condition – according to his own system of priorities.
As winter started, the patients’ dances began. They were dreary affairs with recorded music played over inadequate amplifiers from a stock of scratched and out-of-date records. Mr Tucker suggested to me that one of the male nurses would be glad to arrange some live music. One of the doctors volunteered to play the trumpet and a clerk the drums and quite a lively little band emerged. I asked the Committee for money for music stands, and other necessities and the patients’ dances livened up considerably.
The Regional Board granted us some money for long-overdue repainting inside some of the wards. No one wanted to perpetuate the dark green paint, but they were not sure how to improve the existing colour scheme. I discovered that we could get free advice from one of the big paint firms and I spent several days with the adviser from London, who produced colourful but pleasant schemes which pleased everyone. Even Mr Merrin, while pointing out that it would be cheaper to paint everything in one colour, admitted that the paints proposed were durable and up to standard. This first repainting was a great success. The ward day rooms were brighter and more cheerful than anything previously seen at Fulbourn.
As the year moved on, the months brought the recurring festivals. At each one I took the role allotted to me, and tried to fulfil it to the best of my ability. This involved some curious tasks. I took the Chair at the Annual Meeting of the Patients’ Social Club, a curious body dominated by a grandiose paranoid ex-soldier. I chaired the Annual Meeting of the Staff Cricket Club, but declined the captaincy of the cricket team. This caused consternation. Apparently, Dr Thomas had been ‘Captain’ for 30 years. In his youth, he had been a keen cricketer and he always watched the hospital team on every possible occasion. The cricket team enjoyed all sorts of traditional favours from the Management Committee; cricketing was regarded as a duty and nurses were paid for time spent playing; their equipment was provided from hospital funds; free meals were regularly supplied. All this became clear as they pleaded for me to continue to be ‘Captain’. Cricket was a game I had disliked and played badly at school; I had managed to evade participation as either player or spectator for many years. No arguments of the patients’ interest or welfare could persuade me to undertake this! Then I realised what worried them: they did not care whether I played or not, but they feared they would lose all their special amenities and subsidies if I did not champion their cause. I assured them that I felt the staff cricket team to be an essential part of the life of the hospital and that of course I would support the continuing subsidy! I was enthusiastically voted honorary Vice-president and a respected fast bowler was elected Captain.
As Christmas approached, I realised that other traditional tasks would fall to me. All English institutions, like English families, made much of Christmas, but for the custodial asylums it was a tremendous occasion. A focus of great attention were the ward decorations. From the time the staff returned from their summer holidays, they began planning their displays and spent long evenings making paper flowers and streamers. A few days before Christmas the decorations were put up, and on Christmas Day, they were at their finest. Christmas afternoon was the only time in the year when the Matron of Fulbourn entered the male side, or the Chief Male Nurse entered the women’s wards. Much else, I gathered, went on, but Mr Tucker, who was gently preparing me for my part in all this, indicated that the Medical Superintendent was never seen in the hospital after lunchtime on Christmas Day! I gained the impression that this was a sort of Saturnalia, when the forbidden was permitted and actions which would earn instant dismissal at any other time – such as being drunk on the ward – were tolerated. However, I prepared to play the part allotted to me.
Dr Thomas had always been Santa Claus at the Staff Children’s party; many told of the conjuring tricks he performed to delight the children. They produced an immense scarlet robe, edged with cotton wool, which had obviously clothed his bulk majestically, but hung around my slighter frame like a collapsed balloon. I donned the cottonwool whiskers, daubed my cheeks with rouge and boomed hollow pleasantries at some 200 children to such effect that my own daughter wept in terrified ignorance of the identity of the strange, red-faced man!
On Christmas Eve, I read the lesson in the hospital chapel and the following morning early went briskly round the hospital, wishing all the Charge Nurses and Sisters a Merry Christmas. Later I took the Chairman, Mrs Adrian and members of the Committee around. I took them into every ward and compelled them to admire every decoration, however inadequate. After the Committee had left, I went into the staff lunches to wish everyone a happy Christmas and finally retired exhausted to the bosom of my family.
I felt convinced that however else I might have improved things, at Christmas I had been inadequate in my roles and a poor substitute for my vast jovial predecessor. To my surprise, however, I heard months later that the thing which had caused most favourable comment was something I had done without any special consideration – namely going round all the wards early on Christmas morning on my own and greeting all the Sisters and Charge Nurses. This, they said, had never happened before.
Gradually, as my first year wore on and I got to know my position and tasks in the hospital, I began to evolve a plan of action for bringing about changes. I had looked for books on how to run a mental hospital, but could find very few. However, a pamphlet recently published by the World Health Organisation seemed to express much of what I was groping toward. A chapter on ‘The Community Mental Hospital’ filled me with excitement. The hospital, the report said, should be a ‘therapeutic community’. In clear and telling phrases, it spelled out some of the things I was feeling – that patients’ individuality should be preserved, that locks and keys were largely unnecessary, that patients had a far greater capacity for responsibility and independence than was generally recognised; that they required a full day of well-organised work and activity, and finally, that the atmosphere of the hospital and the quality of the staff interrelationships were most important aspects of the total treatment programme and the special responsibility of the medical director (World Health Organisation, 1953). This seemed to me a blueprint for action.
Paradoxically, my first act within a few days of my arrival had been to lock up a ward. Mr Tucker had told me that the male nurses in charge of the Admission Villa were very worried about the situation there. It emerged that they had been ordered a few weeks earlier to run it as an open ward. On investigation I found that Derek Russell Davis, full of enthusiasm for the new ideas, had persuaded Leslie Buttle to order that the Villa be unlocked. I went and talked to the Charge Nurses of the Villa; obviously capable men, they seemed very worried. They said they felt they could not be responsible for the patients they had to contain if they were forced to try and run the ward with the doors open. When I asked Leslie Buttle, he said that he had never really been in favour of it, but Derek Russell Davis had persuaded him. I felt that little would be gained by forcing the nurses to do something that made them frightened, so I agreed that the door should be locked again. Three years later it was unlocked – and stayed open.
In the autumn of 1953 the Lancet printed an article describing the three ‘Open Door’ hospitals operating at that time in Britain – Dingleton Hospital in Melrose (open since 1948 and the pioneer in advancing these new ideas), Mapperley Hospital, Nottingham and Warlingham Park Hospital, Croydon. I had this article copied and distributed to the Charge Nurses and Sisters of the hospital. The following spring, I made a special journey to Croydon to see Warlingham Park, where T.P. Rees was at the height of his activity.
This was a most important visit for me and for Fulbourn. I was tremendously impressed with what I saw – the open wards, the busy workshops, the patients going about their business, sensibly and briskly, dressed in ordinary clothes, well turned out, cheerful and friendly towards Dr Rees. The flamboyant touches excited me – the small piece of railing left standing to show ‘how it used to be’, Dr Rees’ tales of battles and storms with reluctant nurses over patients’ freedom, the big land movement jobs undertaken by patients. Of some things I felt a little doubtful: the ‘habit training’ wards where incontinent patients were taught how to become continent through rigid discipline and ladders of promotion and demotion seemed rather authoritarian to me; I also felt that I could not copy Dr Rees’ constant emphasis on personal communication with him – as a framed newspaper cutting put it ‘the Medical Superintendent whose door is always open to all comers’. But there was much to admire and we at Fulbourn were so far behind. It was a revelation to me of what a mental hospital could be. I also visited Mapperley Hospital, Nottingham and Graylingwell Hospital, Chichester during that first year; after each visit I returned dismayed with how far behind them we were at Fulbourn.
The plan set out in the WHO pamphlet, together with what I had seen at Warlingham, gave me something to aim for and, perhaps more important, a tangible goal to put before the staff. But much had to be done first. The first challenge was to get patients doing something, instead of sitting around passively. I discussed the matter with Mr Tucker and he began to agree. It would be a good thing, he said, to get more patients occupied; they had tried to do it in the past, but they had been blocked; they would like to start again. I discussed the idea with the Charge Nurses, leaving aside the delicate question of their ‘good workers’ and concentrating on the large group of ‘unemployable patients’ who sat around the wards. Gradually, interest in patient occupation rose. At first it was probably just a response to my professed interest; this was the current bee in the bonnet of the new Medical Superintendent; any wise or ambitious man should note the new direction of the wind and trim his sails accordingly. However, by spring 1954 I felt that the male nurses were also ready. I had many talks with Mr Tucker about the importance of full occupation and how much work it would involve. We dubbed Mr Allen ‘Occupation Officer’ with the task of getting as many male patients working as possible. He plunged into the task with happy vigour. All working parties – on the farm, on the gardens, in the Engineering Department – were increased in size. Ward orderlies were taken off menial tasks and put in charge of squads of patients. We looked everywhere for tasks which patients could undertake. The dilapidated grounds were an immediate focus. Parties were sent out to weed paths, to cut undergrowth, to clear rubbish, to dig out weeds. The rusty railings at the front gate were rubbed with wire brushes and then repainted. The lamp-posts around the grounds were repainted. All the shabby cast-iron garden seats were brought in and repainted. Even the front door was given a coat of varnish. As the easier tasks were done, others were found. An area of broken ground, a mess of weeds and builders’ rubble, was laboriously levelled. A shrubbery that obstructed the view was grubbed out root by root. The male patients who went out on these jobs were the most pathetic and helpless, mute individuals who had done nothing for years. Many of them achieved little at first, but gradually they became more active and it was soon clear that their physical health was improving with the fresh air and gentle exercise.
Although my overall aim was to arouse the enthusiasm of the staff gently, I did not hesitate at this time to apply direct pressure. Daily, I would go round the wards with Mr Allen and if I found a patient sitting idle, would demand a full explanation from the Charge Nurse. I visited each of the work gangs, commending the staff in charge and chatting to the patients. I would ask each Charge Nurse ‘What are you doing for the patients today?’ and would show little sympathy or patience for excuses based on other people’s inaction or disinterest.
We reviewed the patients’ rewards. A system of pay for the patients had been instituted in 1950, when reward by tobacco and sweets had stopped. However, the money was allotted rather haphazardly; I was interested to discover that, owing to Mr Merrin’s vigour, patients working for the engineers got half a crown a week extra above anything they might get on the wards. With Mr Allen’s help, I revised all the pay scales; I stopped all pay to patients who would not work, and rewarded others according to the skill or responsibility they carried. Some of these revisions caused indignation and there was one stormy meeting with the Charge Nurses, when they protested against the withdrawal of many established doles. I made it clear that I stood behind Mr Allen; that I regarded work as an essential part of treatment and that I expected every patient to be occupied in some way. I further made it clear that I regarded this as one of the major tasks of the Charge Nurses and that I thought a group of well-occupied patients far more creditable than well-polished door knobs.
This mixture of pressure, threats, rewards and flexibility gradually produced results. During the summer of 1954 we got more and more men out on some kind of work or another and as the staff began to see for themselves how the patients’ physical health and behaviour improved, they grew keener. They gradually began to bring forward their own ideas, especially at the Charge Nurses’ meetings, of tasks that needed to be done, ways to rearrange work, small projects for groups of patients and so on.
However, not all projects worked. For years, there had been dissatisfaction among the cricketers over the state of the cricket ‘table’, where the pitch was laid. On our chalky soil grass grew poorly. On our cricket field it was especially poor and the teams had to play on matting. Even then, the grass was poor – rough, full of bare patches and slippery areas. The cricketing nurses were convinced that the Farm Manager did not give enough care to the task. At Mr Tucker’s suggestion, I arranged that a nurse who was a prominent cricketer should be freed of all other duties and given a squad of patients every day and any other necessary facilities, so that he could get the cricket field into really good condition. I was assured he would do it easily. He did not. The task was undoubtedly more difficult than the nurses had realised, but the main failing was in the man in charge. A glib talker, he had radiated confidence and determination; as I passed the field each day, however, I would see him and the patients sitting chatting. After a few months, the pitch was worse than it had ever been and it had to be returned to the Farm Manager, who reported the matter in full to the Farm Committee. They were obviously amused and perhaps pleased to see one of ‘the doctor’s projects’ fall flat on its face!
