Whitewash and After: ‘Most Good Is Done by Stealth’

Abstract

Kenneth Robinson, Minister of Health, announced that the inquiries disproved the allegations in Sans Everything and vindicated the hospitals. However, careful reading of the reports indicated much unsatisfactory practice. Newspapers criticised the Ministry for its deceitful and ‘deplorably hostile’ view of Sans Everything, and public support for AEGIS increased. More hospital staff voiced concerns and attempted to make improvements. In 1969, investigations at Ely Hospital revealed appalling standards, gave credence to Sans Everything and reiterated AEGIS’s proposed remedies. AEGIS continued to chip away at the shield defending officialdom and worked to improve hospital provision. The government established a NHS inspectorate (1969), reviewed the complaints system (1971–1973), appointed an ombudsman (1973) and created blueprints for improved services for people of all ages with mental handicap and mental illness (1971–1972).

Early in 1968, disturbing reports about psychiatric hospitals supplemented information presented by AEGIS (Aid for the Elderly in Government Institutions). The media gave generous coverage to: a fire at Shelton Hospital which killed twenty-four patients (Anon. 1968a); appalling overcrowding at Central Hospital, Warwick;¹ a geriatric ward at Powick Hospital, Worcestershire (World in Action 1968); and poor care of mentally handicapped children at Harperbury Hospital, Hertfordshire (Shearer 1968). Most reports also highlighted doctors and nurses trying to make improvements. In July 1968, Robinson announced Findings and Recommendations, the white paper summarising the outcomes of the Sans Everything inquiries (Ministry of Health (MoH) 1968a). Other allegations and investigations about ill-treatment shed light on the Sans Everything events and inquiry processes. They help explain why the Ely Inquiry (DHSS 1969), rather than Sans Everything, became regarded as pivotal to the reform of the long-stay hospitals (Martin and Walshe 2003, p. 6) although AEGIS paved the way for that to happen.²

In October 1968, government reorganisation abolished the Ministry of Health, amalgamating it with the Ministry of Pensions and National Insurance to become the Department of Health and Social Security (DHSS). Robinson stepped down as Minister, and Harold Wilson appointed Richard Crossman as Secretary of State for Social Services. Crossman appointed Abel-Smith as his chief advisor on health and welfare. Under Crossman, the DHSS acknowledged the importance of improving the psychiatric hospitals. New concepts helped, such as the ‘dignity of risk’ rather than the ‘security of protection’, and ‘normalisation’ which promoted the idea that disabled people should be supported to live as normal a life as possible in the community (Nirje 1969). Following the devaluation of the pound in 1967, the authorities were subject to austerity measures. Economic pressures affected health and welfare services for everybody, but the least-valued members of society—older, mentally ill and mentally handicapped people and others with chronic disorders—were particularly affected. Good intentions for them competed against other demands, such as highly valued acute and high technology medicine and surgery, on a worrying background of increasing real costs of the NHS (OECD 2011).

Improving psychiatric hospitals was tricky, particularly in the context of the long-term goal to close them and to shift services to the community and district general hospitals (DGHs). Plans to close hospitals created new challenges. Work in poorly maintained buildings designated for closure could be grim. Staff whose jobs were threatened had to consider finding alternative employment, which could affect their family life and their home, especially if they lived in tied accommodation.³ Ensuring improvements in patient care in these circumstances needed support for staff and collaboration between management and clinical leaders to ensure a positive culture change within the hospitals (Carse et al. 1958). Intensive media involvement could produce improvements in the short-term (Shearer 1976, p. 113), but new ways might not be maintained. Severalls Hospital, for example, ‘reverted to a situation of poor leadership’ when Russell Barton, frustrated by conflict and personality clashes at the hospital and with the Regional Hospital Board (RHB), emigrated to the United States (Gittins 1998, pp. 87–89, 92).

Behind the scenes AEGIS continued to supply information to Abel-Smith,⁴ chipped away at the shield defending officialdom and worked to improve hospital provision, assisted by the press. Plans initiated under the Labour government (until 1970), were followed up by the Conservatives (1970–1974). These included establishing a NHS inspectorate, reviewing the complaints system (DHSS 1973), appointing an ombudsman, and creating blueprints for improved services for people with mental handicap and mental illness (DHSS 1971a, 1971b, 1972). Numerous factors influenced health and social care developments, emphasising the risk of ascribing too much, or too little, to any one event, person or organisation, including to AEGIS.

More Psychiatric Hospitals in the News

The stream of press and public interest in the psychiatric hospitals in 1968 contrasted with the situation three years earlier when media reports were rare. Happenings at four hospitals—Shelton, Central, Powick and Harperbury—informed the public of appalling conditions and revealed positive and negative attitudes of the hospital leadership and those higher in the NHS hierarchy. Behind the scenes, Barbara pushed, supported and inspired staff at the hospitals, and the media reporting on them.

On the night of 26 February 1968, a fire on a forty-two-bed ward at Shelton Hospital killed twenty-four women patients (Anon. 1968a). Robinson announced a public statutory inquiry under section 70 of the NHS Act (MoH 1968b).⁵ It was the first section 70 inquiry in the history of the NHS that directly concerned patients.⁶ Unlike the Sans Everything inquiries, it had Council on Tribunals oversight.⁷ Various factors contributed to the fire, including hospital bureaucracy, which delayed emergency help because the ‘night porter [had] to obtain the authority of one of the hospital fire officers before calling the Fire Service’ (Osman 1968).⁸ The destroyed ward was locked and minimally staffed,⁹ less hazardous than the locked unstaffed wards at Friern¹⁰ and St Lawrence’s.¹¹ Dr JC Barker, a psychiatrist at Shelton, attended the inquiry on several occasions. He told Barbara that staff tried to cover up inadequacies and that ‘conflicting evidence is quite horrifying and I am sure is giving this hospital a very bad name’.¹²

Despite the problems, some staff at Shelton, such as David Enoch, did their utmost to make improvements. Among other things, he established an education programme, about which he reflected in 2015:

I started education days—in Shelton—education for doctors and nurses—in the nurses [home].…There was a big hall for them to have entertainments.…I took Thursdays over…and had cases presented, a visiting lecturer, and a debate.

In the end, of the three other psychiatrists, two of them [asked]:

‘Could we present a case?’

‘Of course!’ I said, ‘I’d love it for you to present a case! Look at the experience you have got.’

Well, they didn’t want to know anything before.¹³

During one of their education days staff highlighted challenges of making improvements:

Dr Cartwright::

wards are overcrowded, the patients are inadequately dressed and there is the very minimum of facilities.…This, in itself tends to make these patients chronic. They are all grouped together and shut up together and there appear to be very few comforts or amenities for them.

Dr Barker::

I quite agree with you.

Dr Thomas::

Try asking for them!¹⁴

In Enoch’s opinion, Barbara’s high-profile work and Sans Everything contributed to initiating this sort of discussion: ‘I can’t over emphasise its power’, difficulties in psychiatric hospitals became ‘something that people discussed more’.¹⁵

A second hospital in 1968 attracted national attention, Central Hospital, Warwick. Similar to Friern, Ely, Storthes Hall and Whittingham, Central had ongoing difficulties that showed no evidence of diminishing with time. Barbara first wrote to medical superintendent Edward Stern in 1966, congratulating him on his ‘truly valiant attempt’ to improve his hospital.¹⁶ He involved local MPs who made a ‘very distressing’ three-hour tour of the hospital (Anon. 1966b, 1966c) and asked Robinson to investigate. Robinson agreed that conditions were unacceptable (Anon. 1966d), but little changed. Six months later the press reported deaths of two elderly patients. One drowned in a bath and the other was pushed over, attributed to overcrowding, meal-time chaos and frayed tempers. MPs described the situation as ‘desperate’. Stern offered ‘to join any delegation’ to see Robinson, but Robinson did not reply to his letters (Leamington Spa Reporter, 1967; Robb 1967, pp. 10–11).

In March 1968, days after the Shelton fire, William Price MP told the House of Commons that Central was: ‘the most overcrowded mental hospital in Britain. Only by the grace of God have we escaped a major disaster through fire or epidemic’. He described:

Seventy three men living in a ward made for 38. We saw patients carrying their toothbrushes and other personal belongings in their pockets because there was no room for lockers between their beds. We saw long-term mentally disturbed patients living in adapted corridors and in recreation rooms. We saw a ward where nurses had to move five beds before they could change the clothes on the sixth, and we saw a lot more besides. I am not by nature squeamish, but the memory of that day will haunt me for the rest of my life.¹⁷

Shortly after, a patient’s family accused two nurses at Central of ‘brutality’. A four-hour inquiry reported that the patient ‘put up violent resistance’ so the staff needed to restrain him, and that although ‘no excess force was used’, the patient sustained injuries to his face and neck. Particularly vulnerable areas of the body, such as face and neck, should not have been injured in the course of restraint, but no archives have been identified indicating that the committee challenged staff about this. The staff were exonerated. Whether, similar to the Sans Everything inquiries, the committee made assumptions that staff actions were justified and patients were in the wrong, is unclear. The family, however, was dissatisfied with the outcome (Anon. 1968i).

