Care of the elderly in hospital/community: the Hospital/Health Advisory Services

Infamous scandals in Victorian workhouses surfaced in 1840s. At Andover, the inmates of the town's workhouse were starving and, perforce, had to eat the marrow from horse, dog and cattle bones, which it was their job to crush to produce bone meal fertiliser. The Hudderfield situation was far worse. The official report stated that the sick poor ‘had been most shamefully neglected’. They lacked necessary clothing and bedding. Beds, in which patients suffering from typhus had died, were repeatedly used for new patients without any attempt at ‘purification’. The beds themselves were little more than bags of straw and shavings, and swarmed with lice. Two patients with ‘infectious fever’ were placed together in one bed. A living patient had occupied, for a considerable period, the same bed with a corpse!  

In response to public concerns, the Lancet set up its own investigation, The Sanitary Commission, which reported in 1866. It stated that ‘State hospitals are in workhouse wards.  They are closed against observation.  They contravene the rules of hygiene’. ‘The fate of the ‘infirm’ inmates of crowded workhouses is lamentable in the extreme; they lead a life which would be like that of a vegetable, were it not that it preserves the doubtful privilege of sensibility to pain and mental misery’.  ‘If all the infirm were medically treated there would be a very large percentage of recovery’.  The Editor of the Lancet called workhouses ‘The Antechambers of the Grave’. 

At the turn of the century, the government set up a review of the Poor Law. The 1909 Royal Commission’s Minority Report advocated a need ‘to break up the present unscientific category of the aged and infirm’ and ‘to deal separately with distinct classes according to the age and mental and physical characteristics of the individuals concerned’.  

Between 1941 and 1945 government commissioned teams surveyed hospitals in England and Wales. Many, in varying degrees, made devastating observations about the care of the chronic sick: they had some of the worst accommodation, their medical care was frequently condemned and staffing levels were often inadequate. Interestingly, both Lionel Cosin, who became director of the Oxford geriatric unit, and George Godber, who became one of the greatest Chief Medical Officers we ever had, were members of the visiting teams. The Nuffield Provincial Hospital Trust summed up the reports saying that the surveyors reserved their bitterest criticism for the provision of care for the chronic sick. 

In 1967 Barbara Robb published, Sans Everything: a Case to Answer. The book quoted examples of inappropriate hospital care with authoritarian and depersonalised systems used on wards of unnamed mental and geriatric hospitals in England and Wales, and suggested solutions. The publication received wide publicity and prompted enquiries at the hospitals, whose identity were later revealed: four were mental hospitals and two were geriatric:  Cowley Road Hospital, Oxford and the North Wing of St. James Hospital, Leeds. A Queen’s Counsel chaired each investigating committee together with a doctor, a nurse, and one or more lay members from outside the region concerned.  Lord Amulree was a member of the team which visited Banstead Hospital, Surrey while Norman Exton-Smith went to Cowley Road. The results were published as a White Paper in 1968. It concluded that the majority of allegations of cruelty were unfounded or based on unreliable evidence and that the complaints were inaccurate, vague, lacking in substance, misinterpretations or over emotional.  The unnamed director of Cowley Road Hospital, presumably Lionel Cosin, was singled out for praise for his achievements in changing a custodial regime into an active geriatric unit, with 100 acute beds out of 212 beds. The reports were considered a whitewash. Robb remained unsatisfied and complained to the Council of Tribunals, which rebuked the Minister.  

The Hospital Advisory Service

Another scandal occurred in 1967 at the Ely Hospital in Cardiff in a unit for the mentally subnormal. A nursing assistant made specific allegations of cruelty to patients, coupled with pilfering of their food and property. Geoffrey Howe, Q.C., chaired the Inquiry in 1969, which confirmed the allegations and reported that the whistle blower had been victimised. When the scandal broke, the Secretary of State, Richard Crossman, considered he had been caught out because no one had warned him and therefore he was politically ‘at risk’.  He was exasperated to discover that his Department knew about the problem, had done nothing and had not informed him. Crossman reacted by creating the Hospital Advisory Service (HAS) in 1969, which was to act as his ‘eyes and ears’, would be responsible to him alone and be independent of the Department.  

How did the HAS function?

Its headquarters were in south London with a staff consisting only of the director, his deputy, 6.5 whole time staff equivalents, together with a small number of specialists who formed the visiting teams, and a shoestring budget, in 1988, of about £1 million. Its visits to local hospitals, a form of ‘peer review’, began in 1970 under its first director, Dr. A. A. Baker. They assessed existing services mainly for elderly people and those with mental illness and, where necessary, advised on changes in management and patient care. Good practice was identified but the HAS did not investigate individual complaints.   