Although we were seeing great success in improving the daily life of the patients, I felt aware of other rather depressing cross-currents and undercurrents during this first year. By the autumn, the Enquiry on the missing stock was concluded. The two members reported that some £10,000 worth of material could not be accounted for. However, they did not think there had been mass thefts; they thought the losses were due to the fact that Mr Tucker – always anxious to avoid upsetting anybody – had failed to carry out adequate inventory checks for at least ten years and possibly longer, so that the annual wastages by damage, minor theft and loss had gone unrecorded and had accumulated to this large sum. They reported this conclusion to the Management Committee, who unanimously resolved to censure Mr Tucker severely. I had not been directly involved in either the losses or the Enquiry, but I was shocked at the situation which had suddenly blown up. I did not know much of Health Service rules, but I knew enough of elementary justice to know that you should not condemn anyone without allowing him to challenge the evidence and to put his point of view. Though I thought that the conclusion was almost certainly correct, I suspected that much of the Enquiry had been managed rather casually. A great deal of gossip had been repeated; the Subcommittee had not examined Dr Thomas, who was certainly partly involved; Mr Mitchell, the Hospital Secretary, who was surely partly responsible, had been the secretary to the Enquiry Committee; no evidence had been recorded, nor had anyone been on oath. I wondered whether I should intervene or let them fumble themselves into a real mess? Then I thought of the patients and the hospital. Mr Tucker was very popular with the staff and the Union; many would feel an injustice had been done. There might well be a public enquiry, running on for months and doing the hospital great damage. At the very least, all the old canards would be given further publicity and all the old animosities reinforced, at a time when I was trying to draw people together in a united effort to help the patients. I decided I must do everything I could to stop the disturbance spreading.
I spoke to Mrs Adrian who had realised things had gone awry, but was not sure what to do. I saw Mr Tucker and discovered that he had no idea that he was in such severe trouble; he thought he had cleared himself! I decided to breach confidence and I gave him some notice of the censure that was in store for him. As he gradually realised how bad things were, he asked me what he should do. I advised him to get a Union adviser forthwith, which he did. Soon I heard, and passed on to Mrs Adrian, that the Union official had advised Mr Tucker to refuse to accept the reprimand, to challenge the whole conduct of the Enquiry, and to demand a public hearing. At this stage, I saw Mr Tucker again. I told him that a public hearing, though gratifying, would be very painful for him; that though he might succeed in blackening many reputations, it would finally, I felt sure, also lay the blame on him, and might well result in his dismissal and loss of pension; that I should deplore it because it would do so much harm to the hospital. I finally asked him to accept the reprimand. After a sleepless night, he agreed to do so and the reprimand was given in private by Mrs Adrian. Although unpleasant for all, especially Mr Tucker, it was not humiliating. It was recorded in the Management Committee minutes, but no further publicity was given to the matter. The hospital heard no more of the affair. A year later, when nearly everyone had forgotten it, the Public Auditor asked to have the whole matter reopened with a full public enquiry and possible criminal charges. The Management Committee refused, pointing out that they had taken all necessary action at the time and fortunately the Auditor did not press it.
Such episodes were not uncommon in the early years of the National Health Service. They were the result of decades of parochial administration, the stresses and lowered standards of the war years and the lack of proper control procedures. Hospitals dealt with them in different ways; sometimes Ministerial public enquiries did major damage to the morale of a hospital.
There were also other drives to clean up inefficiencies surviving from earlier times. The hospital food was poor. The patients in the far wards, in particular, received stone-cold food on icy plates in winter time, and in summer time their bread, which had gone through a ‘bread and buttering machine’ became parched, cockled slabs, which had quite soaked up the dabs of greasy margarine. Much of the food sent to the wards went straight into the swill bins and only the hospital pig herd benefited. The Catering Committee of the Management Committee had tried to improve things without effect; the Catering Officer, a pleasant ineffectual woman, was quite incapable of dealing with the group of surly, lazy, dirty men who had been in the hospital kitchen for years; the Head Chef was Secretary of the main Union in the hospital.
The Regional Board hired a firm of National Caterers to advise them. They visited the hospital and wrote a blistering report. They pointed out how bad the food was; they said the kitchens were antiquated and inadequate; they said the whole delivery system would have to be reorganised; but most important, they said that nothing could be done unless both the Catering Officer and the Head Chef were discharged.
This gave the Committee the chance they needed and they acted with firmness. Both officers were given three months’ notice to go. The Catering Officer departed without complaint and got herself a job at a smaller hospital where she did well. The Chef called in Union advice and appealed; his appeals were heard, but the dismissal confirmed. During the summer of 1954, new staff were appointed and the cooking steadily improved. The Regional Board, on the Caterer’s advice, put in a system of steam-heated services, and some years later built us an entirely new kitchen. They also, gradually, increased the food allowances, so that the food supplied to staff and to patients improved steadily.
Over the months, I also had to manage a series of discipline problems. A patient asked for an interview and said he had seen two male nurses mishandling a disturbed man; the relatives of an elderly patient complained that the ward sister had slapped the old lady’s face and pulled her by the hair; a husband complained that his wife had been bruised by the brutality of nurses. In every case, I investigated the matter fully in the company of the Chief Nurse – examining the patient, listening to the story, hearing what the nurses had to say – and then gave my conclusion, first on the facts I found, and then on what action I proposed to take. I found these enquiries fraught with difficulties. I resented the attack on the hospital and felt sorry for the desperately overworked staff trying to do their best. I had to call on all that I had ever learned in the Army and elsewhere about the process of judgement, both to establish the facts and to get the best result for the hospital and the patients. As a psychiatrist, too, I found the role of reprimander most difficult; I wanted to help the culprit, to understand why he had erred, rather than to inflict on him the necessary punishment. Always afterward I felt exhausted, inadequate and dissatisfied. But no one ever challenged one of my decisions or appealed further.
The drive for full employment was managed in the traditional way, as something done by energetic staff to passive patients – people without responsibility or opinions. However, the patients’ response to the opportunity to work gradually won them respect in the eyes of the staff.
I had one particular piece of good fortune in 1954 when Fred Houston joined us as Senior Hospital Medical Officer (SHMO) – a grade for those experienced doctors who were not well-enough qualified to be Consultants. There were two applicants – one a dreary, tired man, the other an eager little man, who came from De La Pole Hospital, Hull, then becoming known for its active treatment of patients. He poured forth an enthusiastic tale of all that had been done there and I felt attracted to him at once. He was a godsend to me, and we worked very happily together for years.
During the summer, it became clear that full occupation for the patients raised many administrative problems: there was competition between departments for the best patients; there were problems over who supervised squads of working parties; there were difficulties over supplies of raw materials. To grapple with these problems I started a regular meeting every Monday at noon. Though other meetings waxed and waned, this one dealing with the challenges of the working life of the patients and the hospital continued throughout my career at Fulbourn. To begin with, the members were Mr Allen (recently designated ‘Occupation Officer’ of the male side), the Head Occupational Therapist, the Deputy Matron, Miss Legge and myself. Soon after his arrival, Fred joined as a regular member.
Our first concern in the summer of 1954 was the occupation of the men and the problems that arose. A typical difficulty was the supervision of the garden workers. Under the old regime, a gardener came up to the hospital every morning and went round the wards collecting the patients who were members of the ‘garden gang’. Often, the nurses had not got the patients ready and he had to wait. Then he took them to the garden office but by then it was almost time for their mid-morning break; later in the morning he took them back to the wards in time to get off for his own lunch. The result was that the patients did very little work, but spent most of the morning standing around waiting for someone to collect them and walk them somewhere. Until now, no one had been greatly concerned and it served to confirm the staff view of the unimportance of patient work.
It took weeks of discussions to change this; we had the Farm Manager to the Occupation meeting and also the men in charge of the squads. The talks were very revealing. The gardeners did not like squad duty; they told tales of a gardener discharged years ago for allowing a patient to escape; they revealed fears of violent patients; yet at the same time, they told tales of men who had regained sanity and interest by working with them. We tried to meet their fears and to encourage their therapeutic interest. We assured them that they were not responsible for preventing escapes, but we did want the patients stimulated and challenged by their work.
Point by point, we clarified things. It was agreed that some patients did not need to be escorted, so these men were told to report at the gardener’s office for work at starting time. They were told that they would lose pay if they were late. All the patients’ pay rates were adjusted and we arranged that the gardener and Mr Allen would review them regularly and promote those who were working well. Ward orderlies, released from other work, were put in charge of the patients thought to need supervision. The gardeners were thus freed from ‘escort duty’ and could give more time to supervising the patients actual gardening and providing more skilled work. Gradually, over the months, the quality of patients’ work improved and they were given better and more varied jobs; more of them got themselves to work in the mornings; many worked individually on fairly skilled tasks. Finally, the six most skilled were given allotments to cultivate in their own time and an annual prize was awarded for the best allotment.
This was just one of many problems. In each case, we brought the staff into discussion; nearly always, they disclosed ancient fears and insecurities – especially of their responsibility for escapes or damage. Often, they revealed considerable therapeutic zeal, making suggestions of what the patients might do, putting forward the names of men who had improved greatly, suggesting new projects. Always I tried to increase the opportunities and responsibility offered to the patients and to challenge any assumption that they were incompetent merely because they were patients.
Most of the projects were worked out in the Charge Nurses’ meetings, which we were now holding every few weeks. As activities developed, I was delighted to find the nurses themselves coming forward with ideas. The mens’ admission ward asked permission to develop its garden. They had a fairly large area, divided up by thick hedges; they asked permission to grub these out and to develop flower beds. The Farm Manager expressed grave doubts and pointed to the recent debacle over the cricket pitch. Somewhat daunted I asked the nurses if they really could do it. However, they seemed confident and so I backed them. On this occasion, my confidence was justified; the admission ward garden went from strength to strength and was never handed back to the Farm Manager. First, they grubbed up the hedges and made their flower beds. Then, they tackled the lawn. It was level enough for bowls, but was a mass of weeds. They had in the ward a patient who was a groundsman, recovering from a melancholia episode; he undertook to make them a bowling green and by high summer, they were able to announce the opening of a hospital bowling green, with matches most evenings. Later the ward raised money and bought themselves roses and herbaceous perennials and made their garden the envy of the hospital. Even on this project though, there were administrative difficulties. The ward had no gardening tools; the Farm Manager would not lend them his. We appealed to the Friends of Fulbourn, a donation of £10 started us off and over the years, a full stock of tools was built up.
In my meetings with the Charge Nurses, I came increasingly to respect their quality, their knowledge of the patients and their initiative. There were two Charge Nurses on each ward, one on each shift. I found that nearly everyone deplored this as no ward policy could develop with two alternating masters and messages were frequently lost between the two shifts. Some wards were also too large; two contained over 100 patients. The staff complained particularly about the mens’ refractory ward. This contained all those people who were a problem elsewhere in the hospital – the violent, the escapers, those with criminal records, and all the incontinent patients. As they were all crowded into one ward, constant conflicts arose. During my first months, an angry man rose during the night and struck a noisy man so hard that he died, leading to an unpleasant inquest.