A third hospital, Powick in Worcestershire, featured in a World in Action television documentary, Ward F13. World in Action took the then unusual approach of interviewing people directly responsible for social issues and believed that television could change the way people viewed the world (Goddard 2007). With the opening shots of the hospital, the presenter solemnly declared:

Conditions like these exist in many, but not all, mental hospitals. Most comparable institutions would prefer to stay hidden. Powick didn’t evade our enquiries, and the decision was surprising, for the hospital is ashamed of the annexe.

Ward F13 in the Victorian annexe housed seventy-eight women aged fifty-nine to ninety-one, in overcrowded, noisy and undignified conditions. The documentary showed women having their bottoms washed, being dressed or sitting on commodes in the open ward with no privacy. There was visible rough handling, such as when putting a patient onto a bed and locking an uncooperative patient in a chair with a restraining table fixed in front. The nurses appeared hardworking, overstretched and dedicated, doing their best in atrocious circumstances and with no time to spend with patients other than when dealing with their physical needs.

The medical superintendent, Arthur Spencer, took up his post in 1951, succeeding Dr Fenton who retired after forty-three years. Fenton’s custodial and ultra-economical approach gave Powick the reputation of being the cheapest asylum in the country. In contrast to Fenton, Spencer developed a therapeutic regime in the admissions section of the hospital, but facilities changed little for elderly people and for patients with chronic mental illness in the four wards of the annexe (Sandison 2001, pp. 31–33). Spencer courageously let the cameras into his hospital. He addressed the circumstances, and the likely responses to them, candidly:

There are two possible reactions…one is that people will become incensed at some members of the community having to live in these conditions. The other is that people will be so appalled by what they see that they will shut it out of their minds and reject the whole problem as insoluble and something they cannot face up to.

The first reaction was that of AEGIS. The second reflected common patterns of response by NHS leaders, politicians and the committees of inquiry into Sans Everything. Spencer’s obituary in the BMJ (WDS 1979) described his pioneering and modernising approach at Powick, but did not mention Ward F13, even though it led to major benefits when the government’s Worcester Development Project put Powick at the forefront of developing community psychiatric services nationally (Turner and Roberts 1992). It is conceivable that not mentioning Ward F13 in Spencer’s obituary was because he caused embarrassment and resentment, for colleagues and for the authorities, by saying what needed to be said.

The day after the documentary, Barbara’s informal note to ‘Vanya’, probably Vanya Kewley its researcher, said that some people had a sleepless night after watching it, and it ‘was a triumph for everyone concerned with its production’.¹⁸ The style of the note pointed to Barbara’s behind-the-scenes contact with the production team. A few days later, the press linked Barbara, the documentary and advice from the Council on Tribunals to proposals for a hospital ombudsman (Roper 1968a; Doyle 1968).

A fourth hospital, Harperbury, under the same RHB as Friern, provided care for children and adults who were ‘mentally subnormal’. It was the subject of an article in the Guardian by Ann Shearer (1968), a journalist who admired Barbara, Abel-Smith and Barton and for whom AEGIS was ‘at the back if not always at the front of my mind’.¹⁹ The Guardian took its usual editorial and legal precautions before publishing Shearer’s controversial article, which revealed atrocious standards.

The article came about after the Guardian received a letter from the aunt of a child living at Harperbury, and Shearer was asked to investigate. The aunt invited Shearer to accompany her to visit her nephew, where she witnessed squalor, including piles of faeces, some on a table. After publication, the staff invited Shearer back: ‘they had cleaned the ward, put clothes on those children, and put flowers on the table, and it was the flowers on the table which was the last bloody straw. I was so angry that they would take me for such a fool.’²⁰ Flowers to admire was an inappropriate, incongruous gesture in a children’s ward where toys would have been more fitting.

The RHB was furious about the article and accused Shearer of ‘unauthorised entry’, which was incorrect, as a patient’s relative had invited her. Senior staff at Harperbury rejected Shearer’s criticisms, saying that she lacked formal training or experience of working with mentally subnormal people. NHS managers described her as irresponsible, denied the allegations and blamed her for worsening staff morale and recruitment, undermining public confidence, and laying the last straw on the breaking backs of staff (Shearer 1976, p. 110). These defensive responses, eerily similar to those experienced by Barbara and the Sans Everything witnesses, give the impression of being automatic rather than stemming from methodical consideration.

Rather than appealing to the Ministry to help put things right, the RHB complained to the Press Council, which investigated and interrogated Shearer. At the inquiry, as she recalled in 2015, Lord Devlin asked her how many piles of excrement she had seen. She found the question so bizarre and irrelevant to the main issue that she angrily replied ‘Shit is shit, my lord.’²¹ The Press Council upheld the RHB’s complaint and criticised the Guardian for lack of objectivity and accuracy. Considering the subject important, later in the year the Guardian extraordinarily republished the offending article alongside the Press Council’s judgement. It did this because the judgement did not specify where the article lacked objectivity or accuracy and it wanted to give readers the opportunity to form their own opinion (Shearer 1976, pp. 109–110). Hackett (1968) was irate about the reprint. He wrote to the Guardian: ‘I doubt there is another country in the world where the finest nursing service in the world has this kind of ridiculous unnecessary attack made on them by newspapers as the result of a bitter fight for circulation.’ Psychiatrist Leopold Field (1968) responded with a letter that NHS managers, when criticised, ‘develop an acute attack of paranoia and defend themselves in the most hysterical of terms’. Field rejected Hackett’s statement about the ‘finest nursing services’ as ‘impetuous nonsense’. He challenged Hackett’s views that hospitals should be immune from press scrutiny and criticised Hackett’s ‘outrageous statements diametrically opposed to the facts’.

Another television documentary, Something for Nothing (BBC 1968), marked the twentieth anniversary of the NHS. It reflected on achievements of the ‘technology revolution’ and new hospital buildings, but it called the NHS the ‘sacred cow of the politicians’, and said, ‘The NHS today doesn’t work.’ It criticised the ‘British tradition of amateurism’ embodied in inefficient Hospital Management Committees (HMCs), and the ‘inept, slow, tardy administration’ of higher NHS echelons. It discussed the ‘burden’ of older people and, menacingly sincere, to solve the problem of the number of older people requiring treatment and care, it proposed the option of voluntary euthanasia for those who had ‘signed the forms’ and were ‘of no practical value to society or themselves’. Robinson was livid about the programme, and Crossman was ‘disgusted’. Crossman described it as a

monstrous programme, full of mistakes and also annoyingly…all about euthanasia, where it put people off by its libertarianism, [and] at the end it put people off by guying a hospital committee…it was wrong in every possible way. And we are having an enquiry made.²²

The government reprimanded the BBC, the consequences of which became apparent after publication of the white paper on Sans Everything.

Announcing Findings and Recommendations, the White Paper on Sans Everything

Robinson wanted to ease the way of the publication of the white paper, Findings and Recommendations (MoH 1968a), so he arranged a ‘planted’ question in the Commons.²³ On 9 July 1968, Labour MP Roy Roebuck asked about progress being made on the inquiries, and when the Minister expected to announce the results. The reply was instant. Robinson announced that the inquiries proved that most of the allegations in Sans Everything were ‘totally unfounded or grossly exaggerated’ and that the committees reported ‘very favourably on the standard of care provided’.²⁴ Robinson concluded his announcement: ‘the publication of the White Paper should discourage anyone from making…ill-founded and irresponsible allegations in future.’ Roebuck criticised Sans Everything for causing distress and wasting public money with ‘wild and irresponsible allegations’. MPs responded with relief to Robinson’s reassurance, and continued to attack Sans Everything. Only Paul Dean, a Conservative MP, probed. He questioned that, if only ‘most’ were unfounded, then some were founded, and minimum standards needed to be achieved: he asked for an inspectorate. A press release concurred with Robinson’s announcement.²⁵ The Confederation of Health Service Employees (COHSE), which defended its members at the inquiries, rapidly congratulated itself that its ‘quiet unwavering year-long stand is vindicated’.²⁶ Several national newspapers published reports based on the press release, announcing that the white paper vindicated the Ministry (e.g., Jackson 1968; Rawstorne 1968; Wilkinson 1968).

