40 Years On Part 2: The staff

In my previous blogpost, I described some aspects of hospital services for people with learning disabilities 40 years ago, and wondered about continuities and differences from then to what’s happening in ‘specialist’ inpatient units for people with learning disabilities. Fortuitously, in the same year of 1976 a Committee of Enquiry (Department of Health and Social Security, 1979a) commissioned a large-scale survey of 967 nursing staff working in hospitals for people with learning disabilities (Department of Health and Social Security, 1979b). In this blogpost I want to do something similar to the previous post but focusing on staff – what do the results from this survey tell us about how things were 40 years ago, and what would a similar survey of staff in inpatient services today reveal?

From the previous blogpost, it’s important to remind ourselves that in 1976 there were nearly 50,000 people with learning disabilities living in mainly big hospitals (compared to the approximately 3,000 people with learning disabilities in specialist inpatient units in 2015), of which 9% were children aged under 16 years old. In some respects it feels like a different world (as we’ll see by some of the questions asked in the survey), and yet…

Over the daytime (presumably staff were more scarce at night), there was an average ratio of 1 member of staff to 7.3 people with learning disabilities. As far as I know, there is no equivalent information for specialist inpatient units now.

Although only a minority of the people with learning disabilities in hospitals in 1976 were in specialist units equivalent in stated function to specialist inpatient units today, hospital nursing staff in 1976 reported that over a quarter of people (27%) ‘had behaviour problems (for example, being aggressive, destructive or overactive)’. On the day before they were interviewed for the survey, almost a quarter of day staff in hospitals (22%) reported that they had spent over an hour ‘dealing with behaviour problems (e.g. restraining aggressive, destructive or noisy residents)’. In the specialist units of 2015, exactly 27% of people with learning disabilities were also reported to have a ‘behavioural risk severe enough to require treatment’ (NHS Digital, 2015).

What else were nursing staff doing in 1976? Nearly half of them (44%) spent at least an hour the day before the survey engaged in ‘social aspects of care’ (playing games, handicrafts, going for a walk or to the shops, encouraging people to do stuff), over half (56%) spent at least an hour providing basic care, and 13% spent at least an hour giving medical attention or treatment (giving out drugs or looking after people who were physically ill). Almost half of staff (47%) said they liked the social aspects of care part of their job the best – others said it was providing basic comfort/care (28%) or looking after people when they were ill (22%). However, only 11% of staff thought that the most important aim of the service they worked in should be ‘to enable some of the residents to live out of the hospital or hostel within the next few years’.

The survey also asked nursing staff about restrictions imposed on people living in the hospitals. Like the minimum standards I mentioned in the previous blogpost these questions reveal more about low expectations than anything else. How would current inpatient services (bearing in mind that a greater proportion of them impose some level of ‘security’ on people living there) measure up?

For example, in 20% of hospital wards in 1976 no people with learning disabilities were allowed to use the kitchen. In most wards (77%) people would ‘usually be allowed to watch a late TV programme at the weekend’ though, and in over a third of wards (36%) ‘some of the residents get up at a different time at weekends than on weekdays’. The vast majority of wards (82%) had not been locked on the previous day, although 14% of people had stayed indoors all day even though they weren’t ill. In a third of wards (34%) people were asked about what they would like for their meals at least once a month, and in most wards (80%) everyone had their own locker or cupboard. However, not many wards (17%) had meetings with people living on the ward to ‘discuss topics such as meals, bedtimes or other rules’.

Wards where staff wore uniforms were more likely to have more restrictive practices.

One area where the 7 days of action families will recognise little progress is in how hospitals allowed (or restricted) family access in 1976. According to the nurses in the 1976 survey, in almost three quarters of wards (74%) ‘relatives can come at any time in the day or the evening’. For most of the rest (23%), ‘relatives can come when they like if they ring first’, and in only 4% of wards ‘relatives should only come on fixed visiting days or times (but exceptions are made)’.

Perhaps most starkly, the 1976 survey asked a set of pretty pointed questions about the attitudes of nursing staff working in hospitals for people with learning disabilities. I don’t know if a similar attitude survey has been done recently with staff working in inpatient services for people with learning disabilities, but comparing staff now to 1976 would be very instructive.

So, with some apologies for the language used in the survey questionnaire, I’ll finish off with a table of some statements that were put to nursing staff in hospitals and how they responded:

Statement	Percentage of nurses agreeing or disagreeing with the statement
	Agree (slightly or strongly)	Neither agree nor disagree	Disagree (slightly or strongly)
We cannot expect to understand the odd behaviour of patients/residents	26%	9%	65%
A carefully designed training programme for a patient is more important than kindness	33%	13%	55%
Adult patients/residents should be treated like young children	15%	10%	75%
Hardly any severely mentally handicapped children could be properly looked after at home by their parents	43%	9%	48%
Residential homes or hospitals for the mentally handicapped should be sited as close as possible to the community they serve	86%	7%	7%
Mentally handicapped patients who have been discharged from hospitals are often not properly cared for in hostels	37%	37%	26%
More mentally handicapped patients/residents should be sterilised	40%	24%	36%
Mentally handicapped adults should be discouraged from developing sexual relationships	27%	20%	53%

To people with learning disabilities in inpatient services now, and their families, I genuinely wonder how much of the picture revealed by this staff survey 40 years ago feels like ancient history, and how much feels familiar?

References

HM Government (1979a). Report of the Committee of Enquiry into Mental Handicap Nursing and Care (Chairman Peggy Jay): Volume I. London: Her Majesty’s Stationery Office.

HM Government (1979b). Report of the Committee of Enquiry into Mental Handicap Nursing and Care (Chairman Peggy Jay): Volume II: OPCS Survey of Nurses and Residential Care Staff. London: Her Majesty’s Stationery Office.

NHS Digital (2015). Learning Disability Census Report – England, 30^th of September 2015. Leeds: NHS Digital http://digital.nhs.uk/catalogue/PUB19428