Latitia Fairfield
- Author:
Letitia Fairfield c.b.e., m.d., ch.B., d.p.h.
By a custom established at some unknown date by the now defunct Boards of Guardians, Observation Wards occupy a more important place in the system for dealing with mental patients in London than they do in many parts of England. As most readers are aware, there are two main channels for entering mental hospitals as a certified mental patient. First, the Relieving Officer can arrange for a visit by a magistrate and doctor to the house of the alleged ” person of unsound mind “, and if an order is made, can thereupon remove him forthwith to a mental hospital. The alternative method is for the Relieving Officer to take his patient to a ” workhouse ” or appropriated hospital with suitable accommodation, and there to have him seen by magistrate and doctor. If certified, he must be removed within fourteen days to a mental hospital.
Probably owing to the great shortage of mental beds in the London district and the consequent impossibility of removing patients promptly from their homes, the London Guardians practically never utilised the first method, but brought all mental patients into observation wards, situated either in their workhouses or Jn the infirmaries. This custom has been continued by the London County Council since they took over the Guardians’ responsibilities in April, 1930.
Theoretically this method of dealing with psychotic patients has much to commend it. The three days detention in the. ward allowed by the initial Relieving The London County Council has no responsibility for the contents of this article. Officer’s order, may be extended by another fourteen days if the medical superintendent chooses to use Section 24(2) of the Lunacy Act. This period gives an invaluable opportunity of arriving at a diagnosis, of observing symptoms in a doubtful case, of allowing for recovery in an acute confusional patient, and of deciding on the best method of disposal?all this without inflicting the much dreaded stigma of certification. Unfortunately, the Guardians had in many instances apparently overlooked some important facts. They forgot that ” observation ” cannot be carried out unless there is someone to do the ” observing In few of the nineteen wards the L.C.C. took over, was there any medical staff with psychiatric experience, and in many the nursing staff was untrained and totally inadequate. In some of the smaller wards containing only six or seven beds, there was only one attendant on duty at a time. If he needed help with an excited case, an untrained assistant or gate-porter was summoned. It had also been forgotten that mental patients arc patients and not a species of delinquent. The gloom of many of the units and the lack of reasonable amenities was deplorable. Worst of all, however, was the complete absence of classification. Nine out of the nineteen wards had only a single ward for all types of patient; twelve had no day room. The depressed and acutely sensitive case of attempted suicide, the shrieking maniac, the noisy, restless dement, the young mother with puerperal psychosis, lay side by side and could get no respite from each other’s company except in the padded rooms.
In some of the Infirmaries, however, conditions existed which indicated an enlightened spirit and showed the way to progress. At Hackney and Fulham Hospitals, well designed blocks had been constructed and the patients enjoyed real medical and nursing care and good classification. At St. Peter’s, Stepney, and St. John’s, Battersea, a consultant had been appointed to visit weekly and excellent psychiatric work was being done under adverse conditions. On these small beginnings, the appropriate Committee of the L.C.C. decided to build its programme. Before discussing the scheme which was prepared in 1930 and is still in course of evolution, it would be well to describe briefly the varied types of patient for whom provision is required.
(1) First and most important there is the “alleged lunatic” of the good old days now promoted to a ” person of unsound mind ” by the terms of the Mental Treatment Act. He is brought in by the Relieving Officer or the police and must be seen by the Magistrate within three days, though he may be detained for another fourteen days. Of this class London has about 6,000 to 7,000 admissions per annum.
(2) Patients originally admitted to L.C.C. Hospitals and Institutions for physical ailments, or for destitution, and subsequently found to need detention on mental grounds.
(3) Senile dements over the age of 70 whom it is the practice of the Council, following the lead of the late Guardians, to transfer to a special hospital at Tooting Bee, without certification, wherever possible. Only violent, suicidal or very resistive patients over 70 are, in London, dealt with under the Lunacy Act and sent to Mental Hospitals.