Now Mr Tucker and the Charge Nurses suggested that this ward might be split in two, separating the violent patients, who needed restraint, from the regressed patients who needed training and prompting. They were in a two-storey building – day rooms, kitchen, bathroom and office downstairs, dormitories upstairs; this could be divided to give a separate ward on each floor.
Thinking things over one evening, I realised that this division could be combined with changing the staffing so that there was only one Charge Nurse per ward, throughout the men’s side. Even the Finance Officer was pleased, for the rearrangement reduced the wages bill slightly. The Management Committee accepted the plan with pleasure. At the same time, I took note of the plea which the Charge Nurses had made repeatedly to me, that they should be allowed distinctive uniforms. Thinking it over, I could see no sound social argument against it and, since they begged for it so earnestly, I agreed. They soon appeared in long white coats, which pleased them greatly.
The change to single Charge Nurses had many valuable effects. With only one nurse in charge on each ward, responsibility was much clearer. Men with capacity had a real chance to do something distinctive and several of them took the chance to develop very lively units. The division of the disturbed ward was a great success.
The two Charge Nurses responsible were both Welshmen in their early forties – Joe Pattemore and Tom Lewis. Pattemore took the disturbed patients, Lewis the regressed. They asked how the patients should be divided, and left me a list of the 100 men on the ward since this was considered a job for a doctor. As I went through the list that night, I found that I only knew about 15 of the 100 men. I realised that I would have to go through all the case-notes and interview all 100 patients – a task that would take weeks. I then called Pattemore and Lewis to me next morning and asked them to divide up the patients between them. This they did in one day, for they knew them all well. I accepted their division. At the time, my only conscious motive was to evade a wearisome task, but later I saw that I had been wiser than I knew. By giving the Charge Nurses the task, I had showed my respect for their judgement in what was officially regarded as an exclusively medical area. By letting them choose the men they would work with, I had made them even more committed to making the scheme succeed. Furthermore, I had clarified for myself the principle that a doctor should never do a task that a nurse could do – from which it might follow, by extension, that a nurse should never do what a patient could do.
The building work to turn the upper floor into an adequate ward, which had been sanctioned by the Committee, had not started yet. I asked Pattemore and Lewis if they wished to wait, but they were so keen to get on with the division that they asked to start at once, despite the disadvantages. We arranged for Lewis, who was going to take the regressed patients, to spend a week at Warlingham Park to see their system of habit training. He came back enthusiastic about the approach, but convinced that we could do better at Fulbourn. He threw himself into the task with exuberant enthusiasm and soon began to show results. Before he began, it had been necessary to collect a gallon jar of paraldehyde mixture every week from the dispensary for use as a sedative for 50 patients; by Christmas time, the weekly dose for the ward was down to one small half-pint bottle! He got his men going regularly to the lavatory, so that the wet stained trousers became a thing of the past and the ammoniacal smell of urine no longer hung permanently about the ward. Nearly all his men had hitherto been regarded as unemployable. He soon got a number of them out on working parties, and when the weather improved, he started taking the others for walks around the nearby villages. Within the ward, he started improving their life. At first, it was fairly spartan, but as we installed the kitchen, the new furniture and the new curtains, the ward became pleasant. He taught the men to care for their new home and to maintain a higher standard of cleanliness.
In Pattemore’s downstairs ward things too began to change. When the irritating and helpless patients had been removed, the staff could concentrate more attention on the ‘disturbed’ patients, who were younger, more active and more capable. The staff reviewed each man and his work and moved many of them to more testing tasks. They rearranged the ward life, with more games and parties. They endeavoured to get everybody out for some time each day. They soon found that with better attention, there was less need for restraint and coercion, the amount of emergency sedation fell and the use of the padded room decreased. Thus, within six months during my second year the programme of ‘Work for All’ began to pay dividends for the men and the male staff became increasingly enthusiastic about the general concept of treatment by social planning and reorganisation.
During this time, we also conceived the Sports Ground Project that was to keep all of us – the patients, male staff and myself – busy for several years. When I first visited the hospital, I was impressed by the fine sweep of land in front of the main building, and was sad to see that it was devoted to crops. Old pictures showed that it had once been a sports field but that during the First and Second World Wars it had been ploughed up. The present sports field, behind the hospital, was unsatisfactory – ill-sited, poorly levelled and bare of grass. I suggested using the front for sport, but I was told that it was ‘the best farming land in the hospital grounds’ – that it had been manured for a century and the Chairman of the Farm Committee, Alderman Street, would never let it go.
The more I looked at it, however, the keener I became on the idea. I talked to Mrs Adrian and selected members of the Committee about my idea and found them receptive. I wrote to the National Playing Fields Association, who referred me to an architect who specialised in Sports Grounds. In the autumn of 1954 I put the plans before the Committee. I had taken some care to prepare the climate of Committee opinion. All summer, they had heard a string of complaints about the present pitch and about the need for patient occupation. I had talked persuasively to a number of key members. I had even got the architect to prepare an alternative scheme, which had manifest drawbacks. The strategy worked. Despite the voluble protests of Alderman Street and the Farm Committee over losing their precious well-manured field, and the doubts of the Engineer and the Finance Officer about the feasibility and the cost of the project, the Committee voted to develop the front of the hospital as a sports field by patient labour. Mr Allen and I were delighted and went about saying that in five years’ time the cricket team would be playing on grass (rather than matting) for the first time in Fulbourn’s history, while the Farm Manager and Alderman Street were sullen and disgruntled, predicting that no good would come of it all.
The first task was to clear and level the land. This was a good project for unskilled workers, and all through the summer of 1955 we had every possible male patient and staff member out on the field, digging, shifting soil, excavating chalk and levelling land. At first, some of them did pathetically little; they would just stand behind a wheelbarrow until it was full, push it a few yards, and then wait for someone to empty it. But even they gradually took more interest and, in fact, one of our more striking rehabilitation successes occurred on this particular project. Jacob, a 45-year-old man, had been in hospital seven years, diagnosed with catatonic schizophrenia and was mute, unoccupied and incontinent. We put him out on the squad, and at first he just pushed a barrow. Then he began to show more interest; we were grading some ground and he began to hold the levelling rods for the orderly in charge. We then recalled that he had been a surveyor, and deliberately involved him in the planning of projects; he began to comment on what we were doing and show us better ways of doing it. His behaviour began to improve; his incontinence ceased, he dressed himself properly, he began to help the staff on the ward. He was moved to a better ward, where he fitted in well and began to take an active part in ward life, playing cards with skill and cunning. A member of the Management Committee who had known him before his admission was delighted by this change and took Jacob home for several weekends. Jacob had no close relatives in his village, but he owned a small house there and had a number of friends who wished him well. Finally, about two years after he first went to work on the sports field project, Jacob left hospital for good. Only a few recoveries were as dramatic as this, but nearly all the men who worked out on the project made some progress. The Charge Nurses reported a marked decline in violence and incontinence on the wards, and less sedation was needed.
One group which was soon affected by the new atmosphere in the hospital was the ‘Farm Gang’. They were competent labourers, strong, biddable and well-behaved. Their Charge Nurse, Eric Raines, found many of them jobs in Cambridge (though they still lived at Fulbourn) and they became comparatively affluent, acquiring clothes, bicycles and radios.
One of those who moved on at that time was Hugh who had several labouring jobs around Cambridge. The foreman on one building site became quite fond of him. When the night watchman left, they offered Hugh the caravan. The situation suited his solitary nature and he laboured by day and slept in the caravan at night. No one pilfered from the site when Hugh was there! They moved the caravan from job to job and Hugh stayed contentedly with them for years.
During the winter of 1954, I discussed these projects with various London friends and, as a result, Morris Carstairs and Neil O’Connor of the Maudsley Social Psychiatry Research Unit invited me to accompany them during the spring of 1955 on a tour of Dutch mental hospitals specialising in work and rehabilitation. This ten-day tour was most valuable to me and to Fulbourn. I was amazed at the quality of work being done by psychotic and mentally handicapped patients in Dutch hospitals. They were not content to stick to ‘hospital work’, but were producing goods for the commercial market, up to commercial standards. They were assembling pens and shop displays; smoothing, polishing and painting clogs; assembling army equipment and putting together parts of wireless sets. I could see that their finished products were up to market standards. No such work had ever been done by patients in English mental hospitals and I would not have believed it possible unless I had seen it. I had accepted that the best that patients could do was unskilled labour, such as levelling the sports ground. I now realised that the scope for patient work was far greater than I had thought and I returned determined to start commercial work at Fulbourn.
This turned out to be a harder task than I had realised, and many sessions of the Monday Occupational Meeting were given to plans, high hopes and false starts. Mr Allen suggested making and selling decorated matchboxes. We bought the materials and made several score. When we tried to sell them, no shops found them attractive and they were left on our hands. We then thought of brush making. We got a stock of material – hair and pierced wooden backs – and set up a workshop. We trained a group of patients until they were making brushes well and fast and we offered them to the Supplies Officer. He took them willingly, but then careful costing showed that the cost of raw materials for each of our brushes was rather more than the manufacturer’s price for a finished brush!
Then Fred Houston took a hand. With a suitcase full of samples of patients’ work which I had brought back from Holland, he went round business after business in Cambridge. Time and again he was rebuffed, but his enthusiasm was undiminished and after about 30 unsuccessful visits, he found an interested listener in the manager of a local electronics factory, who had a number of small assembly jobs to be done. We got together a small group of patients and started.
However, it was not long before we realised we needed a workshop. The hospital was so crowded that we could not clear a ward to serve this purpose, but by this time the idea had attracted the enthusiasm of Alderman Holmes, the new Vice-Chairman of the Management Committee, and we persuaded him to suggest that amenity funds be used to purchase and erect a wooden hut – as this could be done fairly quickly without waiting for Regional Board money.
Even then there were still further problems to solve. We wanted to pass on to the patients all they earned; the Finance Officer wished to take most of the money into the hospital accounts. A battle seemed about to develop, but fortunately Morris Carstairs and Neil O’Connor had established an appropriate model when working at the Manor hospital in Surrey. With Ministry permission, they deducted only five per cent for hospital expenses and passed over 95 per cent of what the manufacturers paid to the patients who did the work. This constituted a ‘precedent’; after long arguments in front of Mrs Adrian, the Finance Officer was defeated and we were able to pass 95 per cent of the money on to the patient workers.
We set up the wooden hut in the airing court of the women’s wards and in the autumn of 1956, we opened our workshop. We called it ‘Fulbourn Industries’ and it remained a key rehabilitation facility for years. At first it provided employment for 24 women, then two years later it took in men. It did not become very large – never more than 40 patients and three staff. The type of work was always complex and challenging, though over the years we worked for a number of different manufacturers, assembling car radio aerials, television aerials and circuits, painting toys, assembling Christmas games, making straw mats for cheeses and tinsel Christmas trees. The patients made about 15 shillings per week on average, with a ceiling of £2; for many of them, this was riches and the first step to independence.
One of the first recruits to Fulbourn Industries was a patient called Dr Winkel. I had first noticed her as a silent, grey-haired, bowed figure who sat in a corner of the occupational therapy department doing embroidery. I learned that she was a medical doctor from Germany, a refugee who had been admitted to Fulbourn during the war in a melancholic paranoid state and was now mute, refusing to speak to anyone. For years she had been a star member of the select group who were allowed to attend the Occupational Therapy Department; she produced embroidery of meticulous workmanship but bizarre design, sought-after by medical staff as ‘schizophrenic art’. She appeared to have settled for a silent life in the asylum.
