The Institutional Care
MENTAL WELFARE
By H. FREIZE STEPHENS, M.R.C.S., L.R.C.P.
All Local Authorities arc aware that institutional treatment is costly, and that in these days of financial stress the need for a careful survey of the expense evoked by such treatment is inevitable. According to the Committee on Local Expenditure (England and Wales), whose Report was presented to Parliament in November, 1932, ” the cost of institutional treatment is the most expensive item in the cost of those health services which provide treatment,” and their obvious recommendations are, first, to lessen the expenditure on this form of treatment, and secondly, to provide and promote alternative methods of treat- ment by the more extended use of clinics and out-patient departments. In the mental deficiency world this would entail developing more fully the policy of ” Cheaper Institutional and Increasing Communal Care.” But because of the urgent need of beds for mental defectives considerable caution should be exercised in not confusing ” cheaper ” with ” lesser ” accommodation.
How can cheaper institutional care be effected? Again, quite obviously, by paying due attention to capital costs and the costs of maintenance. With regard to the latter the Committee on Local Expenditure believe that large economies could be secured by simplifying and standardising institutional supplies and by systematic central purchasing. If each of the several institutions under the control of a Local Authority decides on the types of articles it requires and caters separately for its own needs (e.g., of soap, disinfectants, dusters, towels, etc.), there would be abundant scope for waste of money and effort, whereas if the Local Authority should receive statements of the requirements of each institution, co-ordinate them, do away with unnecessary variations in the types of articles used, purchase them in suitable quantities and make arrangements for their supply, either to a central store for issue to the several institutions as required, or for delivery direct to those institutions, as may be more convenient, considerable economy and more satisfactory service should be achieved.
Moreover, by combining the experience of its several institutions, each Local Authority would be in a position to determine the number and types of articles really necessary and so could be able to effect a simplication in the institutional purchases for its area as a whole; again, where standard specifica- tions were possible, central buying would make it easier to ensure that the articles supplied conformed to the standards adopted. With regard to such specifications the general adoption by Local Authorities of the standards deter- mined by the British Standards Institute would enable statements of com- parative costs for their several areas to be effected more easily and usefully. Although, as the Committee on Local Expenditure are careful to point out, such comparative statements are not in themselves an index of efficient or ex- travagant administration, they would be of real value in directing attention to possible improvements in administration in any particular area.
Concerning capital outlay the Committee on Local Expenditure is of the opinion that much of the institutional accommodation already provided is excessive in first cost. They find that ” the average cost of isolation hospitals in England for which loans have been sanctioned in the last five years is ?jyo per bed, excluding the cost of the site (in one instance the cost is jCi,oj2 per bed), the average cost of sanatoria and hospitals for tuberculosis sanctioned in the last ten years in England is about per bed, excluding the cost of the site, and the average cost of mental hospitals ^475 per bed,, excluding site and furnishing.” The corresponding cost of mental deficiency institutions is not given, but the Committee maintain that for such institutions ” much of the provision recommended by the Board of Control is of a standard disproportion- ate to the cost of maintaining the same number of productive fit persons.” Because of the infinite variety in the capital costs of Local Authority institutions, the Committee on Local Expenditure recommends an immediate inquiry into ” building costs with a view to arriving at standards which will provide without extravagance the essentials for the treatment of disease and take account of modern methods of construction.” Such an inquiry has been undertaken for mental deficiency institutions by the Hedley Committee whose duty it was ” to consider and report what are the essential structural require- ments of a complete colony for mental defectives of all types and to what extent the cost could be reduced by the adoption of semi-permanent or tempor- ary buildings or other new methods of construction having regard to the comparative cost of maintenance as well as the initial capital expenditure involved.”
The Hedley Committee, it will be remembered, was appointed in Janu- ary, 1930; more than a year later, in March, 1931, the members of this Com- mittee issued their Report and in it they bore testimony to the care which had been exercised since the passing of the Mental Deficiency Act in preventing extravagance in the design of mental deficiency institutions and in the struc- ture of the buildings erected. It is quite true, they record, that one or two witnesses suggested that the standard of accommodation required by the Board of Control should be reduced, but these witnesses ” admittedly had little or no actual experience of the problems involved, and upon examination were unable to suggest any other practical method of providing for mental defectives needing segregation in institutions or to point to any specific instance in which the present requirements of the Board of Control could be said to be excessive.”
k’ We think it only fair to state,” the Hedley Report maintains, ” that the Board by drawing up suggestions for the guidance of Local Authorities, and by the close scrutiny of schemes submitted to them, have exercised effective control of expenditure on this service, and it is 110 easy task to cut things finer than they have been cut already.” Fairy tales, like old soldiers, never die; ?ne of the oldest of these warriors is this Extravagant-Demands-of-the-Central-
Authority story, and in the Report of the Committee on Local Expenditure it rattles its aged bones as gravely as any respectable Christmas ghost. To those who are aware of the facts, however, it is abundantly manifest that the Board long has realised the cardinal importance of controlling the expense of con- struction in the development of the colony policy, and the steady fall in the cost per bed is an indication of the vigilance exercised.