Hospitals were notified of an impending visit.  Prior to the team’s arrival informal discussions took place between the Director and hospital management. Recently discharged patients were asked about their experiences. This information was supplied to the visiting team, which comprised ‘in post’ professionals: consultant geriatrician or psychiatrist, senior nurse, a member of the paramedical staff, an administrator and a social service practitioner nominated by the Social Service Inspectorate. Visits lasted one to three weeks, followed by report writing for a week.  The reports’ specific headings ensured all subjects were mentioned. They remained confidential to the unit but became public in 1985.  

At the beginning of each visit, the team met members of the Health Authority, key senior staff, local GPs, representatives of the Community Health Councils and voluntary organisations. GP opinions were sought but were not always forthcoming. Later team members met medical, nursing, paramedical, and social work staff on an individual basis, and then visited hospitals, residential and care homes. The HAS requested a response to the report after six months and two years later carried out a follow up visit. By 1976 a total of 1,410 hospital units, involving just over a quarter of million beds, had been visited at least once. The Service issued annual reports but this lapsed in the mid-1970s but reappeared in 1983. 

What did the reports find?

Two studies reviewed 65 individual HAS reports between 1985 and 1989. The most common complaints were poor sanitary conditions, overcrowding on the wards, use of restraints, inadequate personal clothing, and neglect of privacy especially in toileting. Reports mention patients being put on commodes in full view of others and toilets without doors or curtains. Poor communication occurred among and within professions. In the worst case, health authorities and social service departments did not meet together to discuss or plan services for elderly patients.  Many recommendations required no extra funds but did require improved management and attitudes! The first director maintained that the problem with care of the elderly with mental illness was not so much that of facilities but of attitudes.  

A review of three annual reports, 1983-1986, pointed to a continued lack of financial investment in community support services, delayed admission of elderly people to hospital, lack of dedicated beds, inadequate treatment, with long-term care often provided in ancient buildings operating an institutional regime. Treatment of long stay patients was not unkind but was of devastatingly low quality. A recurrent finding was that older people could experience two very different standards of care depending on whether they were in a geriatric and non-geriatric ward. In the former, the general overall package of care was much superior to the latter. The design of new geriatric wards emphasised improving clinical and nursing efficiency rather than the personal needs of the patients. Unhappily, too many health authorities remained pessimistic and uncommitted towards specialist services for older people. It was HAS experience that levels of ‘input’ measured by resources and staffing, were not always a reliable measure of quality or success. On the positive side, the reports included extensive lists of examples of good practice and indeed, the 1987 report placed particular emphasis on the dissemination of this information. Furthermore, visits brought together people of the same hospital group who did not seem to know each other.  

Criticisms of the HAS

Although the HAS was seen to perform a useful function by highlighting problems and identifying good practice, it attracted multiple criticisms.  Detractors pointed to a lack of standards against which a service could be assessed and that spending was not compared with areas with similar social, economic and demographic profiles. Too much reliance was placed on professional opinion. It could not enforce change, and was not as influential as the Audit Commission or the Social Service Inspectorate.  The Service’s original role as the ‘eyes and ears’ of the Secretary of State had disappeared. It was also criticised for being prejudiced towards the long stay services. But, as the first Director pointed out, it was the task of the HAS to help under-privileged services catch up with those better endowed. However, some censures were ill founded.  It was accused, for example, of failing to diagnose the problems at Normansfield Hospital, Teddington, in 1976 but it had identified them, had given appropriate advice, which had been mostly ignored. The case illustrated how difficult it could be for the NHS, with its multiple levels of authority, to deal with cases where there were personality clashes.

Change was definitely on the horizon and monitoring systems underwent considerable transmogrification. In 1995, the HAS became the Health and Social Care Advisory Service, which was followed by the creation of the Commission for Health Improvement in 2001. The Healthcare Commission replaced it in 2004, followed by the Care Quality Commission (CQC) in 2009. 

Where are we now?

The CQC dwarfs the original HAS. Its budget in 2009 was £164 million. It has major offices in London and Newcastle, more layers of administration, much enlarged staffing and glossy publications.  Teams number some 30 persons who measure eight core services using five key questions. Its remit is larger, covering care provided by hospitals, general practices, dentists, ambulances, care homes, and home care agencies.  However, its 2013-4 annual report is so wide ranging that it is difficult to identify specific care concerns about the older people, although dementia does receive specific attention.  

Shortly after its appearance the CQC went through a turbulent time when it lied to Parliament in 2010/2011 saying it had carried out 15,220 inspections and reviews when had only completed 7,368. It was then severely criticised for the Ash Court and Winterbourne affairs and for gagging its own staff. A major clear out of higher managers followed. The new chairman considered that the CQC’s previous management was totally dysfunctional and was not fit for purpose but even in 2014 new members of staff were still being appointed with inadequate qualifications. 

The CQC’s focus now concentrates on the quality and co-ordination of patient care. Will it succeed?  The recent debacle over general practice assessments does not augur too well but time will tell. Was Sir Keith Joseph still correct in saying that occasional scandals improve Social Services? 

Michael Denham

Acknowledgement: I am grateful to Dr. Peter Horrocks for his views and comments on the article.