To our surprise she asked to try Fulbourn Industries and soon proved one of the most capable electrical assembly workers. She used her earnings for new clothes and belongings and became more lively and talkative. I asked her how it was that she preferred this rather dirty work to embroidery. She replied, ‘Well, they appreciate it, don’t they?’ When I queried further she retorted, ‘If people pay you for what you do, it shows they appreciate it, doesn’t it?’ I realised that she had never been paid for the ‘creative work’ which she had done for years in the genteel OT Department. Gradually she became more talkative, discussing the outside world with the staff of the Industrial Hut. She made some trips into Cambridge and started writing to old friends. One of them, who lived in Cornwall, came to visit her, then took her for a visit and finally took her out of hospital permanently – cured by Industrial Therapy.
During my first year I found myself gradually being drawn into attempting to improve the public relations of the hospital. When I first arrived in 1953 I realised that nobody in the Cambridge area knew much about Fulbourn Hospital, and that what they did know was bad. The comments quoted by the Charge Nurses at their first meeting to support their plea for a new name for the hospital confirmed this. ‘Fulbourn is a name to frighten children with’ – ‘They only think of it as the place the loonies go – I don’t care to tell my relatives that I work at Fulbourn’, and so on.
Miss Brock had quite a bit to say about this – ‘The Press are very unfair to us, doctor. All they ever print about us are the inquests and the silly things that are said at the Management Committee meetings. Why, one day, I complained about the cakes and the next thing I knew, there it was in the paper ‘Rock Buns too Hard to Eat, says Matron’ – I felt so foolish!’ All our inquests were reported – often with the witnesses’ comments in full. In my first month, we had a particularly nasty inquest after one man on the disturbed ward hit another so hard that he fell and fatally fractured his skull. The inquest was given a full page of the Cambridge Daily News with full (and slightly inaccurate) details of what everyone said including the allegation of a woman juror that ‘the poor man’s body looked as if he had been starved to death’. To a casual reader the impression was clear: Fulbourn Hospital was a seedy institution where patients were starved and fatally injured in uncontrolled brawling.
Dr Thomas’ policy – and, indeed, the traditional mental hospital practice – was to keep the Press out at all costs. He regarded them as dangerous and hostile; the less they heard the better. This of course worked as a self- confirming hypothesis. Since the Press were excluded, they only heard about the hospital when something went wrong and required public enquiry – an inquest or a hostile HMC meeting. This they printed and, since it was all they printed, the reader got the impression that nothing but bad things happened at Fulbourn Hospital.
Gradually during the first year I worked out a different policy – of giving the Press as much good material as possible about the hospital. The reporters who came to the hospital were usually junior, inexperienced, pleasant youngsters, who were keen and enthusiastic and who responded very readily to courtesy and consideration. They were only too glad to take down anything and try to get it printed. Every time we had any sort of a party or function I would ring them up and invite them to attend. They came to the opening of the Sports Club and took the picture of Mrs Adrian pouring the first drink (which won her a rebuke from a Temperance fanatic!). They came to see the Christmas festivities and took pictures of the Friends of Fulbourn presenting their Christmas presents – which gave their activities a useful boost. They came to the Staff Children’s Christmas party and took a picture of me dressed as Father Christmas. They came to the opening of the new Tuberculosis Wing in the second spring and took many photos of the gathering and repeated the speeches in full. All this began to present a different picture of Fulbourn Hospital to the people of Cambridge.
I gradually began to think that perhaps I should apply myself more actively to this matter of public relations. In those days, the early fifties, the phrase was little heard, and was usually regarded with some distaste. Doctors in particular were very hostile to and frightened of publicity. As medical students, we had been taught that ‘advertising’ was one of the worst medical sins; some doctors had been struck off the Medical Register for committing this offence. So I felt very nervous about starting to promote the hospital – and one of my colleagues warned me – ‘It will do you no good, David, with the people who matter.’ However, when I saw how much good publicity helped the hospital and how directly it benefited the patients, I began actively to cultivate the local press.
A reporter always attended the meetings of the Hospital Management Committee and it was clearly right that the meetings of a public body running a public institution should be open. I found it difficult, however, to speak spontaneously and vividly when I knew that what I said might be in headlines the next day, to be read by acquaintances, friends, enemies and, worst of all, the staff and patients of the hospital (who saw the paper long before any official information could reach them). I suggested to Mrs Adrian, who put it to the Committee, that the Press be asked to withdraw at the end of the formal proceedings. This was accepted and became standard practice. It meant that after the reporter left, we could all speak more freely and that if members raised unexpected questions, I could give an extempore answer without having it broadcast. At the same time, I started a practice of going through the agenda with the reporter, indicating which subjects might give rise to lively discussion and which might be of interest to the general reader. This they enjoyed and they took to ringing me the next day and discussing the material before writing it up. This worked well as I could show them the encouraging aspects of a situation and often get them to give prominence to some report the Committee had received. Equally, I sometimes could steer them away from emphasising some unfortunate happening or some unhappy remarks. As a result of this work, I came to know the reporters personally and since I was always ready to give them help, they would often ring me on other subjects. All this helped to ensure that references to the hospital were helpful and optimistic, rather than critical or disheartening as they had been before.
Every month, the Medical Superintendent had to give the HMC a written report and every year an annual one. In his later years, Dr Thomas kept these very brief and in March 1953 he had simply repeated his Annual Report verbatim, just changing the figures! This seemed to me a opportunity missed, and I gave a good deal of care and attention to the Annual Reports I wrote about the hospital. I came to use them as an opportunity to tell the hospital (and the Committee) what they had been doing, to remind them of their achievements and to suggest what they should do next. I distributed them to the senior staff as well as to friends and colleagues; the material was often quoted in the local newspaper.
However, in spite of all these efforts, Fulbourn still had by and large, a poor reputation. On reading the local paper during my first Christmas, I saw that the Mayor of Cambridge and the Chairman of the County Council visited all the other local hospitals, including the old workhouse, but none of them came to us. I commented acidly on this and one of our Committee members, a City Councillor, persuaded the Mayor, a personal friend, to visit us unofficially in February. The next year, I wrote early to the Mayor asking him to visit us at Christmas. He agreed and came on Christmas Day 1954 in the afternoon. The precedent was established and every Christmas thereafter the Mayor visited us – and was photographed doing so by the Press.
Apart from handling the Press and thus indirectly affecting what the people of Cambridge heard about their mental hospital, I was also gradually drawn into public speaking in Cambridge. Not long after my arrival, I received a letter inviting me to speak to a meeting of a ‘Men’s Fireside’. Rather flattered, I agreed to speak on ‘Modern Psychiatry’. Other invitations followed. I discovered that in rural England at that time there was a great network of meetings (usually weekly through the winter) – desperately seeking speakers who were at least audible, preferably entertaining and ideally informative as well. Women’s Institutes, the Church Groups, business/philanthropic groups, political groups, medical groups and university groups for students were all avid for speakers. I found that I enjoyed these occasions and seemed to be quite successful with them. At first I talked in general terms, but I soon realised from the questions that they wanted to hear about their own local mental hospital, so I began to talk about that. As we began to do things we were proud of, such as opening the doors, I spoke about that too. Gradually, I began to see this voluntary speaking as a major part of my work to change the way in which Cambridge people viewed Fulbourn Hospital.
In 1955 we began to increase the patients’ freedom. This had been in my mind as a possibility from the first since I had always been unhappy about locking people up, and even worse, secluding them in padded cells. It was only gradually, however, that I came to see the question of patient freedom as one of the most important parts of Social Therapy. Shortly after my arrival, in 1953, I had distributed the Lancet articles on patient freedom and open doors to the Fulbourn nursing staff. My visit to Warlingham, an Open Door Hospital, in 1954 had shown me the truth of what the WHO report had asserted – that there was no need for the majority of mental patients to be locked up. A visit to Dingleton Hospital, Melrose – the first British Open Door Hospital (opened in 1949), further confirmed my conviction that we could – and should – have more freedom at Fulbourn.
In 1951, three wards, one male and two female, had actually been opened. These were the wards in which the ‘hospital workers’ lived – long-term patients who worked in the laundry, in the gardens or in the staff houses. They were all quiet, reliable people and no trouble had arisen when the doors of their wards were unlocked. These wards were near the centre of the building; the wards beyond were still locked – as were the communicating doors on the corridors and the main entrance at the porter’s lodge. All visitors and patients had to be let in and out, and often escorted for considerable distances along corridors through doors marked ‘This door must be kept locked at all times, by order Medical Superintendent.’ Everyone in the hospital knew of the great importance of keys and the need for their careful custody. At the end of the working day, all staff had to hand their keys in at the porter’s lodge and there were penalties for any who mislaid their keys or even took them home. Keys were always in evidence, rattling in male nurses pockets, jangling in doors, hanging on chains from women nurses’ waists, even twirled on the ends of their glistening chains by strolling nurses. They were the ever-present sign of the barrier between the locked-up and the lockers-up, the imprisoned and their warders.
In 1954 we began to talk about opening more wards and I looked round for one that was suitable. A women’s ward looked satisfactory – Female 7, housing 80 long-stay women patients, many of them paranoid. I discussed the idea with the nurses, who expressed grave doubts. I then asked them to name any patient on the ward who might cause difficulties or run away. They could name very few; I moved them to other wards. They then asked who would ‘take the rap’ if a patient escaped. In the old days if a patient escaped, a scapegoat had always been found. There would be a full Enquiry, and finally blame would have been placed on one person, who was then demoted or sacked. I assured them that this would not happen. If a patient in an open-door ward left the hospital there need be no Enquiry, and no nurse would be blamed. The mistake, if there was one, would have been mine in allocating that patient to that ward. But I also made it clear that I did not regard a patient’s unauthorised departure from hospital as inevitably a bad thing. It was only unfortunate if harm to the patient, or to people outside, resulted from it. It might actually be a way of starting rehabilitation. To some of the older staff, this was a novel view. There were still many discussions and many doubts.
One day in 1955, then, the door of F7 was left unlocked. Nothing dramatic happened. A few patients were seen to go in and out of the door during the first day, apparently just to taste the delight of it. Several elderly women approached the nurse in charge and pointed out that someone had foolishly left the door unlocked – intending to save the nurses from a reprimand. Soon, all became accustomed to the open door. A review after a week or two showed that there had been no difficulties, but the nurses said they were amazed how much time was saved now that they did not have constantly to answer the bell or go down the ward to let out a patient going to work.
This was the first step in the policy of opening ward doors which was to occupy – and preoccupy – the hospital over the next three years. Each time there would be discussions to be held, doubts to be aired and practical layout problems to be solved. In some wards it was physically easy – just a matter of agreeing to open the door; in others it was genuinely difficult because they opened into other units. In some we had to build partitions, or remove barriers. But underlying the practical issues were deeper ones such as staff fears of losing authority, of scandals, of madness out of control. We all had to work through a great deal.
The open-door policy had interesting effects on the paranoid people who had long protested their detention. Mrs Broadbent, the solicitor’s wife, was at first most upset at the opening of the door of her ward. She spoke anxiously to the staff telling them that someone had left the door open by accident. When told it was a new policy she was very perturbed. Finally she accosted me, protesting that an open door was most unwelcome as all sorts of riff-raff might get in. Later, however, she came to enjoy the freedom of the grounds; she acquired pets, especially a tortoise which she carried everywhere with her in a shopping basket. Then she slipped off and paid a visit to her native town. The staff discovered it had happened and told me. We were all most alarmed – but there were no messages and we gradually realised that nothing untoward had happened! Her husband had seen her and been terrified, but she had paid him no attention. Eventually, she went to live in Devon with a friend who seemed as eccentric as Mrs Broadbent herself.
Mr McTavish, the big old Scotsman who proclaimed the coming of the Prophetess, continued to protest his detention to me every time I went through the ward. Finally I said to him ‘Mr McTavish, the door is open; if you want to go, go!’ Drawing himself up to his full height he roared ‘Ah willna leave this place until Ah get ma Legal Discharrge!’ and stalked away to his room. He continued to live on the ward, a respected and helpful senior citizen and to protest to all visitors, until a stroke and then heart failure brought his stormy life to its close.