In their Report for 1930 the Board note that the most recent contracts indicate that the cost of construction of a complete colony for mental defectives may now be taken as slightly exceeding ^300 a bed, which compares very favourably with the cost per bed of other Local Authority institutions, and as this figure includes the cost of workshops, assembly hall, and all the admin- istrative buildings of such a colony, including kitchen, bakehouse and laundry, it cannot be said to be excessive; nor is it satisfactory to compare, as is so often done, the capital cost of thus providing for mental defectives with the cost of housing the normal population, or, as the Committee on Local Expenditure phrase it, ” the same number of productive fit persons.”
Moreover, the adoption of the colony plan has enabled the Board to advise further economies in the initial costs of institutions for mental defectives that are not possible with other Local Authority institutions, for in the colony system the various units need not be built at once, but only as required, and experience has shown that much that has been regarded, and rightly regarded, as necessary for the proper functioning of a complete colony may be dispensed with in the early stages of its development. Where the estate includes a man- sion adaptable in whole or in part as an administrative unit, the Board suggest that the most economical procedure would be to concentrate on the building of villas only, and these can now be constructed at a cost of a little over ?100 a bed. If, further, the villas are provided with coal ranges for cooking purposes, such an expensive unit as the central kitchen would be unnecessary.
In these days when the need for beds for mental defectives has become so urgent, and the available money for that purpose has been reduced almost to famine point, whatever advantages may be urged in favour of the central kitchen in a fully-built institution are largely unimportant with developing colonies, for the money allocated to the construction and equipment of this unit and its adjuncts, the bakehouse and the quarters of the kitchen superin- tendent and the kitchen staff (bed rooms, sitting rooms, and mess rooms) could be used to better advantage in the provision of additional accommoda- tion for patients. The Board of Control contends that ” cooking in villas is practicable, though it may not be so convenient if, however, in the villas erected such facilities for cooking were available as is present in any fair-sized boarding establishment, nurses, male and female, would not be wanting to undertake efficiently all the duties of a cook-housekeeper.
In addition to the money saved on initial outlay the adoption of what might be termed ” de-centralised cooking ” in colonies for mental defectives has a further economic advantage in effecting simpler arrangements in staff by the elimination of the kitchen and domestic groups, as their duties in each self-contained villa would be carried out by nurses, male and female, with the aid of patients and under the direct control of the Matron and her assistant. With the disappearance of the kitchen and domestic staffs, so prevalent and almost so inevitable in the larger old-fashioned types of institution, there would go also all those odds and ends of differences in duties and obligations, salaries and emoluments, the unnecessary gradings and accoutrements of apartments, uniforms, meals, and hours of work, resulting in useful economies even in such items as book-keeping and administrative charges; indeed, with so many occupiable and trainable patients the kitchen, domestic, and even the laundry staffs, should be superfluous in a colony for mental defectives, as all their several duties could be undertaken by the patients under the direction of nurses, and nurses only.
This unification of the colony staffs should serve to enhance rather than to detract from the proper training of mental deficiency nurses. In writing on this subject in ” The Nursing Times ” for March 20th, 1926, I drew atten- tion to the value of variety in the training of such nurses, especially in their acquiring the art of supervising mental defectives of all grades and ages. The trained supervisor is the product of years of experience, but in the course of her training the probationer should learn something of the general principles of supervision and control, and to such knowledge she would the more readily attain if in addition to her daily contact with patients in the villas and on the playing fields she were granted access to them in the various workrooms and workplaces of the colony; such access the principle of the unification of the staffs would ensure.
In the same article I suggested that in addition to this general experience, at least six months of every probationer’s training should be spent (preferably in her third year) in the personal management of a group of defectives in one of the departments of vocational training in the colony. This should be an essential phase of her pre-registration education, and it should not entail her being expected to acquire an expert, or even a technical knowledge of that particular branch of vocational training in which she seeks to gain her experi- ence in the management of mental defectives at work. Again, a probationer may be, prior to her probation, a skilled craftsman in some particular industry (e-glaundry work); after her training and registration as a nurse she would be doubly qualified both as such and as a craftsman, and, correspondingly, would be useful to the institution in which she worked; but her special train- ing as a craftsman should not exempt her from fulfilling any part of her special training as a nurse, such as night duty in the villas. For these purposes, also, the principle of employing only one type of staff, namely, nurses, would help.