The full text of the white paper became available later in the day. The press made a rapid U-turn after reading it. The Times shifted from saying that the hospitals were ‘cleared of cruelty’ (Roper 1968b) to denouncing the white paper as a ‘whitewash’ and stating that ‘Nurses, distressed by reports of the White Paper, had been ringing AEGIS urging her to continue’ (Anon. 1968b). The Sunday Times criticised Robinson’s complacency, wondered if he had read the white paper and referred to his ‘deplorably hostile view’ of Sans Everything and rejection of criticism from outside the NHS (Young 1968). Rolph wrote about journalists’ embarrassment when they realised the inconsistency between the press release and the full white paper: they ‘could see how they had been misled. I don’t remember hearing pressmen so angry’ (Rolph 1968).

In the Observer, the National Association for Mental Health (NAMH) and Spastics Society criticised Robinson for his handling of the inquiries (Staff reporter 1968). Helen Hodgson (1968) in the Guardian condemned the inquiry methods and regarded Robinson as ‘deluded’ if he thought the allegations were ‘authoritatively discredited’. The Patients Association (PA), backed by the NAMH and the National Council for Civil Liberties²⁷ wrote directly to Harold Wilson, asking him to establish an independent inquiry into conditions for older people in psychiatric hospitals (Anon. 1968h).²⁸ Wilson redirected their appeal to the Ministry,²⁹ which was ineffective, unsurprising considering that ministerial apathy about older people’s care was the rationale for their request.

The medical profession did not know which way to step. One report commended the inquiry committees: ‘unsentimental, impartial and intelligent men and women authorised to investigate the total situation at each hospital and guided by Queen’s Counsel’ (Anon. 1968f). The same report noted that ‘throughout the country the psychiatric services in general and particularly the psychogeriatric services, are in an appalling mess’. The Lancet described Robinson as well intentioned but said that the inquiries should have been under the Council on Tribunals to ensure they were done ‘in way that the man on the Clapham omnibus would regard as impartial’ (Anon. 1968g). A BMJ editorial highlighted the ‘deplorable hospital facilities with which valiant staffs are trying up and down the country to provide satisfactory care and treatment of their patients’ and that ‘the sordid conditions in which many are condemned to live out their days in hospital are a disgrace to the nation’ (Anon. 1968j). One letter in the BMJ told doctors not to be complacent: they were part of the cause (Mathers 1968). The British Medical Association (BMA) recognised that it ‘would have to put continual pressure on the Government, on the local authorities, and on Regional Hospital Boards (RHBs) if the necessary urgent financial assistance was to be obtained’ to tackle the problems (Greenberg 1968).

Crossman understood Barbara’s fury about Robinson, ‘that what he was doing was to smother perfectly legitimate criticism of what was going on’.³⁰ He criticised Robinson’s announcement as

obviously untrue. In fact the reports didn’t by any means deny all the allegations and if he had had the common sense to say they deny all the most important, the gravest and most serious allegations, well there are of course a number of criticisms about geriatric hospitals. If he had emphasised the criticisms and welcomed them and said that of course they were not fully met and he was going to meet them, that was right. But he didn’t. He gave a sense of complacency and complete defending which he does as a bit of a bureaucratic minister.³¹

An editorial in New Society, attributed to Townsend (Cochrane 1990, p. 117), also described Robinson’s statements in the Commons as ‘untrue’, and criticised him for disbanding a group of professors and doctors that he set up in 1966 to plan hospital geriatric services (Anon. 1968e). Applebey of NAMH reportedly said that she ‘nearly dropped’ when she heard Robinson’s announcement (Anon. 1968c; Rolph 1968). Rolph (1968) declared that he almost did likewise and criticised the committees of inquiry, especially at Friern, which, by failing to interview the Sans Everything witnesses, drew conclusions based on ‘blind and inaccurate guesses about the information of which it stupidly deprived itself’. The Daily Mail summarised the government’s response: ‘Whitehall washes whitest’ (Anon. 1968d).

Barbara did not shrug off the humiliation and discrediting but became more cautious, sometimes wrongly interpreting criticisms as malicious, to the extent of risking losing allies and supporters.³² Brian and the AEGIS friends supported Barbara emotionally as much as they could during very stressful periods of the campaign.³³ Harvey wrote to Rolph about his ‘characteristically splendid article’ in the New Statesman: ‘How glad I am that you have given Barbara some of the enormous credit she deserves. I wish it could be known how you have helped with the kind of expert advice that I was unable to give, and the non-stop backing.…Much love, Audrey.’³⁴ Davie wrote to Barbara:

I have just finished reading the latest fiction entitled Findings and Recommendations....Overriding my own feelings of disquiet and anger is my sympathy for you over the treatment accorded you in this nauseous little blue book. But one must admit that, in its way, this book is a masterpiece—of the art of distortion by omission and the application of overwhelming bias. In short, fiction of a nasty kind featuring ‘Goodies’ and ‘Baddies’ with the Hospitals cast in the former role…and our goodselves in the latter.³⁵

Barbara worked with Desmond Wilcox, editor of BBC2’s Man Alive current affairs series, to create a programme about Sans Everything to coincide with publication of the white paper.³⁶ Barbara’s cast included Barton, Cross, Daniel and the Cowley Road witnesses. Part of the programme was filmed in advance, including scenes of patients and staff at Severalls. Barbara contacted her solicitor before the screening, concerned that some of the recorded interviews did not follow the agreed plan. For example, the interview with Daniel went over old ground of the allegations and did not include new material—namely, the hostile atmosphere of the inquiry and that she received threatening phone calls.³⁷ The Man Alive team invited trade union representatives, members of RHBs and Robinson, although Barbara was not informed that Robinson was involved until the day. In part, that might have been because Wilcox had trouble persuading him to appear. Wilcox’s telegram to Robinson on 12 July revealed the latter’s ambivalence and the Ministry’s pressure on RHB chairmen to conform. Wilcox wrote:

I sincerely regret your decision not to appear in next Tuesdays Man Alive.…I think your confidence that the BBC will still be able to make a balanced programme is not being helped by your own Ministry advising those chairmen of Regional Hospital Boards invited by us to appear that it is not in the Ministry’s interests that they should do so.…May I now solicit your cooperation in allowing representatives of Regional Hospital Boards to appear in the discussion. It must be considered a matter of public concern if fair balance is prevented because of pressure of this sort.³⁸

The live discussion was a shambles, including three interviewees introduced incorrectly and a crash interrupting the proceedings. Similar to 24 Hours the previous year, the programme allocated Barbara and her supporters little time compared to her opposition, and Robinson had the last word:

I think this White Paper speaks for itself, to anyone who reads it with an unprejudiced eye.…Basically, the crucial element in this book were the stories of deliberate, calculated cruelty. This is what made the book sell;…The credibility of the book, I think, has been destroyed. I wouldn’t, Mr Wilcox, expect the authors of the book to apologise for the damage, the harm they have caused. This cannot have helped the recruitment of nurses. This cannot have helped the morale of the nursing profession.…But by and large, this task [of looking after elderly and mentally ill people] is discharged, in my view, extraordinarily well, by a dedicated body of nurses, who certainly do not deserve the generalised smear that this book conveyed on them.³⁹

Neither ‘a generalised smear’ nor ‘deliberate cruelty’ formed part of Barbara’s allegations (e.g., Robb 1967, pp. xiii–xvi; Rolph 1968). Despite the evidence, including within the white paper, there was no leeway in Robinson’s argument that NHS practices were right and Barbara and AEGIS were wrong.

