Photographs: Tony Othen
- Author:
John Payne
Without the ability to earn a living and be independent any ‘recovery’ from mental illness is bound to remain almost meaningless. For patients who have become ‘institutionalised’ after long stays in hospital the outlook for a return to independent life would be even bleaker but for the kind of lead being given by the unit described here.
When someone has been ill we are only prepared to accept that he has fully recovered when he resumes work?if he is ‘better’, but not back at work yet, then there is still room for doubt, the recovery is only partial. We see real fitness in terms of being fit enough to work?there are no shades of grey, it is essentially a black or white issue.
To help people get back to work after a period of illness the state has established elaborate ‘rehabilitation services’, physiotherapy, occupational therapy, social work support, retraining schemes, sheltered workshops, industrial resettlement units and all. The dictionary definition of ‘rehabilitation’ is ‘the act of restoring to forfeited rights and privileges’ from the Latin rehabilitare (to have again). How, then, do the mentally ill fit into the state’s plan for the restoration of rights and privileges ? The simple answer is ‘Not at all neatly’ and a lack of neatness is not something easily tolerated by officials responsible for drawing up plans of state.
There are two distinct groups of mentally ill people. One group, the short-stay patients who need only a period of weeks in hospital before being processed ?comparatively smoothly?through the rehabilitation services, cause few problems. The second group, the long stay, ‘chronic’ patients who lose touch with the changing ways of the world and become ‘institutionalised’ (apathetic, docile, resigned and incapable of self-help after years of reliance on the hospital regime) pose enormous problems of rehabilitation?problems which, in many cases, still seem to be insuperable.
St. Wulstan’s Hospital, Malvern, a psychiatric rehabilitation hospital which covers five counties A young member of the team manufacturing clothes hangers adds the finishing touches to the job with a hand press.
(Worcestershire, Warwickshire, Staffordshire, Shropshire and Herefordshire), handles the ‘insuperable’ problems.
St. Wulstan’s is laid out in the geometric, austere pattern of an army camp?long low buildings, lots of right angles, with covered walk-ways linking the buildings. It was built in 1942-43 for the treatment of American forces’ psychiatric casualties during the war. In the 1950s it was used as a tuberculosis sanatorium and re-opened as a psychiatric rehabilitation unit in late 1961.
It takes the ‘failures’ from the workshops and industrial therapy units of the 12 mental hospitals in the Region. The only requirements for admission are that the patients must be under 55 years old, have been in hospital for two years already and be fit for ‘informal’ status. In fact, the average length of stay in the ‘parent’ hospital before patients come to St. Wulstan’s is 12 years which puts all new arrivals firmly into the ‘chronic’ category.
The philosophy of the treatment at St. Wulstan’s is to make life inside hospital as much like life outside as possible, to make work compulsory and leave recreation to the initiative of the patients, to tie all work to training, to pay patients fairly according to output rather than effort and to get every patient fit enough to become independent of hospital care, no matter how long that may take. It is emphatically not an aim to help patients ‘settle down’ into a static environment.
Although there is a tacit atmosphere of tolerance and perseverance at St. Wulstan’s, it is not the equivalent of a large sheltered workshop. The staff have simulated real working conditions for the 210 inpatients and the 90 who now live out but come into the Hospital every day to work.
After a 3’,-week assessment period in the Intake Unit, patients start straight into a 36 J -hour working week, Monday-Friday. During their assessment period, apart from having physical, psychological and psychiatric examinations and being interviewed by a social worker about their family situation, patients are given a variety of work to do?industrial, domestic, outdoor, clerical, etc.?so that their aptitudes, handicaps and attitudes can be identified.
The patients’ attitudes are particularly important. The will to work, the desire to become independent ?what Dr Roger Morgan, Director of Rehabilitation, calls ‘stickability’?is crucial because it is this quality
A man in the carpentry shop checks the joints on a picture frame. that St. Wulstan’s has to nurture and develop if a patient is to hold down a job outside the Hospital. In order to help foster a positive attitude towards working, a sense of involvement and ‘belonging’, the Hospital is divided up into four ‘personnel units’. There are 12 wards and four workshops with patients and staff from each group of three wards going to make up the work force and supervisory staff of one workshop. So, going to work means literally crossing the road with your mates and taking up where you left off the day before as members of a team each with a well-defined job to do.
The four workshops?Grey, Red, Blue and Gold? are structured to allow for progress from one to another as the patients’ performance and output improve. ‘Grey’ is the admission and assessment workshop although this does not mean that patients with very limited ability and poor potential may not stay in it for a couple of years while the staff persist in looking for signs of improvement or hoping to find the right niche eventually.