About this time, we also reviewed our visiting arrangements. Visitors had always had to meet patients in the main hall of the hospital – a large gloomy place, where they sat under the eye of a nurse on ‘point duty’ (rather like visiting rooms in a jail). We discussed this policy at a joint meeting of Sisters and Charge Nurses, with the explicit aim of seeing how we could improve the visiting arrangements – which all agreed were unsatisfactory. One of the nurses mentioned that other hospitals allowed visitors to go to the wards and asked why we did not. It was difficult to find a good reason why we did not. Some said that it was not good for relatives to see how shabby and bare the wards were; someone else pointed out that the visitors had already heard a far worse tale from the patients anyway. Some said that the visitors would interrupt the ward work; others pointed out that getting the patients dressed in their best and escorting them to the visiting hall and back took up a lot of staff time anyway.
It became clear that a majority of the senior nurses were in favour of having the visitors come to the wards and so I happily agreed. This turned out to be a great improvement and staff, visitors and patients all approved. The most important gain was an unexpected one. Relatives mentioned to me how nice it was to meet the people who looked after their sick relatives; staff said that for the first time, they saw something of the parents, wives and husbands that their patients so often mentioned. The previous method had kept them apart, for the duty nurse in the visiting room seldom knew the patients he was watching. From these meetings many advances slowly came. In some rehabilitation wards, the nurses were able to open discussions with the relatives about possible weekend trips to the home. Misunderstandings, based on patients’ misconceptions and delusions were checked; the nurses found that the relatives were more tolerant than they had been told and the relatives found the nurses less harsh than they had been described. In the old women’s ward, the Sister made tea for the relatives; they began to contribute towards its cost and she was soon able to take up substantial collections for the Friends of Fulbourn.
All these steps served to break down the isolation of the wards; gradually, they became less of a bizarre, sealed world and some of their strange ways were modified. Neither patients nor staff were so willing to show their less pleasant side when people from outside were in the ward – foul language, stripping off clothing, obscenity all became rarer. As more wards were opened, lively discussions took place among the staff. Some who had seen other hospitals or had experienced the relief of opening a ward argued persuasively with the older or more cautious members, who constantly stressed the past histories or unreliable habits of the patients. I took an active part in all these discussions. They all knew I believed in greater freedom, but I stressed constantly the need for full discussion and being sure about what we were doing.
At that time I myself was not even sure how far we could actually go. I knew that most patients did not need to be locked up, and that we could go further than we had done, but I was not convinced that every single ward door could be unlocked. There was much general discussion on the topic in psychiatric circles. In England in the mid-1950s the Royal Medico-Psychological Association held a debate between Dr McDonald Bell of Dingleton who put a passionate case for open doors and Dr Joshua Carse of Graylingwell, a Superintendent well-known for his advanced and liberal views, who told dire tales of patients invading neighbourhood kitchens with choppers and stressed the need for some wards to remain locked.
In October 1955, I gave the Annual Address to the Cambridgeshire Mental Welfare Association and discussed among other things the question of Open Doors. This was printed in the Lancet in 1956. Drafting my address forced me to clarify the issues in my own mind and I realised that at that point I did not believe we could run Fulbourn with all the doors open, though I wished we could. In my address, therefore, I hedged. After discussing the open doors of Dingleton with enthusiasm I said:
This has raised the demand that the principle [of open doors] should be applied elsewhere, and there has been criticism of hospitals where doors are still locked. The open door is a great ideal and it is certainly possible in any mental hospital to have all but two or three wards open. But hospitals which are near large towns and receive disturbed urban patients cannot, I think, go further than this. (Clark, 1956)
Only two years later I was happy to be proved wrong, when we opened the last ward doors at Fulbourn.
There were two particularly challenging areas on the men’s side: the Admission Villa and the ‘disturbed’ ward, Male 5 (M5). The Admission Villa was ‘open’ in 1953 when I came to Fulbourn, but the anxiety of the staff about this was so great that I had agreed to them closing it a few weeks after I arrived. By the summer of 1957, only the Admission Villa and the disturbed ward on the men’s side were locked, and the other Charge Nurses now challenged the need to lock the Admission Villa.
The Charge Nurse of the Villa, a former RAF Warrant Officer and a most conscientious man, was certain that the patients must be locked in. He pointed out that many of them were admitted direct from their villages; how would it look, he said, if the patient escaped and arrived home before the duly authorised officer who brought him in? Finally, the Charge Nurse of the disturbed ward offered to take any admissions that the Villa could not handle. Having discussed it with my Consultant colleagues, I said that we doctors would be answerable if any nasty questions were asked about escapes. The Admission Ward Charge Nurse continued to protest, until one day at a Charge Nurses’ meeting the excessiveness of his anxiety became ludicrous and the other Charge Nurses started to laugh at him. This was too much and he agreed to take the plunge. We all reassured him and I took good care that no really troublesome or worrying patients were left with him for the next few weeks. The door of the Villa was unlocked, and everyone watched to see what would happen. Nothing very striking occurred at first; the life of the patients went on as before. Recent admissions commented that they had been terrified by the door being locked on them – it was now much better. The junior nurses commented on reduced tension in the ward. In due course a patient did run away, but by the traditional escape route, the lavatory window, not by the open front door! At the Charge Nurses’ meeting we all agreed that the open door on the Villa was a great success.
The last men’s ward, Male 5, was more difficult as by now it contained every man whom other wards had felt to be unsuitable for liberty or an open door. This was Pattemore’s ward, the ‘disturbed’ or ‘refractory’ ward. It also took about ten per cent of the admissions – all those men thought to be too difficult or too violent for the Admission Villa. Pattemore was keen to see how much liberty was possible, but was understandably alarmed about some of his patients. We had a number of discussions, privately and in meetings. Fred Houston, who was in clinical charge of the patients on the ward, was keen to try opening the door and the other Consultants said they would back him. In discussions with the nurses, all the old fears came up again. What would the relatives, the duly authorised officers, the police, the coroner say? Who would carry the can for an escape? Who would answer the Hospital Management Committee, the City Council, the Board of Control? Once again, we went through all the arguments and I gave all the reassurances I could.
Finally, we agreed that the door should be open, but that the nurse in charge should have the authority to lock it again at any time he felt necessary. I re-emphasised that this was a step that we were all taking together and that if anything went wrong, I would bear the criticism. By this time, the nurses knew me well enough to know that I meant this. My own anxiety was, however, high. Many of these men had been violent; many had made suicide attempts; two or three had committed homicide; many had recently needed to be locked in padded cells; many had attempted escapes. What might they not do? Was I making a dreadful mistake? Might someone – a patient, a person outside, a child – perhaps be injured or die because of my lack of judgement?
In February of 1957 we cautiously opened the door of the last men’s ward. For the first days and weeks we all waited tensely for something dreadful to happen. The runaways and potentially violent patients were closely watched. Nothing went wrong and the close watch gradually declined. After two months, the staff began to feel more comfortable and more confident with their new plan. The door was never locked again.
The staff and the patients commented on the change in the ward. There were fewer violent episodes, fewer black eyes and much less use of the padded room for seclusion. This ward contained a number of patients who were effective hospital citizens; some were epileptics who were in the ward to be under observation in case they had an unexpected fit, fell and damaged themselves. Several of them told me how pleasant it was to be able to go out when they wished, without having to ask someone to unlock the door. The staff were amazed at the reduction of tension; they said that they no longer felt surging hostility on the ward, as they used to. One of them said he could almost enjoy his spell of duty, instead of dreading it. The Charge Nurse, Pattemore, was so impressed that he wrote an article for a nursing magazine about the change (Pattemore, 1957).
It was while working with this last group of male patients that we finally clarified our ideas about open doors. At first, we continued to use the padded room, bed rest, confinement to the ward and restriction of privileges routinely. Then, we also began to question these. We stopped using the padded rooms, and had them removed in 1961. We continued to use compulsory bed rest for patients in a phase of acute mental disorder. We had let some people go into Cambridge, but then had to stop them when we heard they were making a nuisance of themselves. Gradually, we worked out methods that were effective and fair. Some of the men could not have complete freedom; some were not allowed to go out of the hospital grounds; some were kept in the ward; some were kept in a dressing gown or in bed (for a few days at least). This we did because they were so disordered mentally that if they had been allowed out they would have damaged themselves, done foolish things or attacked other people.
Some critics said that this meant we were compromising the Open Door Principle. What did Open Doors mean if some people’s liberty was curtailed? I had many discussions about this with eager reformers, who accused me of cowardice, or of hypocrisy in proclaiming an ‘Open Door Principle’ but still depriving some people of liberty. At the other extreme, frightened conservatives accused me of irresponsibility towards the outside community – and even towards the patients themselves, who they said needed to be locked up for their own good, to protect them against their own impulses; some even told stories of patients who begged to be locked up, because they felt safer.
I was forced, slowly, to realise that this matter was more complex than I had at first realised. It was not just a battle between liberty and oppression. Some patients at various stages of their mental disorder would not be fit to have full liberty, but the fact that five men were unfit for full liberty was no reason to lock up 50 – especially as we had now discovered how bad it had been for the 45 to be locked up in a crowded ward amidst tension and violence. When the staff locked the door some patients saw them as gaolers; when it was open it was easier to see them as nurses. Bunches of keys had stood between nurse and patients and did much to hamper treatment. However, I realised that for some of the patients, at certain times, restrictions on their liberty would be necessary. We had to have a flexible policy which could be adapted to the needs of the people in the ward at any one time, and a variety of devices for limiting an individual’s freedom or responsibility when the disorder or the needs of the ward required it. I slowly realised too, how many other issues, conscious and unconscious, related to this matter – age-old conflicts of liberty and oppression, order and disorder, licence and discipline – the eternal social argument of how society controls the disruptive forces within it and deeper still, the conflict in each of us between instinctive drives and social controls. And I saw too how much my own inner fears, fantasies, hopes and desires were bound up in all this struggle.
While the male staff were opening doors in 1955 and 1956, the women staff became rather envious of the men’s acclaim. The women staff had opened several wards, and during 1957 the women’s Admission Villa, but they pointed out that a group of their wards were so interconnected that we could not open one without opening all of them. Also the ward nearest the door contained a number of simple-minded, unreliable patients who might well wander away and come to harm. We had several other problems among the women’s wards as the number of very frail elderly women was increasing and we did not have enough downstairs wards for them. Then Miss Brock came up with a plan for rearranging six wards, which allowed us to meet nearly all the problems. It enabled us to increase the number of open wards substantially; it gave us two extra downstairs wards for elderly and frail women; it moved the disturbed women’s ward into better quarters, while reducing the number of their patients. The project involved some building of partitions and an extra kitchen, but the Committee agreed to these. They also took the opportunity to redecorate several of the wards.
Just before Christmas 1957, we carried out the rearrangement and opened three women’s wards at once. This left only the women’s disturbed ward and the ward for frail old women locked. We had more demented and confused women than men and they were more restless. They were not likely to improve mentally and they were failing physically; our task was to look after them as humanely as possible for the remainder of their days and to try to prevent them coming to harm. The old men were mostly content to sit quietly in front of the fire, but the old women were often constantly active, pottering about aimlessly. If they found a door, they would open it and might wander out into bad weather and come to harm. We had heard of one open door hospital where an 80-year-old woman had wandered out into a snowstorm in a nightdress and died in a ditch. The coroner and the relatives had been very critical of the ‘care’ given her.