Crossman was delighted with the programme, which he watched with Abel-Smith, without realising that Abel-Smith contributed to Sans Everything and was a force behind AEGIS.⁴⁰ Barbara was enraged by the programme, particularly because Wilcox had assured her it would be impartial. She wrote to Wilcox outlining the distribution of air time in the discussion: Robinson had eight minutes, the ‘opposition’ to Sans Everything had seventeen, while she with her team had eight. She wrote that the programme ‘was very far from typical of the impeccable behaviour I have learned to expect from the BBC.’ Wilcox replied only that ‘we made the best programme possible under the circumstances.’⁴¹ ‘The circumstances’, Crossman explained, was due to the government reprimanding the BBC about Something for Nothing. Wilcox was ‘under control from on top to give fair play to Kenneth Robinson and fair play to the Hospital system’.⁴² The BBC showed its subservience to the government, at the expense of Sans Everything. The public did not know about the political furore behind the bias, but some complained to the BBC about the programme. One wrote that it lacked cohesion, ‘none of the statements which were flung into the pool were taken up or followed through’, Robinson was allowed ‘to evade a straight answer to a plain question’ and ‘Mrs Robb was allowed practically no time to say anything’.⁴³ Another viewer wrote to Barbara that she was ‘appalled by the lack of manners on Mr Robinson’s part, and the small opportunity given to you to speak’.⁴⁴ Harvey was ‘quite ill with anger at the Man Alive thing’.⁴⁵

The Aftermath

In the immediate aftermath of the white paper, the Ministry asked AEGIS not to complain further about the inquiry processes until it had put into action various vital reforms, including an inspectorate and an ombudsman. Barbara later reflected: ‘it was with misgivings that we agreed to protest no more until the health ombudsman was appointed. Little did we guess that meant a five year wait.’⁴⁶ However, other changes emerged. Some, such as the Health Services and Public Health Act (1968), appeared politically tokenistic. Sections of this Act relevant to older people built on earlier legislation that permitted local authorities to provide domestic help and fund ‘recreation or meals for old people’.⁴⁷ The new Act gave permissive powers to local authorities ‘to make arrangements’ for promoting their welfare. However, given that it coincided with publication of the Seebohm Report (DHSS 1968), which originated in concerns about probation and children’s social services (Lowe 1999, p. 268) and prioritised local authorities’ commitment to families, the sections of the Act about older people were unlikely to be implemented in the short-term.

Despite the authorities’ lethargy, constructive responses emerged elsewhere, including from individual politicians and the medical profession. Eric Moonman MP asked Barbara to speak at Labour Party events, including in a lecture series that also featured the Archbishop of Canterbury. Moonman wrote to thank Barbara: ‘You were splendid.’⁴⁸ Some psychiatric hospitals were more proactive in paying attention to the needs of older people. Goodmayes Hospital advertised for a consultant psychiatrist to work specifically with them, and Tom Arie commenced work there in January 1969.⁴⁹ Enoch wrote to Barbara informing her about his geriatrician–psychiatrist planning group on psychogeriatric services.⁵⁰ It comprised enthusiastic pioneers in the field, including psychogeriatricians Brice Pitt and Klaus Bergmann. Their pamphlet linked to Whitehead’s (1965) scheme at Severalls and emphasised the importance of ‘care of the aged in the community, for clinical, economic, social and humanitarian reasons’ (Enoch and Howells 1971, p. 17). It encouraged the British Geriatrics Society (BGS) and Royal College of Psychiatrists (RCPsych) to establish a joint working party on older people, which produced recommendations for clinical practice endorsed by both organisations, feeding into other developments at the RCPsych.⁵¹

Changes occurred in several domains of nursing practice and organisation. For example, the organiser of a King’s Fund Hospital Centre project, which explored nurses’ attitudes to patients and produced guidance for nurses who wanted to start discussion groups with colleagues about this,⁵² informed Barbara that her work inspired it.⁵³ Also in 1968, demonstrations took place at Westminster about nurses’ pay and conditions (Eade 1968). Demands included a living wage so nurses were not dependent on tied accommodation. That would give them greater professional independence as they would not fear losing their job and home if they spoke out. A photograph in the Daily Telegraph of protesting nurses on their way to the Commons suggested a link with recent events: one nurse held a copy of Sans Everything (Anon. 1968k). Peter Nolan (1998 p. 135) commented that when nurses realised that recourse to outside agencies could be more effective in redressing the wrongs of an institution than invoking the authority of senior nurses, ‘the tradition of secrecy within the mental hospitals was broken’. The NAMH newsletter also noted that more doors were open in psychiatric hospitals, affecting patient care and indicating less concealment: ‘If this trend continues, Mrs Robb’s book will have had a considerable secondary effect—one of which is all to the good.’⁵⁴

The Ely Hospital Inquiry

Martin (1984 p. 5) wrote that after Sans Everything ‘By a strange coincidence another inquiry was set up at the same time.’ It was hardly coincidence: the Ely allegations emerged directly from Roxan’s (1967) announcement about Sans Everything in the News of the World. In another analysis of NHS and social care scandals, Butler and Drakeford (2005, p. 113) commented: ‘Ely marked the start…of an avalanche of scandal in mental health.’ However, several of these scandals surfaced after publication of Sans Everything and before Ely became public knowledge. The sequence of events, particularly concerning Ely, is worth exploring because it sheds light on AEGIS and on the Sans Everything inquiries, their flaws and outcomes.

Ely was in Wales, where the UK government was in an unfavourable spotlight following the Aberfan disaster (Report 1967). Geoffrey Howe (a Conservative politician, later Lord Howe) ‘one of the cleverest Conservative lawyers’,⁵⁵ represented the colliery managers’ unions at the inquiry. Howe and Abel-Smith knew each other since their student days at Cambridge, and on Abel-Smith’s recommendation, the Welsh Hospital Board (WHB) appointed Howe to chair the Ely Inquiry (Sheard 2014, pp. 47, 236–237). Howe, following his experiences at Aberfan and unlike the Sans Everything chairmen, was acutely and personally aware that public authorities could turn a blind eye to unsatisfactory and dangerous practices (Hillman and Clarke 1988, p. 86).

Allegations at Ely resembled those in the Sans Everything hospitals. The Ely Inquiry committee had the same terms of reference as its Sans Everything predecessors (MoH 1968a, p. 21; DHSS 1969, pp. 2–3), although under Howe’s chairmanship, the planning and conduct of the inquiry differed from them. Howe challenged the Ministry’s instructions if he disagreed with them. For example, when the Ministry advised him not to publicly announce a private inquiry,⁵⁶ he argued for the benefits of privacy during an inquiry, as opposed to secrecy about it.⁵⁷ Thus for Ely, the inquiry included an appeal for witnesses, compatible with Council on Tribunals guidance (Howe 1999, p. 303).⁵⁸ Howe also broke with the Lord Chancellor’s advice to ‘keep this kind of inquiry narrow’ and intended to investigate up to Ministry level if necessary (Crossman 1977, p. 426).⁵⁹ Howe requested documentation about NHS services and complaints procedures,⁶⁰ unlike Lowe at Friern, who the Council on Tribunals criticised for being unaware of protocols.⁶¹

Michael Pantelides, the informant, made many allegations about Ely, including staff teasing, assaulting, hitting and inappropriately secluding patients, pilfering food, trying to fit the wrong dentures into a patient’s mouth, and inflicting pain when clumsily cutting toenails (DHSS 1969, pp. 122–124). The Ely committee cautiously evaluated Pantelides’ integrity: despite being unreliable and mistaken at times, ‘he seldom, if ever, identified smoke in the absence of fire’ (p. 9). His allegations thus deserved serious attention. The committee’s analysis of Pantelides’ integrity resembled the Springfield Inquiry’s opinion of Davie.⁶²

The Ely committee upheld many of the complaints. Nursing care was ‘old fashioned, unduly rough and [of] undesirably low standards’ (DHSS 1969, p. 24). Staff who complained were victimised. The HMC was ineffective as a management body. Overcrowding (Fig. 7.1), understaffing, and deficits at all levels of administration were largely responsible for failings (pp. 127–133). Recommendations from Howe’s committee affected all aspects of hospital function. They included: employing more domestic staff so nurses could nurse; adequate time for nursing handovers between shifts; in-service training; creating better links with the surrounding community and with voluntary organisations; and publishing an information booklet for patients and their families (p. 115). The committee recommended instigating disciplinary proceedings against one charge nurse who ‘contrived complaints’ against other staff (pp. 55, 132), supporting the impression that dishonesty and victimisation of staff occurred in psychiatric hospitals. The committee also criticised the WHB, which needed to make greater efforts to achieve improvements (p. 132). In addition to local recommendations, Howe proposed wider ranging remedies. Notably, a better system of investigating complaints, a body to consider ‘complaints and disciplinary matters which had not been satisfactorily handled in some other way’ and a system of independent inspection (p. 133) aligned closely with proposals in Sans Everything (Abel-Smith 1967, pp. 128–135).

Fig. 7.1

Officials inspect a men’s ward at Ely Hospital, 1969.

Source: South Wales Echo, April 1969. ​Reproduced with permission from Media Wales.