No targets are set and the work-rate is governed by the workers. Obviously, in a team-work situation, a worker with enthusiasm and aspirations to earn as much as possible sets a standard for the rest and ‘tows’ them along in his wake. So schizophrenic patients try to withdraw from their workmates whereas a couple of mentally handicapped patients in a team (on the coat-hanger making team, for example) inject it with energy and bustle. There are about 25 mentally handicapped patients at St. Wulstan’s?the Hospital was asked to introduce them as an experiment and discovered that they acted as very good catalysts in the work situation.
Both ‘Red’ and ‘Blue’ workshops are fitted with modern, sophisticated conveyor belt systems for the assembly and packaging of soft packs of medical dressings which St. Wulstan’s produces for use in other hospitals throughout the Region. Each patient manning the belt adds only one unit to the pack and the packaging team at the end of the belt are each responsible for one operation in the closing, sealing Preparing materials in the stores for delivery to one of the workshops. The driver of the fork-lift truck is a patient himself.
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and labelling sequence. The supervisory skill in these two workshops is in the business of ‘balancing’ the belt i.e. allocating the various jobs so that a steady pace is maintained and no ‘bottle necks’ develop. Last year these workshops produced 41 million packs worth ?80,000.
That is a pretty staggering amount of money and paradoxically, the very success of St. Wulstan’s in terms of its constantly improving productivity has been causing some embarrassment over the last year. Since money is inextricably bound up with the whole concept and purpose of work, it is also one of the major factors governing the effectiveness of St. Wulstan’s rehabilitation programme. Ten years ago, the Ministry of Health (as it then was) set an earnings limit of ?2 per week on all people either in hospitals or workshops or otherwise in receipt of social security benefits. Earning more than that meant accepting a sliding scale reduction of benefit. This earnings rule has acted as a disincentive in industrial rehabilitation ever since until, in October this year, the earnings limit was raised to ?4.50. At St. Wulstan’s an earnings-related ‘Hospital tax’ system was devised which used to mean that a patient had to earn ?3.20 before getting the ?2 limit in his pay packet. Now a patient has to earn ?8 before getting the ?4.50.
The ‘tax’ system now works on the basis of the first ?1 earned being tax free with all subsequent earnings up to ?8 taxed at 50%. Earnings over ?8 are taxed at 100%.
As payment is related to output, it is not unusual for a patient to notch up ?12 per week?and occasionally top ?20 per week?on paper. All the cash that he is allowed to receive is the ?4.50 limit but he has the satisfaction of knowing that he earned perhaps three or four times that sum?the kind of wage on which he could support himself when out in the community as long as he maintained the same sort of performance consistently.
What then happens to the rest of the money that St. Wulstan’s patients earn? Industrial turnover at the Hospital rose 20? ? last year on the previous year to over ?102,000?almost all on contract and subcontract work.
The ‘Hospital tax’ that St. Wulstan’s is obliged to deduct from patients’ earnings goes into a pool known as the Industrial Fund and, up to now, the majority of it has been ‘ploughed back’ into the workshops?those conveyor belts, heat-sealing machinery, a fork-lift truck, a delivery lorry with two interchangable bodies (which cut the lorry’s turnround time to almost nil).
There is a sick pay scheme (two-thirds of the patient’s average earnings over the previous three weeks), a holiday savings scheme which is subsidised by the Industrial Fund, a supplementary payments scheme for patients earning less than 8op in any one week?all from the Industrial Fund.
Over the past year or two there have been no immediate needs for the workshops?they are as well equipped as they can be?and the Industrial Fund has begun to be used for amenities for the Hospital. Two new projectors in the assembly hall, carpeting for four day rooms in the wards and for three television rooms, a colour television has been bought for the patients. Rather than join the queue and request finance to replace or improve amenities from the administrative authorities of the Hospitals Group of which St. Wulstan’s is a member, it has drawn on the Industrial Fund and been able to say to the patients ‘You provided this improvement yourselves, your efforts and abilities made this possible’. Despite the practical value of the ways in which the Industrial Fund is used and the enormous psychoPatients at work in St. Wulstan’s clerical office which handles all the paperwork for the production workshops. logical value in terms of the patients knowing that their money?which they were unable to see in ? and p. in their hands?was used to buy that heatsealing machine to make their job easier or for installing ‘piped music’ into the workshops, Keith Parsons, Hospital Secretary at St. Wulstan’s, is now finding that it is not quite as simple as that. He is finding that the very success of St. Wulstan’s is creating some procedural problems over the central and regional financing system of the Hospital, there is now some suggestion that the surplus in the Industrial Fund should be returned to the general Exchequer rather than being used to increase the efficiency of the St. Wulstan’s rehabilitation programme.
‘Gold’ workshop at St. Wulstan’s is the one which simulates real factory conditions in the most detail. In this workshop the heavier engineering contracts are handled. Geoffrey Jones, the Hospital’s Industrial Manager (also a qualified psychiatric nurse), goes all over the Midlands and beyond getting industrial contract work for St. Wulstan’s. Currently he has contracts for assembling the power take-off units for the Massey-Ferguson tractor, lock hinges for the Land-Rover, paint rollers for a decorating company and many others.