(4) Mentally deficient patients under Place of Safety Order, or awaiting proceedings on petition. It is, of course, usually undesirable to keep these cases in the company of the psychotic, but it is sometimes inevitable.
(5) Patients awaiting examination by an approved psychiatrist for admission to a mental hospital under the Mental Treatment Act, and patients accepted for such treatment but awaiting a vacancy. (6) A miscellaneous group of uncertified patients, e.g., epileptics with temporary acute mental phases, patients unmanageable from delirium in acute illness, a few psycho-neurotics whose symptoms make them unsuitable for treatment in general wards. None of these, of course, is under ” detention
(7) Convalescent patients from any of these groups but particularly the first, whose orders have run out and who are remaining voluntarily for rest and treatment.
Some of these groups need a few words of explanation to those who are not familiar with the bewildering complications of London administration. The chief difficulties are caused by the Mental Treatment Act?that admirable but very contentious measure. In London, treatment under the Act is available only to those considered suitable by one of the Mental Hospitals Department staff, i.e., by one of the visiting consultants to the observation wards or by a medical officer at a Maudsley Hospital out-patient clinic. If the patient cannot be kept at home pending the completion of formalities, or if there is no immediate vacancy for a suitable mental hospital, he must perforce be admitted to a mental observation ward.
A considerable number of patients, though not as large a percentage as is found in many towns, who are sent in under a Lunacy Act three days order, also prove suitable to be dealt with under either the ” temporary ” or ” voluntary ” clauses of the Mental Treatment Act. It has been a disappointment to some that the ” temporary ” clauses are so little used, but a very keen endeavour on the part of all concerned to search out suitable cases only confirms the view that its proper scope is extremely limited. It should also be noted that many acute contusional patients (including the great majority of puerperal manic-depressives and of alcoholics) who would be treated under the temporary clause in other areas, are in London not sent to a mental hospital at all but are treated throughout their dlness in an observation ward. The ” voluntary ” clauses are a very different proposition. They have revolutionised psychiatric administration and are found to be increasingly popular.
The convalescent group of patients represents those whose orders have run out and clearly do not require certification?or even treatment in a mental hospital ?but are not yet fit for the stress and strain of daily life.
It is a startling commentary on the curious outlook on mental disease prevalent until recently, that many people are puzzled by any reference to such a group and even maintain it does not exist. ” Every mental patient should either be certified or discharged from hospital in three days,” one has heard a magistrate declare though he would not have been in the least surprised to be told that a man sent into hospital with gastric ulcer did not require operation but did need a period of medical treatment and dieting before he resumed full work. The Council has very complete arrangements for sending convalescents to suitable homes; homes of the Mental After-Care Association, the Lady Chichester Hospital at Hove and the Council’s own convalescent homes are all available, and are rendering excellent services in rehabilitating the more promising patients.
With such a heavy burden of responsibility falling on the observation units, the Council decided that they should be greatly extended and properly staffed and equipped according to modern standards. It was considered that many of the evils in the wards existing in 1930, were due to the small size of the units. The scheme, therefore, provided for the amalgamation of nineteen units into six, with approximately 70 to 80 beds in each. Three units were to be situated north of the river and three south of the river. The model unit would provide for male and female patients, and would contain on each side :?
Twelve beds for acute patients under order (two being in single rooms). Twelve beds for less acute patients (two in single rooms). Twelve beds for convalescents. Two padded rooms. A good day-room with space for simple handicrafts and recreation. Magistrates’ room and waiting room. Duty room. Room for psychiatric social worker and students. A cheerful garden with flowers and also with space for ball games.
The experienced imagination can suggest many other desirable addenda but even the simple minimum described was hard to seek in the congested premises of city general hospitals. Our sites for mental units have mainly been found in association with ” chronic ” hospitals, but auxiliary services necessary to bring the treatment of mental disease into line with that provided for physical disease are freely available.