Howe commented that it was a matter of speculation how long the situation at Ely would have persisted without Pantelides’ report to the News of the World (DHSS 1969, p. 123). Howe’s investigation lacked the logical fallacies of the Sans Everything inquiries, such as deference to seniority and discrediting witnesses because of their status and presumed personalities, rather than what they had to say. Malpractice was malpractice even if condoned by senior staff or due to overwork, understaffing or stress. Howe acknowledged the difficulties of the subject matter, especially categorising cruelty, as did the Springfield committee, and was ‘conscious of obscurity about the burden of proof to be applied and constantly aware of the risk of coming to unjust conclusions’ (p. 120). On several occasions the report described events as ‘probable’ (pp. 122–124), but steered towards ‘probably true’, whereas the Sans Everything committees in similar circumstances verged towards ‘probably false’.

The DHSS was embarrassed by the content of Howe’s report, especially when it came to light that the Ministry had filed deplorable reports about Ely three years earlier (Crossman 1977, p. 411).⁶³ The WHB described Howe’s report as ‘a devastating indictment not only of the hospital staff but of pretty well all concerned with it’, and informed the DHSS that ‘it is not suitable for publication’, on grounds that it was too long—83,000 words—and repetitious, ‘particularly in its treatment of the specific allegations’.⁶⁴ As with the Sans Everything inquiries, the DHSS requested an abridged version for publication. Howe undertook this, rather than delegate it to the WHB. By stylistic change, he reduced the length to 76,000 words, the ‘eleven twelfths’ (‘11/12’) version.⁶⁵ ‘Under pressure’ he also produced a 20,000-word summary, in which he referred to editorial interference, indicated that it did not do justice to the case (Hillman and Clarke 1988, p. 91) and noted that the DHSS and WHB sought to conceal damaging information.⁶⁶ The summary would whet the appetites of journalists and lead to demands for publication of the full version. Howe would not bow to embedded attitudes determined to avoid negative publicity: he did not just ask for the full report to be published, as Polson did for St Lawrence’s,⁶⁷ but he fought for it.⁶⁸ Abel-Smith ensured that the full report and the 11/12 version got onto Crossman’s desk (Howe 1994, p. 42). Crossman regarded the report as ‘explosive’ and feared that if he did not publish at least the 11/12 version, he would ‘be at the mercy’ of Howe who ‘would be entitled to go on the tele and talk about the report which had been supressed’.⁶⁹ Crossman also knew that Barbara had regular contact with Abel-Smith so would probably know what was happening to the Ely Report, and he regarded her relationship with the press as a ‘terrible danger’ to the government (Crossman 1977, p. 727).⁷⁰ Crossman also had unpleasant recollections of his own family’s care, which could have made him more sensitive to the issues. In particular, his mother died in a poorly run nursing home: ‘Heavens its (sic) disgusting. I could almost smell the stale smell again, and think how odious it is, and it stirred all the feelings in me.’⁷¹

Critical of Robinson for his management of Sans Everything, Crossman, a shrewd politician, did not want to receive similar, potentially career-damaging, criticism by having his image maligned by the press (Cochrane 1990, p. 121). Crossman made his plan: ‘The report completely vindicated the News of the World story and I might as well make the best of it by outright publication. But I could only publish and survive politically if in the course of my statement I announced necessary changes in policy.’⁷² Before the announcement he briefed the RHBs, and the press, and promised an exclusive interview to the News of the World. He briefed Howe, who was delighted with the 11/12 publication plan. Howe modestly and honourably refused to join Crossman on television, because he wanted to remain as the independent chairman of the inquiry, rather than introduce party politics.⁷³

Crossman announced the Ely Report in the Commons in March 1969, eight months after Robinson announced Findings and Recommendations. The announcement, content, response and consequences were startlingly different. Crossman wrote in his diary: ‘I felt a great gulp in my throat when I started because I think I really do care about this, I do feel righteous and indignant about it, and I launched it out and read it and within 30 seconds I knew I had gripped the House.’⁷⁴ Crossman announced that most of the specific incidents of ill-treatment took place and victimisation of well-intentioned staff who made complaints was ‘odious and alarming’. The report, he said, ‘should be used at once as a basis for remedial action’, creating an inspectorate, protecting staff from victimisation, and improving long-stay provision for mentally handicapped people. Remedial action could prevent the report shaking staff morale. Crossman sent copies of the report to RHB chairmen, announcing his intention that it ‘shall be made a springboard for action rather than a setback for morale in the hospital service.’⁷⁵

Unlike Robinson, Crossman did not blame individuals but expressed a sense of collective responsibility, as nursing leaders, doctors and journalists had done earlier, and hinted at a revision of spending:

We all bear responsibility for leaving it there, and unless we think of these things without blaming others we shall not get them put right. Public opinion has to face it, that if we are spending vast sums, as we are, on making wonderful new hospitals for acute illness and acute surgery, we must bear in mind the hundreds and thousands of people in these other places.

The House supported Crossman’s proposals. Tom Driberg MP asked if the new inspectorate would make an early visit to South Ockendon ‘from which there have been some very disturbing reports’.⁷⁶ The press latched onto the plans for an inspectorate and the concerns about South Ockendon (Roper 1969; Anon. 1969b).

Baroness Beatrice Serota (Minister of State for Health and an acquaintance of Barbara’s in Hampstead) read an identical statement in the Lords. Lord Amulree referred to the government’s courage in publishing the report. Baroness Summerskill made the obvious deduction that if intimidation of staff who wish to raise alerts happened elsewhere, ill-treatment would be unknown to the authorities. Lord Segal, a medically qualified peer, commented on a sense of relief at the publication of the report: ‘These conditions have been known to exist for quite a long time…and have given rise to an enormous amount of uneasiness.’⁷⁷ The Lords accepted the Ely Report, in contrast to their rejection of Strabolgi’s allegations in 1965.⁷⁸ Strabolgi’s revelations then were too shocking to believe: as Spencer said during the documentary about Powick, people can react by shutting appalling situations out of their minds and rejecting them (World in Action 1968). Since 1965, engineered by Barbara, the media had drip-fed the politicians, professionals and public about abuse in hospitals, sensitising their outlook and expectations. The Ely announcement was within the bounds of government and public credibility and provoked constructive responses.

Publication of the Ely Report was a team effort. Barbara was a threat to the Labour government. Howe was highly respected, determined and had a fierce sense of justice. His biographers, Judy Hillman and Peter Clarke (1988, p. 91), regarded achieving publication of the 11/12 version as Howe’s ‘toughest and most formative challenge’ against the ‘Whitehall mandarins’. Abel-Smith, dedicated to the cause, had a foot in the AEGIS camp, knew Howe and was respected at the DHSS. Crossman reframed the deficits of the hospitals as a problem for society that could be dealt with, rather than blaming the patients and informants and portraying the situation as inevitable and insurmountable. Anthony Howard (1979, p. 11), editor of Crossman’s diaries, described his action to publish the 11/12 report, contrary to official advice, as ‘perhaps the bravest political action’ of his career.

Ely’s centrality to the process of reforming the psychiatric hospitals was due largely to its allegations being upheld, in contrast to similar allegations in Sans Everything being overturned. Webster’s view (1998, p. 80) that ‘the Ely Hospital scandal…suddenly precipitated long-stay hospitals to the head of the policy agenda’ is an oversimplification. AEGIS played vital roles in triggering the allegations, channelling Ely into the limelight and setting the policy agenda. Barbara breached the wall of NHS bureaucratic paternalism, secrecy and the myth of universal high standards of NHS care, Howe undermined the foundations, and Crossman took up the cudgel and began to demolish what remained. Barbara congratulated Crossman on his announcement and initiating remedies to improve the hospitals and complaints mechanisms. She recognised that Crossman sought to prevent his predecessor losing face at the same time as he called public attention to some particularly grisly aspects of the NHS. She wrote that the Ely Report ‘marked the end of the ostrich era. Doubtless the old bird still lingers, its bad habits dyed in the feather; but its days are numbered’ (Robb 1969). The Ely Report vindicated Barbara, but there was no official acknowledgement about the way Sans Everything was swept under the carpet. Barbara did not seek an apology and placed clearing her name as unimportant relative to succeeding with her campaign (Robb 1970). She shifted from working outside government circles to being an inside lobbying advisor to the DHSS (Cochrane 1990, p. 140).⁷⁹