Time keeping penalties are in force in ‘Gold’ workshop?a man is allowed 10 minutes ‘lateness leeway’ a week, any more than that and his pay is reduced by 20%. Men working in ‘Gold’ are responsible for getting the supplies they need for their job from the stores personally. The stores themselves are staffed by patients, the man who drives the fork lift truck is a patient.
Apart from the four workshops, St. Wulstan’s runs a concrete casting unit for men who are better suited to fairly heavy outdoor work. The Hospital has 89 acres of grounds but only a small proportion is tended by patients and then only as a specific form of training for men who can subsequently earn their living as gardeners and nurserymen. There is also a laundry and a domestic training unit in which women are retrained to be able to live independently within the community. A clerical section is attached to the workshop administration office and patients handle all typing, stencilling, duplicating and recording work.
Bill Staples, another psychiatric nurse but who acts as personnel officer at St. Wulstan’s, has built up a lot of contacts in the Midlands (together with Geoffrey Jones) for patients who are ready to take on a full-time job away from the Hospital. Many of these are in the catering trades, recently the head kitchen porter at the Midlands’ newest luxury hotel (who is an ex-St. Wulstan’s man himself) rang up to say he had vacancies for two other kitchen porters and would Mr. Staples care to fill them for him. There are also contacts in the immediate area of Malvern wanting casual domestic and gardening work done by St. Wulstan patients. Each job opportunity outside the Hospital is looked on as a valuable training ground for a number of patients in succession.
Over the years a network of lodgings for day patients at St. Wulstan’s has gradually been established to the extent that there are now 90 patients coming into the Hospital each day to work who live in houses offering full board and lodging in Malvern. So many patients have now taken this important step to independence that a day patient co-ordinator has had to be appointed to look after their interests and liase between the Hospital and the lodgings. The Hospital gives all landladies an unconditional guarantee to take back any tenants who prove to be a problem.
One such lodging house was started this year by a young couple, Susan and David Carpenter. They moved from Kent to Malvern and many of their friends were incredulous about their decision to offer their house to a group of St. Wulstan’s patients. But Susan Carpenter’s 10 tenants are quiet, friendly and glad of the chance to share in a home atmosphere. The rent is paid out of Social Security Benefit (?6.50 per head) so, all in all, St. Wulstan patients make model tenants.
The intensive, business-like programme of treatment which St. Wulstan’s provides is remarkably successful especially considering that all patients are already long-stay and are all some other hospital’s failures. In statistical terms one in every three patients who have passed through St. Wulstan’s in its first 10 years have achieved successful resettlement within the community, i.e. 257 out of 803. Dr. Morgan counts the one in five that have had to be returned to their parent hospitals (168) as St. Wulstan’s ‘complete failures’.
Since rehabilitation of long-stay patients takes a long time, about one third of the 10 year intake are still at various stages of the ‘pipeline’ and it is not possible to determine the outcome for them yet. To really take advantage of the ground gained by a resettlement programme like that at St. Wulstan’s, Dr Morgan would like to be able to pay patients the full amounts that they earn and then make realistic charges for the services provided by the Hospital. Plans are being made to try this kind of system in a factory to be set up in Malvern for 30 day patients? if the factory was separated off entirely from the Health Service by becoming a limited company it would be possible to pay what is earned and charge patients for lodgings direct. This would also bring budgeting and social independence into the resettlement programme.
He dismisses the present requirement for industry to make 3% of its jobs available to the disabled as ‘no use in the context of the mentally ill’ and the quota system is open to abuse anyway with the whole question of registering as ‘disabled’ being doubleedged.
While welcoming the raising of the earnings limit to ?4.50, Dr Morgan is inclined to reserve judgement over whether this increase is enough (or whether it is based on the right rehabilitative premises) to stimulate incentive among patients and make them whole-heartedly want to relearn the habit of working for a living. Another cause for concern is the extent to which labour-intensive job opportunities for which the ex-mentally ill are often admirably suited are being constantly decreased as machines take over so creating more and more ‘twilight people’. At present, he estimates that 50 or 60 people in St. Wulstan’s are only there because they are unemployed and are just ‘marking time in a siding’. As far as sheltered employment as interpreted by the Department of Employment is concerned, the only way to progress beyond it is ‘feet first’. Speaking of the philosophy of St. Wulstan’s Dr Morgan makes it clear that ‘the whole of this place depends on the spirit engendered by the people working here, if we took the attitude that all patients were a “shower” and there was no hope for them then that would be a self-fulfilling prophecy’.
As it is at St. Wulstan’s, in human terms, in the space of 10 years, 257 people who had been ‘written off’ before they arrived have changed from being long-stay patients (with all that that implies) into independent working citizens again.
A team of patients at work on one of the conveyor belts on which ‘soft packs’ of medical dressings are assembled. Last year the workshop produced million of these packs worth ?80,000.
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