So we were doubtful about opening the old women’s ward door. Finally, we compromised by putting a latch on the door above the ordinary handle. Any person in possession of their faculties could open the door easily, but the old ladies would rattle the knob fruitlessly and then wander away. I wondered if it was sophistry to call this an Open Door, but it was open to visitors, to staff and to anyone who had enough sense to observe and act simply. In one sense, it could be regarded as a test of competence; if any old lady got out of the ward, she was better mentally than we thought. The visitors were certainly glad that they could get into the ward without having to wait in the corridor until a nurse came to let them in.
The women’s disturbed ward Female 5 (F5) was a greater challenge, as this contained a number of disturbed young women with suicidal and at times homicidal drives, who wanted to run away. We put to the ward sister the same proposal that we had made to Male 5, that she could open and close the ward at her discretion. She was doubtful and hesitant, but about six months after the move round, the door was opened in September 1958. On quite a number of occasions, however, the door was locked again for a few hours, days or even weeks. The nurses were apologetic, but felt it was necessary; there were so few of them and the patients were so disturbed. For some years, this continued and it was not until 1961 that it was open all the time.
By now, all our intervening doors had been unlocked and when the last ward was opened, in 1958, I stopped carrying a key. From my first days in mental hospitals I had always carried a key, often a bunch of keys, so that I could get in and out of wards. Now, I left the key lying on my desk and went around without one. At times, I found doors locked and had to ring bells or knock on them, but I felt that this was good; it enabled me to see what sort of a service was given to those members of the hospital community who did not have keys. I was sometimes mildly amused on seeing the face of a staff member fall as she opened a door, to find that the knocking which she had been disregarding came from the Superintendent. It made it no better when she said ‘Oh, I’m so sorry, Sir, I thought it was only a patient!’ Now, keys were of much less importance. Nurses in charge of a ward carried drug cupboard keys, but the hospital keys mattered less. It was no longer necessary to check them in with the porter. Some staff did not carry them at all.
These were also the years when tranquillisers, notably Chlorpromazine (Largactil) were coming into use. After a hesitant start, we used more and more Chlorpromazine, so that by the time we had all the doors open, about half the patients were on Chlorpromazine and many receiving large doses. Could we have done what we did without Chlorpromazine? For quite a time I said that we could, pointing to the fact that Dingleton Hospital was open in 1949 and Mapperly Hospital in 1953, before any Chlorpromazine was available. Further, I would point to hospitals where Chlorpromazine was being freely used, but where all the doors were still locked and tension and violence were as bad as ever. As years went by, however, I came to feel that the tranquillisers had helped us to open the doors.
Some patients’ delusions and hallucinations were checked by tranquillisers; others had their tension much diminished. For many, the drugs acted to keep them quieter, less inclined to violence or panic, without dulling their minds. Altogether, by reducing the general tension in a ward and by eliminating some of the terrifying violence, the drugs made it easier for nurses (and other patients) to make better contact with the most disordered people and made the ward life easier. I finally settled to the opinion that Open Doors and tranquillisers are two necessary and complementary parts of good hospital treatment.
The years 1955–57 were good years during which work and freedom flourished in the hospital and life at Fulbourn changed amazingly. They were also exciting, exhiliarating years for me personally as I started seeing the results of my efforts. The morale of the hospital was high, its atmosphere changed and our reputation in the neighbourhood altered. ‘I hear things are going well at Fulbourn’ was a comment frequently made to me at university parties.
My general pattern of government was fairly settled by 1956. The morning meeting with the doctors was my main instrument of medical policy; all new plans and projects were discussed here and many minor difficulties sorted out. After the early turmoils new doctors accepted that the senior nurses had legitimate comment to make on any matter. Fred Houston was, of course, a member and after the second summer, Leslie Buttle became a member. Although he was officially the Deputy Superintendent, and took charge of the hospital when I was away, he involved himself little in my plans and projects. He had always said that he was ‘interested primarily in clinical work’, especially with outpatients and short-term inpatients. He was responsible for the long-stay women’s wards for my first two years, but as soon as Fred Houston was settled in charge of the men’s wards, I took over personal charge of the long-stay women’s wards from Leslie Buttle.
The doctors’ morning meetings had many other functions. There was the obvious one of exchanging information. The doctors told me and the others about major happenings; the night duty doctor reported on any overnight turmoils. I distributed letters which had been addressed to me but which really concerned others, especially those about particular patients. There was also the more important function of clearing misunderstandings and ventilating conflicts. Sometimes this failed, particularly where differences arose from personal antipathies; at times I would feel surges of irritation run through the meeting without being able to discern the cause, though sometimes I heard months later what lay behind a blow up. One doctor had made one of the maids pregnant and another persisted in having his girlfriend to stay overnight in the residency; one doctor was at odds with his wife, who set her cap at other doctors. Miss Brock knew about these situations, but nobody told me. They contributed undercurrents which I did not understand, sometimes for months. I was often unsure how much gossip I should heed, or seek to find out, about my colleagues’ personal affairs. I finally decided to ignore personal undercurrents unless it was clear to me and to the meeting that they were affecting the welfare of the patients.
It was also in these meetings that the new doctors learned how the hospital worked and what their powers and responsibilities were – toward their patients, the other doctors, the Consultants and the nurses. I found that all new doctors would make a few mistakes which could be corrected in the meeting but more important, that they learned from the comments they heard about others’ mistakes, and they saw how decisions were made. I also came to hope that they learned my approach to a problem and gradually gave up the traditional model of decision-making (in which the doctor gathers the facts, decides the diagnosis and prescribes the treatment, largely unaided) for a method of group discussion. In these discussions all involved in the problem had their say and the summing up, formulating and implementing of the group decision often fell to some other member of the group than the doctor.
I was attempting to extend government by group decision-making throughout the hospital. I welcomed the Charge Nurses’ meetings – it was in and through them that the issues raised by increasing the patients’ freedom were debated to and fro and there that the key decisions to open doors were taken. I gradually developed Sisters’ meetings; however, although there was never another debacle like the first, they went less well. At times, all the women would become very angry – something I found difficult to endure. However, we worked through quite a few problems in the meetings, though Miss Brock always preferred to deal with knotty problems herself by personal interview.
Mrs Adrian, the Chairman of the HMC, was also fond of informal meetings. At least once a month, she met the Officers of the HMC – myself, Mr Mitchell, the Finance Officer, the Supplies Officer, the Engineer and her Vice-Chairman – and discussed all the forthcoming HMC business and many other general matters. These meetings were often lengthy, as everything was fully thrashed out, but it certainly clarified the business, and it often avoided the Officers disagreeing openly in front of the Committee. However, basic differences in approach would sometimes erupt in major Committee battles. The drug bill for Chlorpromazine (Largactil) was an example. In 1953 the annual drug bill for the hospital was small and did not vary much. Then the doctors started prescribing the new ‘tranquillisers’, at first on the admission wards, then on the long-stay wards; they seemed amazingly effective. As Superintendent, however, I had to deal with unexpected repercussions. The hospital drug bill soared because Largactil was quite expensive. The Finance Officer reported this to the HMC, pointing out that the hospital was exceeding its budget, and demanded that I order the doctors to stop this prescribing. I refused, citing clinical freedom – while anxiously asking my colleagues what on earth they were up to, and whether there was any foreseeable limit to their demands.
There was a great debate in the HMC with some members emphasising the need of the patients to have the best treatment available, others the need to protect the public purse from the extravagance of the doctors. This went on for months. I kept careful records of Largactil usage and tried to predict how high the cost would go. Fortunately this was happening all over England, and in all the psychiatric hospitals of East Anglia so that finally the Regional Board made a special allowance of money for the increased bill for psychiatric drugs. The cost of Largactil dropped and its use in the hospital levelled out. The Finance Officer and I settled back into our previous state of uneasy truce.
During the summer of 1955 Mr Mitchell spoke to me, wondering whether there might be value in a Hospital Officers’ meeting. I jumped at this and, taking the impending opening of a new ward, Adrian, as a theme, called the Hospital Officers together one Wednesday morning. In the group were Mr Mitchell, the Group Secretary, Miss Brock, the Matron, Mr Tucker, the Chief Male Nurse, the Hospital Engineer Mr Kelly, the Hospital Catering Officer, Mr Chappell, the Estate Officer Mr Banyard and myself.
The hospital officers proved a challenging group to weld together. At first several of them could see little point in the meetings and would fail to arrive. They felt the tug of divided loyalties – the Engineer, Mr Kelly, was responsible to Mr Merrin, while Mr Banyard took direct orders from Alderman Street, the Chairman of the Farm Committee. There were ancient feuds dividing the departments and in the first years of the meetings we spent much time hammering these out. Miss Brock felt that the Engineering Department was slow in its maintenance work and for months she brought up lists of overdue work. I had to reassure the Engineer privately about what he called ‘the weekly game of shooting down the Engineers’. As he explained each time the difficulties he faced, and at the same time did his best to meet her requirements, she gradually eased the pressure.
The male nurses and the gardeners had feuded for years and Mr Banyard constantly brought these squabbles into the meetings; here again careful elucidation, allowing each person to put his view, and working out a solution explicitly related to the needs of the patients, gradually improved things. I found that I had to be quite open about the conflicts of loyalties and tell the Engineer and the Farm Manager my views, but admit that if their masters refused to accept them they must endure the situation until the conflict was resolved at Management Committee level.
The opening of the new Villa, Adrian, in the spring of 1956 was the focus of the first winter’s meetings of the Hospital Officers. By the autumn of 1956 the meetings were well established as a central part of my system of management. Their manifest function was to coordinate the work of the hospital officers and departments, both for special occasions, such as Fetes, Christmas festivities, Opening Ceremonies and Open Days, and for the general running of the hospital. They also served for the passage of information. The Officers reported on developments in their departments, especially those that would affect other people, such as excavations that would block roads, parties or visitors requiring food, or Ministry auditors making enquiries. I tried to pass on all things of interest that I had heard from the Hospital Management Committee, from the Regional Board or from the Ministry. For years the Officers and departments at Fulbourn had bickered and had often used the patients as shuttlecocks in their games of administrative badminton; now I was able to control this.
Of course there were some recurring conflicts of interest or basic differences of viewpoint which always persisted. An engineer, mindful of long-term dangers such as boiler failure, saw repair priorities differently from a charge nurse irritated by a blocked lavatory. Gardeners like to put plants up walls, engineers like to keep walls clear of vegetation. Administrators wanted stocks carefully controlled, occupational therapists wanted materials to hand and did not like to be bothered with frequent counting. But the effects of even these traditional differences could be modified when each officer heard the other’s viewpoint, and when all plans were submitted to the test – ‘What is best for the patients?’ Over the first few years of meetings we worked through some of the chronic hospital squabbles; gradually the gardeners came to see the nurses’ problems and the nurses the engineers’. As mutual respect grew, they began to settle things beforehand and the principle was established that they only brought to the meeting problems they could not resolve between themselves.
In 1953 Mr Mitchell and I were the only Officers who attended the full meetings of the Hospital Management Committee, and other Officers therefore could not always understand what happened at the meetings. I came to feel that the responsible Officers should be more in touch with the Committee. I disliked being the sole channel of communication between them and having to argue for matters, such as nurses’ uniforms, that I did not care about or understand, or having to pass back decisions with which I did not agree. As a result, I was able to persuade Mrs Adrian and the Management Committee that the Matron and Chief Male Nurse should attend, first the meetings of the Finance Committee and then a year later, the meetings of the main Management Committee. Some of my friends criticised my actions, saying that if I had remained the sole channel of communication my authority would have been stronger. But I did not find this to be the case. Miss Brock and Mr Tucker were grateful to me for pressing for their entry and my rapport with Miss Brock improved greatly. Whereas before she had suspected that I did not press sufficiently vigorously for the things that were needed, she now saw something of the problems involved, the shortness of money and some of the opposition I faced on the Committee.