After Ely, Crossman took particular interest in the subnormality hospitals (Crossman 1977, pp. 607, 664, 726).⁸⁰ This partly detracted from AEGIS’s original concerns. The imperative to prevent stripping and other indignities encountered by older people moved away from centre stage. However, Barbara’s demands for an inspectorate, ombudsman and improved complaints procedures shifted into the formal policy arena when Crossman set up the Post-Ely Working Party (PEP). Crossman or Serota chaired the PEP. Members included Howe, Townsend, and senior doctors, nurses and local authority representatives.⁸¹ Abel-Smith, AEGIS, the PA and NAMH fed into it.⁸² It set the foundations for Better Services for the Mentally Handicapped (DHSS 1971a), a strategy to provide community services as an alternative to hospital accommodation.⁸³ Some critics, however, such as Townsend, regarded these proposals as little better than the Royal Commission (1957), and the local authorities, charged with much of the work, were unenthusiastic (Sheard 2014, p. 315). The PEP also used information gleaned from Barbara’s correspondence with the Council on Tribunals⁸⁴ and discussed a broad range of challenges, including how to handle complaints from staff.⁸⁵

Crossman demonstrated his intention to take the issues seriously by openly visiting long-stay hospitals, thus encouraging the press to report on them. He described Chelmsley Hospital, Birmingham, as ‘Bleak, and oh their lavatory architecture, ghastly buildings, and ghastlily overcrowded; I have never seen overcrowding like it, beds absolutely jammed together.’⁸⁶ Coleshill Hospital nearby, was more modern but had seventy-two beds in a ward designed for thirty-six, with only three toilets (Squire 1969; Anon. 1969d). Birmingham RHB, a remaining ‘ostrich’, was horrified by the publicity caused by these visits and blamed Crossman’s discoveries on press leaks.⁸⁷ To prevent recurrences, the RHB clamped down on its members who now had to seek permission to publicise matters that had not been finalised by the Board. The RHB chairman rationalised his decision as a way to control when, rather than if, information was passed to the public (Adeney 1969), but his actions gave the impression that the RHB preferred to keep problems secret. Crossman negotiated with and cajoled hospital authorities in Birmingham. He reflected in his diary:

My crusade, and I’m going to win this now, there is no doubt about it, in the Birmingham area they couldn’t go on, they are going to concede, they are going to do some building…we didn’t come to conclusions, but I pressed on rations, I pressed on personal possessions, I pressed on dealing with overcrowding.⁸⁸

Publicity probably assisted Crossman to pledge more funding to long-stay hospitals, backed by public opinion. In 1970, he reallocated £4 million to them,⁸⁹ hardly enough, but it was a start (Crossman 1977, p. 726).⁹⁰

More Inquiries

Other allegations of abuse, including at Whittingham, Farleigh and South Ockendon hospitals preceded publication of the Ely Report, although the public inquiries to investigate them commenced after it. As with Ely, Barbara’s work influenced the course of these inquiries and the implementation of recommendations. In particular, Sans Everything triggered the nurses’ allegations at Whittingham (see Chapter 5 pp. 162–164), AEGIS helped develop NHS guidance from recommendations made in the Farleigh Report (Anon. 1971b; 1971c; DHSS 1971c, Appx.5),⁹¹ and behind-the-scenes, Barbara ensured that events at South Ockendon received appropriate attention (Anon. 1974a).

The inquiry at Farleigh demonstrated unhelpful senior staff behaviours and victimisation of complainants. In 1968 Greta Saunders, a new nurse, alleged ill-treatment of patients. From the timing, it is conceivable that Sans Everything influenced her disclosure. The hospital’s chief nurse did not investigate because he ‘thought her an emotional young woman’. He sacked her but offered to reinstate her if she withdrew her claims (DHSS 1971c, p. 22), hardly an ethical way to confront alleged deficits of care. Greta Saunders informed the RHB of her concerns, but still nothing was done. Her husband, Kenneth Saunders, then a student nurse at the hospital, was suspended soon after, for alleged ‘insubordination, using bad language, and failing to obey instructions’ (Fishlock 1969). When a senior doctor and the hospital secretary questioned him about his behaviours, details about the allegations of ill-treatment emerged, and the hospital secretary informed the police. Subsequently, three nurses received prison sentences, each between two and three years, for offences of ill treatment contrary to the Mental Health Act (DHSS 1971c, p. 3). Notably, one of the nurses convicted was allowed to continue working when Mrs Saunders was dismissed (Robinson 1970; DHSS 1971c, p. 22). The committee of inquiry explained: ‘The nursing staff fell into two incompatible groups. The one, tough minded, experienced and in control. The other younger, new to the hospital and at the bottom of the nursing hierarchy. The first group was implicitly trusted, the second disregarded’ (DHSS 1971c, p. 20). This contributed to Abel-Smith’s opinion that complaints against Mr Saunders were probably ‘framed’ by senior staff.⁹²

The criminal trial delayed the Farleigh Inquiry. The committee of inquiry was alarmed by staff ‘stating, or restating, their views that no ill treatment of patients had ever taken place at Farleigh. This was a most unhelpful and unfortunate attitude to adopt in the face of many findings of guilt by a jury’ (DHSS 1971c, p. 24). Alongside the contradictory evidence given at Shelton and Howe’s findings of ‘contrived complaints’ at Ely, this highlighted the lengths to which staff could go to justify their work patterns and attempt to protect their reputations (p. 19) and pointed towards a probable oversight by the Sans Everything inquiry committees. The report added another, worrying, dimension: Farleigh was small with 270 patients (p. 3), indicating that abuse did not occur only in large hospitals. Like Ely, the Farleigh Report recommended national policy changes to ensure better standards of care and complaint management (p. 23; Roper 1972).

Staff also raised concerns at South Ockendon Hospital. In December 1968, Barbara received several pages, posted to her anonymously, that appeared to be from the official record of Beech Villa from the night of 16/17 June 1968. They recorded severe injuries to Michael Pardue, a twenty-three-year-old ‘subnormal’ patient. The nursing report did not mention disturbances on the ward that night, nor identify the cause of the injuries but noted that all patients ‘appear well and comfortable’. The hospital reported the injuries to the police and an internal inquiry resulted in the dismissal of one nurse. However, the conflicting statements in the night report suggested a coverup by night staff and unquestioning acceptance of the report by day staff. The hospital would not allow any public scrutiny of the incident: for them, the matter was closed. Barbara and her AEGIS advisors agreed that if the original reports were genuine, then the internal inquiries into the circumstances of Pardue’s injuries were inadequate.⁹³ Thus began another hospital scandal that continued to occupy Barbara until 1974. That an anonymous member of staff sent the original report to Barbara testified to her reputation of being able to handle staff concerns sensitively. Her independent position reaffirmed the need for an autonomous ombudsman who staff could approach directly.

Other baffling disasters on the same ward included the death of patient Robert Robinson. David Burles, another patient, was accused of his manslaughter, and at trial was found ‘unfit to plead’ (Anon. 1969c). This verdict designated him a criminal with an order for long-term detention in a hospital, and implied that no other perpetrator need be sought. That contrasted with a verdict of ‘not guilty’, which would have meant that the search for the perpetrator continued (Whitehead 1971). The difference between the two verdicts was poorly understood, and Barbara Castle MP had to explain it to Keith Joseph.⁹⁴ The ‘unfit to plead’ outcome alarmed Barbara Robb, who, through Abel-Smith, approached Howe. Howe took the case to appeal, which quashed the verdict, and found Burles ‘not-guilty’ (Anon. 1972). By implication, the perpetrator was still at large, but the authorities did nothing further to find him.

In 1970, Barbara sent her own dossier of evidence to the Director of Public Prosecutions, who passed it to Joseph. He did not respond, so Abel-Smith contacted Howe, (by then a MP): ‘Barbara Robb has collected together a great file of facts and is having considerable difficulty in getting them properly investigated. I was wondering whether you could help.’⁹⁵ Howe called Joseph’s attention to Barbara’s ‘friendship with the press, and the fact that, if the press were gagged, there would be publicity about it. Joseph said he would look into the matter.’⁹⁶ The South Ockendon Inquiry began in 1972.

Six years after the alarm was raised at South Ockendon, Barbara Castle (Secretary of State for Social Services, 1974–1976; Labour government under Harold Wilson), published the inquiry report (DHSS 1974a). Announcing it in the Commons, she paid tribute to Barbara Robb ‘who made such strenuous and successful attempts to ensure that the events which had occurred were not swept under the carpet’ (Anon. 1974a). The day after the announcement, the Times carried seven separate reports on South Ockendon, including one on the front page, emphasising the need to provide better facilities for mentally handicapped people and better management of violence in hospitals (Anon. 1974b). South Ockendon added another worrying dimension: it was a new hospital, and recently had £1 million spent on it.⁹⁷ Thus new buildings, like small hospitals, were not immune from abusive practice.