Five of the projected six units are now being organised, i.e., St. Clement’s and St. Pancras, north of the river, and St. John’s, St. Francis’, and St. Alfege’s south of the river. The three small units in the West End are shortly to be amalgamated into one large unit at Fulham Hospital. Only St. Pancras is a completely new building. St. Francis and St. Clement’s units are skilfully adapted old blocks and St. John’s and St. Alfege’s Hospitals are still working under structural difficulties in old premises.
The staffing of mental units always constitutes a knotty problem. A resident medical officer of experience is required as the London magistrates in all areas but one make a practice of entrusting the task of certification to the medical officer who has the opportunity of observing the patient. Indeed the whole justification of an observation unit is largely abolished if this is not done. We are fortunate in having certain medical superintendents who have made a special study of psychiatry. For our other units, we have obtained officers of experience seconded from the Mental Hospitals’ service. The clinical material in observation wards is a rich field of study supplementary to the more developed and selected cases found in mental hospitals. Each mental unit is, in addition, visited twice weekly by consultants who are either deputies or superintendents of mental hospitals. They do not themselves certify but they see most of the cases admitted and advise on disposal, especially as to the use of the Mental Treatment Act. It is found that under modern conditions, highly expert advice is essential for the proper handling of a case. In the old days there was no alternative other than the Lunacy Act or discharge home, but now a decision has to be made between several possible destinations and the patient may be adversely affected if the decision is an unwise one. Not every man who asks for ” voluntary ” treatment should be recommended to receive it. Sometimes convalescence in a Mental After-Care Home or even certification under the Lunacy Act may be the wiser course. The most difficult decisions perhaps are those required for acute confusional cases. Can they be treated entirely in the observation ward, or should they be sent on to a mental hospital at once? There is a sharp difference of opinion on these points amongst experts, and no cut and dry policy can be outlined for adoption at all our units.
The nursing staff of the units has been greatly strengthened with the most admirable results. The patients and the wards now present evidence of a real understanding of a mental patient’s needs. The rooms are light and cheerful, the meals daintily served, and every effort is given to suggest peace and ” normality “. So many of the patients are acutely ill and stay such a short time that anything in the nature of formal occupation therapy is impossible, but an increasing effort is made to provide light handicrafts. The idea that a mental ward must necessarily look like a third-class waiting room at a country railway junction has been hard to combat, but it is rapidly disappearing.
The latest joined?but by no means the least important member of the observation ward staff?is the psychiatric social worker. It is amusing to look back now on the forebodings which were uttered on the appointment of the first two workers in 1930. ” Our people are different,” said one critic, ” they have too much self-respect to talk about their troubles to a stranger ! ” From the very beginning, however, the medical staff recognised that this was the kind of help they had been looking for all their working lives. There is no limit indeed to the opportunities for service which an observation ward affords, except the time and strength of the worker. Compared with other branches of psychiatric social work it is certainly not easy, as the turnover of cases is very rapid. Much time is spent in preparing case histories which the certifying doctors and magistrates find invaluable, especially in aiding in the disposal of doubtful cases. A certain amount of work can be done in the family and in the industrial adjustment of ” borderline ” patients who can often be discharged home if their special difficulties are settled; sometimes a period of rest and convalescence will further stabilise the case.
The observation wards now take their share in the postgraduate training of doctors studying at the Maudsley Hospital and of students in the course for Psychiatric Social Workers at the London School of Economics. Any movement which brings the wards into the main stream of psychiatric practice is welcomed by the Council.
Though they are still far from the ideal designed for them, the observation wards of London are gradually building up a tradition of medical efficiency and social service. Their work cannot be tested by the percentage of patients discharged or certified or dealt with through other channels. Each case must be decided on its merits under skilled advice and the increasing trust shown bv the public in the advice given is a tribute to the valuable place which the observation ward plays in a Mental Health service.
Back of every research project and every clinic, there is an executive who builds and maintains the organisation without which they cannot survive. If )iiore administrators were interested in research and more research zvorkers appreciated the importance of administration, the whole field of psychiatry would be benefited immeasurably*
WILLIAM A. BRYAN, M.D. Administrative Psychiatry. Geo. Allen & Unwin.
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