The Hospital officers’ meetings improved communications, ironed out difficulties, supplied missing channels of executive command and thus were valuable. To me, however, these manifest gains were much less important than the more subtle ones. The meetings gave the hospital work a purpose that was lacking before. My belief that the value of any project lay in the good it did the patients gradually penetrated even such technical departments as gardening and engineering. In the past other aims, such as economy, preservation of stocks of goods, neatness of the gardens or smartness of the hospital transport had outweighed considerations about the good of the patients. Sometimes this was very apparent. Once we were discussing some inappropriate Ministry memorandum and its effect on the hospital. Mr Mitchell finally said ‘After all, our job is to receive the instructions of the Ministry and of the Management Committee and to implement them to the best of our ability.’ I exploded. ‘Not at all, Mr Mitchell’, I cried ‘Our job is to treat the patients as well as we can, and to make the Committee, the Regional Board and the Ministry understand and meet our needs and help us to do it!’
I tried to ensure that there was always something ahead for the Hospital Officers to work toward. The recurring events of the year’s calendar helped; there was Christmas – with special meals, parties and entertainments; Easter – with the need for special flowers; the Open Day – with the need for guides and special catering; the Fete – with the problem of getting all the patients out on the grounds; the Hospital Flower Show – the big event for the Estate Officer. We always spent time trying to surpass the previous year’s achievements, and afterwards I made a point of congratulating warmly those who had done well. Special events were even more of a challenge: the Officers’ Meetings began with the arrangements for the Opening of Adrian Ward by the Minister of Health in May 1956 and there were other occasions, as when the Royal Medico-Psychological Association held a meeting at Fulbourn, or the Association of Hospital Management Committees, or when we opened our new Occupational Therapy Unit. Perhaps our greatest triumph was the Royal Opening in 1964. Each of these served as a focus for effort and enthusiasm (and, of course, lots of pictures in the Cambridge Daily News).
The most rewarding of my meetings during these years was the Occupation Meeting on Mondays. Fred Houston and Mr Allen both poured in their enthusiasm and each week we worked on the problems and rewards of our ‘Work-for-all’ programme. Mr Tucker seldom came, but Miss Brock began to attend regularly and was soon enthused. A key and founding member was, of course, our Head Occupational Therapist. Fulbourn had had an Occupational Therapy Department since the early 1930s. They occupied a pleasant building, specially built for them, on top of a hillock behind the hospital. In the postwar years, however, they had limited their work to the small group of long-stay patients who were skilled enough to do fairly good work and to the short-stay patients. The Head OT was most skilled and deeply interested in helping those she found congenial – especially the better-educated. She had, however, been disappointed in earlier years in her attempts to get work going on the wards and had rather withdrawn from this. Assisting her was a series of young women, recently graduated from schools of Occupational Therapy who would stay a year or two and then move on. Though temporary and rather uncommitted, they were most valuable to the hospital for they brought youth, enthusiasm and new ideas to the constant question of what would be most stimulating to the patients.
Miss Brock had now taken on board the idea of ‘Work-for-all’ and wanted to start her long-stay women working. She put nursing assistants in charge of groups and asked for materials and help. This led to many difficulties, and much of the first years of the Occupation Meeting was spent sorting these out. Miss Brock found a group of patients sitting idle and scolded the nurse, who said that they had no materials. Miss Brock went to the Department and told the Head OT that she was letting her down. The Head OT telephoned me to complain of Miss Brock’s remarks and we spent all the next Monday’s hour hammering this out. It was slow and wearisome at times, but gradually supplies improved, classes improved and the young occupational therapists started going onto the wards.
One person who responded to the outdoor work was Elizabeth. She went out with the women’s gardening squad and seemed to enjoy herself. She began to look better physically, although in talk she was as bland, curt and uncommunicative as ever. At the first patients’ sports day, Elizabeth excelled. She won the women’s sprint, the egg and spoon race and the sack race; she won more races than anyone else, man or woman. She received her rewards with her usual offhand calm. But the ward reported that the next day she had asked to have her hair washed and set. Her hair was permed and she kept it neat. Her dresses were well looked after. She started using some lipstick and enjoyed the weekly dances. I made enquiries about violent outbursts. These had been far fewer.
Another affected by the new atmosphere was Caroline, the handicapped, simple-minded ‘doctors’ maid’. On her ward she had a friend, Mary, an elderly widow; they sang in the choir together and had beds next to each other. Mary had had a fairly full life before a prolonged depressive state had brought her to hospital; over the years in hospital she had settled into a state of genteel grumbling. Caroline’s energy matched Mary’s faded refinement and they were good friends. As the hospital became more open Caroline and Mary began going out – first to hospital parties, then on shopping trips to Cambridge, then on the Women’s Institute outings. Mary helped Caroline with her clothes and her hair until they looked just like any two middle-aged country women in town. When we tried a Boarding Out scheme, in 1955, Caroline was one of those we managed to place. However, her landlady became ill and had to let her boarders go, so Caroline came back to hospital. Then we found her a place in an old people’s home as a resident domestic and she settled happily there. The energy, good humour, obedience and religiosity which had made her so useful in hospital fitted very well there.
It was about this time that the Head Occupational Therapist resigned to work at a small private hospital, so she could work, she said ‘more selectively and intensively’. We then had several Head OTs. One of them was a woman of many diverse enthusiasms, who started exuberant activities all over the hospital; she was followed by a quiet, conscientious girl – which was just as well, for the exuberant lady had so disorganised the stocks and records that the auditors and finance officers descended on the department and nearly paralysed it by their demands for an adequate accounting of all the raw materials that had been used up!
Our ‘Work-for-all’ drive was started by using the ward orderlies and nursing assistants as leaders of working parties. These excellent people were warm-hearted local men and women from diverse backgrounds who had come to work at the hospital in middle life. They had been hired as ‘untrained’ staff and were originally intended to be used for menial tasks, such as making beds, cleaning toilets, sorting laundry and polishing floors. However, the shortage of staff had meant that many of them had taken on more responsibility. Nonetheless, they had always felt disregarded and despised and they were delighted with the opportunities that the work programme offered – especially since they could often use skills they had learned in other work. Of the men in charge of the Sports Field project, one had been a military policeman, two had worked on public works projects and knew a little of surveying, and one had been a county roadman. The knitting classes attracted women with high skills in handicraft, knitting and embroidery. An ex-Army Physical Training Instructor took on a group of elderly men. To all of them, it gave a degree of recognition they had not experienced before and they responded warmly.
As the work extended, however, we felt that there was a need for more skilled staff. I began putting in applications at regular intervals to the Regional Board and the Ministry; we got permission to engage the tradesmen for whom we had asked. Between 1956 and 1958 we gained an instructional carpenter, a physical training instructor, an industrial supervisor, a librarian and two more occupational therapists.
When we advertised the post of occupational carpenter, one of the applicants was Percy Burgess, from a local carpentry firm. Although he was not impressive when interviewed our external adviser commended him warmly and I agreed reluctantly. We got him a set of carpentry tools and put him in one of the old workshops. He was a tremendous success. He gathered together a group of men from long-stay wards – mostly East Europeans, Poles, Ukrainians, Russians, Yugoslavs, who had come to England from Displaced Persons’ Camps and who were withdrawn, psychotic, thought-disordered and suspicious. The first task was to create the workshop. Percy built all his own benches, racks and cupboards. He took old hospital tables and cupboards and repaired them. He built new furniture. He even made church furnishings and a lectern. His workshop became a favourite spot to take visitors. But far more important was what he did for the patients. These men had been suspicious, cut off and demoralised; they had stood about the wards idle and silent since no one could speak their language. When we fetched interpreters, they said the speech was disordered nonsense. Percy at first communicated with these men by signs and then by leafing through an illustrated carpentry catalogue with them; all of them knew wood and woodworking and one had been a cabinet maker. They worked together; he would show them what he wanted and they got on with it. Gradually, they built up a team; at mid-morning and mid-afternoon, they brewed tea and chatted in broken English. Percy began bringing in his daily paper, discussing the news and telling them of English life; he took them into town with him and to his home. The men became livelier, brighter and more active; their appearance smartened and their English improved. All of them moved from back wards to privilege wards and several of them left hospital. Percy remained as slow-spoken as ever, but I came to have a deep respect for this outstanding craftsman, who had come to work with us because he ‘had always wanted to do something for other people’.
When we rearranged the wards in 1954 in order to put one Charge Nurse on each, we offered ‘Male Open Ward’ Male 1 (M1) to Eric Raines – a bluff cheerful man who was a leading figure amongst the male staff, an outstanding cricketer, a former RAMC Sergeant Major, and a lively raconteur. This ward contained all those men who were useful and well-behaved and deemed fit for privileges. All the top grade hospital workers were there – Arthur the librarian, George the storeman, the cricket team’s scorer and others. Other useful skilled men in M1 were an amateur watch repairer and a barber. There, too, were lodged Hugh and most of the Farm Gang, the strong agricultural labourers who did the hard work on the hospital farm. There were also many quiet men who had been in the hospital many years, held some minor quiet job, did what they were told and gave no trouble.
Eric Raines accepted the job with enthusiasm and soon began making changes. The men in M1 were some of the first beneficiaries of the new property-owning in the hospital. They were on the higher wage rates and began to acquire personal possessions – suits, shirts, soft shoes (instead of boots) shirts with collars that fitted, suitcases, watches, books, bicycles – all things forbidden before. More important, Eric began to change their lives and to encourage initiative. He encouraged them to take part in the work of the ward, distributing the food, managing stocks – tasks traditionally reserved for the nurses. He started ward meetings to discuss problems of life together and they developed a system of open justice with Eric as Chairman – where ward conflicts, struggles for power and the curbing of delinquents was worked out in open and simple terms. They started having parties, first their own and then inviting the ladies of the women’s open ward to join them – a great break with tradition.
Eric encouraged his charges to venture into Cambridge and explore the outside world, so long unknown to them. He then started suggesting to them that they might get paid work outside. At this stage his cricketing contacts proved useful. He knew foremen, gangers and small employers all over Cambridge. The 1950s were a time of full employment in England, when employers found it very difficult to get reliable men for low-paid, dirty, heavy work. Some of Eric’s men wanted freedom – both economic and personal. He was able to recommend them to bosses who were often very pleased with these docile, industrious men. Gradually he developed an unofficial employment agency.
The men also started arranging outings and trips – taking up a collection from those interested and hiring a bus. This caused the Finance Officer some anxiety. The HMC already hired a bus for ‘patients’ outings’. Why should they not use that? I found it quite difficult to explain to him the therapeutic difference between raising your own money, choosing your own destination and your own time and going with your own friends after work as opposed to going passively on a dull, predetermined trip on a bus provided by the management.
In 1957 we got permission to appoint a Librarian and after several tries, had the good fortune to get a jovial woman who accepted the task with enthusiasm. She treated Arthur, the patient ‘librarian’, with courtesy and consideration, letting him stay on, but she got the Library properly open and got the books out on to the wards; she got books from the County Library and increased the circulation. She treated all borrowers, patients and staff, with equal courtesy, enthusiasm and efficiency. She badgered me constantly about the horrid little room she had to use and so I persuaded the Management Committee to replaster and repaint a room marked for demolition and stock it with bookshelves made by Percy Burgess. Thus, we had made ourselves an attractive Library and Reading Room. Arthur moved in with the books and sat contentedly in one corner, rearranging his filing system and his collection of cuttings about the Royal Family.