Following South Ockendon, and linked to recommendations from the Farleigh Report, Barbara collaborated with the Royal College of Nursing (RCN), NAMH, RCPsych and others to develop the first NHS guidance on managing violence in hospitals.⁹⁸ The initial draft focussed on staff education about causes of violence, observing warning signs, seeking help, documenting events, and ensuring that nurses maintain correct professional relationships with patients. AEGIS’s critique added more person-centred ideas, including the importance of team working, preventing violence, providing a ‘therapeutic milieu’ for patients, and pointing to the need to specify techniques included under the term ‘restraint’.⁹⁹ Creating the guidance was frustratingly slow. The final document was published around the time of Barbara’s death (DHSS 1976).

‘The Answers’ Proposed in Sans Everything: Outcomes

The main ‘answers’ given in Sans Everything, to improve the situation of older people in psychiatric hospitals, comprised creating comprehensive psychogeriatric services; establishing a NHS inspectorate, an ombudsman and complaints procedures; and providing housing and raising revenue through Project 70. They met with various levels of success by the early 1970s.

At Friern, change was slow. In 1969, four years after Barbara visited Amy Gibbs, Crossman visited Friern. He described its ‘deplorable atmosphere’ compared, for example, to Littlemore Hospital under Mandelbrote’s leadership. Friern had the same hospital secretary and HMC chairman as in 1965 and still lagged behind expected standards of good practice.¹⁰⁰ Soon after Crossman visited, Peggy Jay, a Labour ‘grande dame’ from Hampstead (Harrington 2008), became chairman of the HMC.¹⁰¹ Barbara was impressed with Jay.¹⁰² By 1971 she had recruited 180 domestic staff so that nurses could nurse rather than do domestic chores, and she had overseen the renovation of six wards. Nevertheless, there was still much to do. A Daily Mail reporter, Douglas Thompson, worked as a nursing assistant at Friern and reported on his experience. Unlike earlier Ministry and RHB condemnation of journalists such as Shearer at Harperbury, Crossman accepted the Mail’s approach: ‘naturally the hospital staff are furious with the Daily Mail for smuggling a reporter into Friern.…But I fear this is the kind of trick which must be used in order to shake the public out of its apathy’ (Crossman 1971).

In 1972, the General Nursing Council (GNC) noted patchy improvement at Friern compared to its visit in 1967. There were more nurses of all grades, a greater emphasis on rehabilitation, and better staff morale, including on older people’s wards. A third-year nursing student contrasted his experiences on one ward, two years apart. In 1970, ‘it was considered a “heavy” ward with the majority of psychogeriatric and infirm patients confined to bed, frequently incontinent and a considerable number suffering from pressure sores.’ In 1972, ‘the same patients are all up, none have pressure sores, and incontinence is kept to a minimum by a habit training programme’, a well-tried effective proactive intervention. Contrary to Robinson’s and the RHB’s fears that bad publicity created low morale, in line with Crossman’s views, when deficits were addressed and the authorities supported change, morale and staffing improved.

On a national level, Crossman implemented his plan for a hospitals’ inspectorate, the Hospital Advisory Service (HAS), soon after the Ely Report. Opinions varied on the need for it, including among the medical profession. The BMA Joint Consultants’ Committee (JCC) canvased responses from the Medical Royal Colleges, indicating diverse opinions, including strong opposition. The Pathologists said that the HAS had little relevance to them and would not be very useful, and that ‘resources hitherto directed to other purposes of the NHS would be taken up in correcting revealed deficiencies in mental and geriatric hospitals.’¹⁰³ The Royal College of Physicians of Edinburgh regarded it as ‘sinister’ and that ‘advice’ might become ‘instruction’.¹⁰⁴ Representative bodies of psychiatrists supported it, proposing that it should be established in all hospitals in line with other policies that mental illness should be provided for in the same way as physical illness.¹⁰⁵ The chairman of the JCC, Sir John Richardson, a physician at a prestigious teaching hospital, disagreed. He stated that a NHS-wide plan was unsupportable: ‘The psychiatric hospitals are a special case.’¹⁰⁶

The Daily Telegraph commissioned an article from Barbara (Robb 1969).¹⁰⁷ She was enthusiastic about the HAS, which would be Crossman’s ‘eyes and ears’,¹⁰⁸ but she also had reservations. Her concerns included that, if set up by the DHSS, the HAS might not be sufficiently independent: it might function better as part of a NHS ombudsman service. Ways to protect nurses and overcome their fear of victimisation were particularly important if the HAS were to feed back fully to individual hospitals. It would need to see all parts of the hospitals, not just those that the HMCs wanted it to see. Barbara was also sceptical about the director of the HAS, Dr Alex Baker. Before being appointed Senior Principle Medical Officer at the Ministry in 1967, he was ‘medical administrator’ at Banstead Hospital which was implicated in Sans Everything. In 1990, he recalled his time at the Ministry and the instruction given to him that his ‘first duty was to protect the Minister, i.e. to make sure that any advice, or anything the Minister said, was in keeping with accepted policies and would not lead to criticism in Parliament’ (Baker 1993, p. 200). He would need to break with that instruction to establish an independent inspectorate.

Crossman, anxious about Barbara’s influence through the media, sought to placate her. He and Serota invited her to meet Baker over lunch at the House of Lords. The meeting was initially tense. Barbara noted: ‘poor Dr Baker was as outraged at having to discuss his problems with me as I was to say anything to him.’ Nevertheless, they discovered common ground, discussion was lively, and revealed much about the challenges faced by the HAS and within the DHSS, including an extreme lack of lateral thinking among the department’s civil servants. Baker described: ‘everyone was digging his own little hole, straight down, and getting embedded deeper and deeper in it’, and Barbara added, ‘and what is more they’re not even digging it with spades. They are using tiny little trowels.’¹⁰⁹ Crossman, offered an alternative unflattering description of his department: they were ‘pen pushers’ and ‘the only thing which corresponds to them I should think in British History is the old Colonial Office which used to run the Empire from inside the Ministry’.¹¹⁰ The DHSS might no longer be an ostrich with its head in the sand (Robb 1969), but lateral thinking and effective communication were alarmingly weak. Barbara left the meeting and, ‘As we shook hands Mr Crossman said, “So we’ve met—at last!” We had—and for me it had been fun.’ ¹¹¹

The HAS visited many hospitals with long-stay wards in England and Wales, and found good and bad practice. Standards of communication varied, at all levels in the hospital, from senior management to day-to-day care of patients. In many large psychiatric hospitals, staffing levels were the same on wards for younger active psychiatric patients requiring less nursing care as on those for frail and dependent older people, who often had nursing needs more in line with patients in geriatric wards of general hospitals that were better staffed (DHSS and Welsh Office 1971, pp. 2, 25). Baker’s first round of visits targeted known trouble spots. The HAS annual reports anonymised hospitals but described situations similar to those at Powick, where elderly patients:

sleep, eat, excrete, live and die in one large room. As would be expected, under such conditions, the wards will be quite sordid with foul smells, and all kinds of personal activities and distress publicly exposed. Sometimes the nurses concerned seem to become so hardened to the sight, sounds and smells of this type of accommodation that they seem unable to realise the impact on first visitors, and indeed on new admissions. Doctors therefore may continue to admit to these hospitals and maintain this type of degrading situation (NHS 1972, p. 26).

Thus problems were particularly evident to newcomers. Baker was determined to listen to them because valuing them would help reduce victimisation. The HAS made constructive suggestions, such as encouraging community psychogeriatric nurses to treat patients in their own homes (NHS 1974, p. 31).

Many staff found the HAS visits helpful in understanding and solving problems,¹¹² others did not:

we had been hospital advised. They arrived in the middle of a strike…they said, well, we’ll try to make it as gentle as possible. So we had our week. They found 25 things wrong which we knew about, and as my new hospital management said, 23 of them had financial implications. How do we set about that? And they said, well, let’s start on the other two. ¹¹³

If managers ignored the HAS reports, they were open to criticism from the RHBs and DHSS,¹¹⁴ although at least one RHB also ignored HAS reports, irritated that the HAS could recommend changes without providing money to implement them.¹¹⁵ Overall, the credibility and official status of the HAS raised awareness of service inadequacies and led to changes within the hospitals. However, the magnitude of the problems, including the need to improve the wards and modify staff practices within a conforming rigid hospital culture, precluded rapid transformation. Particularly important, the HAS ensured that the responsible authorities officially endorsed frank discussion about NHS quality of care.