Finally, the regulations for the training and examination of candidates for the Certificate of Proficiency in the nursing of mental defectives granted by the Royal Medico-Psychological Association requires that candidates for the Final Examination for this Certificate must select one or more of the sections of the special part of the syllabus. There are four of these sections, namely (a) Bedside Nursing; (b) Special Methods of Teaching Mentally Defec- tive Children; (c) The Teaching of Mentally Defective Adults in Workshops, Industrial Occupations, Gardening, Housewifery and Laundry Work;
(d) Physical Training, Drill, Dancing, Indoor and Outdoor Amusements. It would appear, therefore, that for this important Nursing Certificate the unifica- tion of the colony staffs would be not only useful but almost essential, and that the abolition of the kitchen, domestic, and laundry staffs, and their replace- ment by patients working under the direction and supervision of nurses would constitute no bar to the latter obtaining this Certificate.
Whether they have adopted decentralised cooking or not, the newer colonies would do well to consider this suggestion of employing only one type of staff, namely, nurses, for the supervision and training of their patients. It would result in effecting a saving not only on maintenance costs but also on capital outlay, for then provision would not have to be made separately for such officers as the kitchen superintendent, laundry mistress, needleroom mistress, handicrafts mistress, and their necessary reliefs, all of whom would be members of the nursing staff, while patients would do the work of hired housemaids, messroom maids, officers’ maids, matron’s maids, kitchen maids, laundry maids, sewing maids, and so on; similarly, in the male sections of the institution male nurses would work with parties of patients on the roads, on the lawns and gardens, on the farm, and in the workshops, thus dispensing with the usual groups of employees now engaged for such purposes; indeed, in the early days of one of the new colonies known to me, male nurses were at work even as clerks and assistants in the Steward’s department, continuing with their duties as nurses after office hours with a consequent saving in initial wage costs.
Other items of expenditure in which useful economies might be effected resulting in cheaper institutional care are :?-
(a) Patients’ clothing. Ugly clothes are never economical, as defectives, like most of us, cherish more the things that are attractive and tend to destroy those that are not. Modern ready-made sports coats, pullovers, and flannel trousers of diverse colours, machine products that can be bought by the gross quite cheaply, are to be preferred to dark ill-fitting tweed suits of the orthodox pattern, crudely cut, clumsily put together, and imperfectly finished at often unnecessary expense in institution workshops; bright jumpers and skirts, also machine-made and marketed at reasonable prices by the gross, are less expensive to buy, and short coloured frocks with low necks and tiny sleeves are cheaper to make than dull drab dresses, full-throated, extending decorously but expensively to ankles and wrists.
(b) Elaborate staff uniforms, bedecked with rows of braid and brass buttons for the men, heavily and copiously constructed, abundantly aproned, and fitted with starched caps, collars, cuffs, and belts for the women. (Think of the saving in the weekly laundry bill when such contraptions cease to burden our young nurses!) Simple lounge suits or cheap drill coats long enough to reach to the knees and of a size large enough to be worn over their own clothing, are more economical for the former, while the latter would be more comfortable, healthier, and neater in inexpensive overalls or light cotton dresses with Peter Pan collars and elbow sleeves. Roth of the latter types of garment could be made, easily and cheaply, in the institution needleroom.
(c) Imported and hired entertainments for the patients, who do not always understand and cannot appreciate them, and who are happier preparing and presenting their own concerts and plays which should cost practically nothing to produce.
(d) Unnecessary and often expensive occupations, like raffia, lace, and fancy leather work, the products of which are not readily saleable and could not compete with cheap machine-made articles, resulting in much pre- ventable waste of materials and money. In these financially difficult times only such industries should be practised as would tend to meet the needs of each institution, but pig- and poultry-keeping with the cultivation of every available patch of land with vegetables should prove to be as useful as in the days of the submarine peril.
In these and other ways there is no doubt that many means of effecting economies in institution expenditure may be found, some peculiar only to particular Local Authorities, while all should be subject to the will to provide for the largest number of urgent cases within the prescribed financial limits, however restricted these may be, until the days of expansion are again at hand and the present tremendously critical period, which the Pope has likened to nothing less than the Flood, has passed away, let us hope, for ever.
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