During 1956 the Regional Board, who were responsible for all major building projects in the hospital, examined the Occupational Therapy building and decided it would make a good ward. We pointed out that they must rehouse Occupational Therapy and they obtained money to build us a new department. Originally it was only to be workshops, but they had appointed an imaginative young architect and from the discussions which he and I had a delightful building emerged with wide glass windows, spacious work rooms and pleasant views. We moved into it in 1958 and celebrated by arranging a loan exhibition of paintings by hospital patients to which we asked many local artists and connoisseurs.
More money was coming from the Government during these years, as they had become aware of – and, consequently, ashamed of – the state of Britain’s dilapidated mental hospitals. The money was doled out by the Regional Boards, but hospitals did have some choice in how the money allotted to them was spent. In many areas, Management Committees put their money into long-term projects; they would empty a ward of patients, redesign it, put in new heating and lighting and windows – then reopen it, magnificently re-equipped, and decant back into it the pathetic, long-term patients who had been jammed up elsewhere during the two years of rebuilding. This process was, of course, popular with Regional Boards and the Ministry because it created impressive buildings, but I fought against it.
I asked for more staff – especially to help with occupation (getting the patients working) – and specifically more nurses, with the slogan ‘Brains not Bricks!’. When we had money for physical improvement, I demanded that it be spread throughout the hospital and be used directly for the patients. We put in new mattresses and new windows throughout the hospital; we supplied lockers wherever we could squeeze them in; we repainted each ward; we put in new furniture, some in every ward; we supplied all day rooms with curtains and finally even the dormitories. As a result, no group of patients or staff felt neglected and forgotten (as happens when all work is concentrated on one building) and each ward got the things that they felt they needed most – rather than what the Regional Board or the Management Committee thought would be best for them.
The method was, however, somewhat piecemeal. The Engineer and Supplies Officer complained that no one ward was ever in first-class condition and the Finance Officer said that we were not getting full value for our money. However, I believed that in this way, we got better value in patient improvement, as the staff saw that those in power cared about what they asked for and were therefore better motivated in their work. We brightened up the whole hospital with new and cheerful paint, new furniture and colourful curtains. I felt happy and proud of the hospital and felt that I personally had done a lot to bring about the improvements at Fulbourn.
The climax of the early years was in 1957. The work programme was going well. We had got nearly all the men and many of the women working and the sports field had made visible progress. We had opened a number of wards. Our local reputation had changed – partly because we were doing better work, but mainly because we were actually telling people of the work we were doing. My work with the Press was paying off.
The new ward which was first suggested in 1953 had been built and named Adrian Ward. In May 1956 we had had a grand opening ceremony, performed by the Minister of Health. This was our first great public event, and for weeks beforehand the hospital officers planned anxiously. Everyone of consequence in the district was invited. There were Members of Parliament, Lords and Ladies and a handful of Mayors. We even had as guest of honour the 95-year-old Mrs Florence Keynes, the mother of Lord Keynes, who had been the first woman Chairman of the Visitors Committee in the 1930s. She observed the proceedings with approving, but acerbic wit. We erected a marquee for the ceremony (hired at considerable cost, the subject of later recriminations) and the distinguished audience heard the Minister, a distinguished figure, make an undistinguished address; however, it was smooth and polished and, though full of platitudes, contained some amusing quips. The Bishop blessed the building, the Minister opened the door. After a tour of the building, the visitors were served with tea and then duly departed in their limousines. Everything went as it should. That evening I was exhausted, proud and delighted. I rushed round the hospital thanking everyone for all they had done. The following day, a full page of the Cambridge Daily News was filled with pictures of the great and admirable doings at the once despised Fulbourn Hospital.
Another part of our drive to inform the public about our work was the staging of Open Days, starting in 1955. We found that all kinds of people were asking about the hospital, so we set aside one day in the summer to show them what we were doing. For the first Open Day all our guests were invited – City and County councillors, social workers, probation officers, district nurses, General Practitioners – and about 200 people came. I welcomed them and we sent them round the departments and wards in groups led by Charge Nurses and Sisters. We then gave them tea in the hall with a question and answer discussion afterwards. This was a most successful exercise; most of the visitors were pleasantly surprised at what they saw; it was far better than they had believed. Even more striking was the effect on the nurses and sisters who acted as guides; many of them went into parts of the hospital they had never entered before; the questions the visitors asked them challenged their knowledge of their own hospital; the admiration made them proud of what they were doing.
Over the years we gradually extended this, having one or two Open Days every summer. We invited many groups – and then the general public. We placed advertisements in the local paper inviting people to apply for invitations; hundreds responded the first time. Many people came to see what we were doing – including potential clients. There were remarkably few problems. The patients on the long-term wards were delighted, and often hailed old friends from their villages. A few people who had come in more recently were less pleased to be seen in Fulbourn – so we set aside areas to which those who wished might withdraw. Once the hospital was fully Open Door, of course, taking people round became easier and we began to arrange for groups to go around by appointment.
In 1956 we held our first Nurses’ Badge Day. Our nurses had never had badges to mark their graduation as Registered Mental Nurses. Miss Brock and I managed to persuade the HMC to find the money for some handsome silver badges with a fine heraldic design incorporating the arms of the City of Cambridge. That summer, we gathered many who had trained at Fulbourn in earlier years, and they received their badges from Dame Elizabeth Cockayne, the Senior Nurse at the Ministry of Health and a Dame of the British Empire. The occasion passed off well and Miss Brock was delighted; she felt that at long last her hospital and her nurses had become respectable.
More importantly, the patients, the very reason for the hospital’s existence, were doing better. They were more active and looked healthier; many more of them had freedom and a number expressed their gratitude openly. Instead of shambling about the airing courts, they were to be seen going off into Cambridge at the weekend, smartly attired in their Sunday suits and dresses.
In 1957 the King Edward’s Fund Staff College, London ran a refresher course for Medical Superintendents ‘known to be doing outstanding work’. To my surprise and delight I was invited. This I felt was real recognition; my peers, the men in the same job, thought my work was good. In February and March of 1957 I spent four weeks at the Staff College in Bayswater. I found myself with some of the most admired Superintendents in England – men like Duncan Macmillan of Mapperley, Rudolf Freudenberg of Netherne and Francis Pilkington of Moorhaven. Best of all, for me, was Maxwell Jones of Belmont, bubbling, irreverent, charismatic, fascinating. We were a group of ten. I was amongst my masters and eager to learn. Many experienced people came to talk to us – T.P. Rees of Warlingham, Aubrey Lewis from the Maudsley, Walter Maclay from the Board of Control, Alexander Walk the psychiatric historian, Members of Parliament, top Civil Servants, even the Chief Auditor. Our Course Director was Sir Wilson Jameson, a wily old Scots public health doctor who, as Senior Medical Officer at the Department of Health in 1946, had helped Aneurin Bevan create the National Health Service.
The most valuable talk was over meals and in the evenings. At first we talked of the good things we were doing and had done. Then, in the second week, as we came to trust one another, we talked of our difficulties, our frustrations and our failures and then finally, in the last week, we began to talk of how we might overcome some of them and where we might go next. All the month I was learning, thinking and picking up ideas. I came back to Fulbourn with enough to keep me going for several years – Open Doors, Therapeutic Workshops, Industrial Units, Halfway Houses, Therapeutic Communities – there was no end to what we might do.
During the late fifties and early sixties I became more involved with the work of the Cambridgeshire Mental Welfare Association and gradually came to realise what an exceptional organisation it was. One of the oldest mental welfare organisations in Britain, it had been founded in 1909 by some high-minded Cambridge University ladies, notably Lady Ida Darwin and Dame Ellen Pinsent, because of their concern about neglect of the mental defectives in those days. In later years the CMWA had started many projects – the first psychiatric social worker in Cambridge in the 1920s, the first occupation centre in the 1930s and the first child guidance clinic. Now, filled with ideas from her Royal Commission work, Mrs Adrian was pushing it to new projects, such as Halfway Houses. She had recruited Pauline Burnet to help her, making her Secretary and later Chairman. I got to know Pauline better, particularly after we discovered that we were almost twins, being born on consecutive days in August 1920.
By 1957 our family and social life was fairly steady. We were well settled in the Medical Superintendent’s house in the south-west corner of the hospital grounds. We filled the house with young people, au pair nannies, young relatives and Hungarian refugees and gave frequent and large parties. We grew our own food (with the help of patient gardeners) and raised chickens, ducks, geese, rabbits, hamsters. Our three children attended Cambridge schools but made the whole hospital their playground – to the delight of many of the patients and staff (and the irritation of some others). They made friends among the patients and came home with tales of Chinese princesses unjustly detained and strange happenings in the water tower.
In 1956 Dr Noble retired and there was a vacancy at Addenbrooke’s. Beresford urged me to apply for it, so that I could concentrate on clinical work, rid myself of the ‘burden of administration’, and develop a private practice. This seemed a most attractive prospect and I was tempted. My wife and I discussed it at length, but I concluded that I would rather go on with the task that intrigued and challenged me most – turning Fulbourn into a good hospital and relieving the degraded life of the long-stay patients.
About this time Winston House started. I had spoken often about how difficult it was for our long-stay patients to move out of hospital, even when they were no longer mentally disordered and were holding a job in Cambridge earning a good wage. The transition from the regulated, ordered, supported and disciplined ward life, where meals, clothes and entertainment were provided, to the life of a boarding house or bedsitting room where one had to manage, cater, plan and organise for oneself, was too difficult for many and they came back to hospital defeated after a spell ‘outside’. There was a need for transitional facilities between hospital and life in the community. In 1956 Mrs Adrian heard that a building in Cambridge named Winston House – which had been used as a hostel for delinquent youths – was vacant. It was funded by the Cambridge Rotarians and run by the ‘SOS Society’ – a national organisation that ran homes for homeless people. She talked to them and persuaded them to work with the Cambridgeshire Mental Welfare Association to develop Winston House as a Halfway House for recovering psychiatric patients. These negotiations took many months, but by 1958 Winston House was ready to open.
When I first went to Fulbourn my prime aim was to do a good job running the hospital. I was not much interested in anything else and it took all my energies. I kept some contacts with my professional friends in London and attended some psychiatric meetings – but not very actively. I kept in touch with the Social Psychiatry Unit at the Maudsley and Morris Carstairs, who was then running it, and it was he who invited me to go with him and Neil O’Connor on the trip to Dutch mental hospitals in 1955 which gave me such an exciting idea of what industrial therapy could do for the mentally ill. From that trip came an article in the prestigious medical journal, the Lancet.
Apparently the word began to go around English psychiatry that lively things were happening at the mental hospital at Cambridge and people started coming to visit us. In the late 1950s a number of American psychiatric reformers were paying visits to England to see the British Social Psychiatry of which they had heard so much. They went first to the British mental hospitals which were leading the country at that time (such as Mapperley Hospital, Nottingham and Warlingham Park Hospital, Croydon), but some of them added Fulbourn to this trip. Alfred Stanton and Morris Schwartz, the authors of the revolutionary book The Mental Hospital which had been the first analysis of a hospital as a society of people (both sane and insane) acting and interacting on one another, came to us in 1955. Leading mental health sociologists also visited us – John and Elaine Cumming in 1956 and Warren Dunham in 1957.
In preparation for the centenary of the hospital in 1958 I had been reading through the old Annual Reports and getting to know something about the early days of Fulbourn Hospital. I was conscious of the importance of the occasion and invited the Royal Medico-Psychological Association to hold a meeting at Fulbourn. I told the HMC of the anniversary and offered to write them a centenary book, telling something of the doings of their predecessors. In 1957 I was looking forward to increasing activity and renown. Sadly, this was not how things turned out.