The HAS impacted on two other Sans Everything ‘answers’: Project 70 and comprehensive psychogeriatric services. The HAS described ‘Dumping Syndrome’, the tendency to place ‘rejects’ from the community in the psychiatric hospitals (HAS 1971, pp. 20–21). This reignited Project 70 ideas, to create housing estates on the sites of psychiatric hospitals, advocated by AEGIS since 1966 and rejected by Robinson (Anon. 1966a).¹¹⁶ Independent from AEGIS and Project 70, Lord Hayter (1972), in a letter to the Times, drew public attention to the possibility of building on hospital land, and MIND (the campaigning name adopted by NAMH in 1972 (Mind 2016)) took up the theme in 1975.¹¹⁷ Project 70 was ahead of its time. Building homes on psychiatric hospital land and refurbishing hospital buildings for domestic housing became common in the 1990s. By then, in a consumer-led housing market keener to purchase than to rent, the original financial model of Project 70 was not implemented. After Friern closed in 1993, like many similar hospitals, the estate was sold to a housing developer.

The HAS influenced the development of psychogeriatric services, in conjunction with new enthusiastic psychogeriatricians who had forged links with the DHSS. The blueprint Services for Mental Illness Related to Old Age (DHSS 1972) provided psychogeriatricians with clear objectives and a baseline for negotiating future provision (Hilton 2008, p. 304). As earlier, recommendations were permissive and lacked dedicated funding, but they provided a timely mandate for clinicians beginning to develop, lead and improve services (Arie 1973). A nucleus of enthusiastic psychogeriatricians began to meet, including Bergmann and Pitt (previously in Enoch’s study group), and Arie and Whitehead, all at least indirectly influenced by AEGIS. The group grew and in 1973 became the RCPsych Special Interest Group for the Psychiatry of Old Age (GPOA).¹¹⁸ The GPOA (in 2017, a RCPsych Faculty) aimed to promote good practice by sharing experiences, developing services, training staff, encouraging research, exerting pressure on government and other bodies, and commenting on all matters relating to the mental health of older people.¹¹⁹ In many ways it adopted and broadened AEGIS’s initial ideals of dedicated and proactive mental health services for older people.¹²⁰ However, Barbara was less prominent publicly, and the GPOA overlooked its AEGIS inheritance.

Despite more professional and government interest, change was slow, as in other ‘low-tech’ specialties that overlapped with social needs. In 1971, the Times reported that the amount of home help provided by most authorities ‘was derisory’, and that the ‘geriatric service must become the top medical priority’ because delays would only add to longer-term costs (Anon. 1971d). Age Concern (now Age UK) and MIND carried out a survey of provision for older people in psychiatric hospitals (MIND 1973). They identified important deficits, including inadequate assessment facilities, ‘wards of nearly 50 deteriorated and incontinent patients in the care of four nurses’ and staff discouraging visitors. The DHSS had set no timetable for transferring older people from psychiatric hospitals (p. 7), an obstacle to longer-term planning. DHSS-led mental health meetings tended to consider older people’s services peripheral to their main business (Cawley 1973, p. 4) and postponed discussions about them (DHSS 1974b, p. 12). MIND questioned the DHSS’s commitment to psychogeriatric services (MIND 1973). Prioritising older people would be hard to achieve, despite the need and enthusiastic clinical leadership, because financial constraints, competing NHS and social care priorities, stereotypes about older people and low expectations about their health, militated against it. Nevertheless, dedicated psychogeriatric services expanded, from about six in 1966 to 120 in 1980 and then across the entire NHS (Arie and Jolley 1999, p. 262). Experience in the HAS whetted Baker’s own appetite to work in psychogeriatrics, and when he stepped down after four years as HAS director, he opted to specialise in the field (Baker 1993, p. 204).

As well as contributing to establishing the specialty of psychogeriatrics, AEGIS made many broader contributions to the NHS, including towards creating the office of ombudsman (MoH 1968c; DHSS 1970). The Council on Tribunals advised on robust procedures for this role, prompted by Barbara’s complaints to them.¹²¹ Nurses welcomed the proposals (Anon. 1969a). Similar to establishing the HAS, opinions differed in the medical profession, which was overall conservative when considering changes that it perceived would affect its autonomy. The BMA opposed an ombudsman to whom patients could complain directly, on the grounds that it would destroy the ‘trust, respect and mutual rapport’ that characterised the doctor–patient relationship (Anon. 1970a). Whitehead (1970) took an alternative view, criticising the ‘usual biased, illogical, and egocentric claims…that hospital staff are better at investigating themselves than anyone else’. The Lancet (Anon. 1970b) endorsed Whitehead’s view: ‘For once, cannot the profession shake itself free from its occupational obscurantism?’. Joseph announced plans for the ‘Health Service Commissioner’ in Parliament in January 1972,¹²² with intentions to formalise the role in the NHS Reorganisation Act. During early readings of the reorganisation bill, Barbara and Strabolgi campaigned for, and achieved, amendments to ensure that staff who complained on behalf of a patient were allowed to go straight to the ombudsman, thus bypassing the internal hospital hierarchy and helping overcome concerns about reprisals.¹²³

AEGIS’s proposals for improving NHS complaints mechanisms (Abel-Smith 1967) received prompt initial attention, but conclusive outcomes were tardy. DHSS research in 1969 corroborated evidence about victimisation of staff and patients who made complaints, and that NHS investigations often left complainants dissatisfied and without knowing how to take the problem to a higher authority. The DHSS report incorporated evidence from voluntary bodies ‘not confined to the less reasonable organisations’, which it did not name.¹²⁴

The DHSS and Welsh Office (1973) appointed the Davies Committee in 1971 to review complaints procedures, the first comprehensive review in the history of the NHS. The Committee included Applebey and Shearer, social scientists and health service professionals (p. iv). It acknowledged the role of the scandals, particularly at Ely, Farleigh and Whittingham, which ‘by themselves would have amply justified our appointment’ (p. 3). It took evidence broadly, including from most HMCs, AEGIS, the Council on Tribunals, the BMA, and from 1,000 other organisations and individual members of the public, indicating a high level of concern (pp. 112–113). It produced a twenty-six-page code that covered all aspects of complaint management, including guidance for chairmen of inquiries and recommendations to protect staff who feared victimisation. The code endorsed many of AEGIS’s suggestions (e.g., pp. 125, 158). Doctors disliked the recommendations but patients’ groups, including the PA, supported them. Implementation was slow, related to the relative lack of power of patients’ groups compared with professionals (Mold 2012, p. 2034). Only in 1985, after a House of Commons Select Committee, did the Hospital Complaint (Procedure) Act make it compulsory for hospitals to establish procedures for handling complaints (Mulcahy 2003, p. 41).

Barbara, Opponents and Allies

Many people influenced the course of the AEGIS campaign. Within the higher ranks of NHS management, three stand out: Robinson, Hackett and Crossman. Their personal influence was huge, but at times it is difficult to fathom out the reasons for their course of action. Robinson and Hackett shared an unchallengeable belief in the adequacy of NHS long-stay provision. Their attitudes matched those of other establishment figures, such as chairmen of the Sans Everything inquiry committees. In contrast, Crossman’s perspective was closer to that of AEGIS and was associated with steps to improve provision.

Robinson did not publish a memoir and there are no substantial biographies. His entry in the Oxford Dictionary of National Biography praised his achievement of remaining popular with the government and the medical profession and contributing significantly to developing the NHS, such as by negotiating the general practitioners’ (GP) charter (Jeger 2004). A medical journal (Anon. 1965), based on an interview with an anonymous ‘member of the Government’, described him in glowing terms: ‘He wants to provide the sick with the most humane and effective means of getting better’ and ‘he is roused to high indignation by injustice, unnecessary suffering, exploitation of the weak…but indignation does not drive him to personal quarrels or enmities.’ Obituaries may be biased, tending to praise the deceased, but in the absence of other biographical sources, Robinson’s requires consideration. The obituary in the Independent (Dalyell 1996) praised Robinson unconditionally for his firm adherence to socialist principles, profound understanding, good judgement and expert knowledge. It cited surgeon Sir Roy Calne, who described Robinson as ‘one of the few Ministers of Health that the medical profession have liked’, because of his ‘transparent compassion and his understanding of the profession.’

Praise for Robinson from GPs and surgeons did not concur with psychiatrists’ and social scientists’ experience of him. Enoch, for example, described him as ‘hardworking, but defensive’, rather less impressive than some of his predecessors.¹²⁵ In 1969, Townsend criticised him for discrediting Sans Everything because, by doing so, he deferred the possibility of major reform of the psychiatric hospitals.¹²⁶ Townsend also commented that he failed to promote better mental health services for which he argued previously (Robinson 1958), and that he ignored the authoritative work of experts, including Russell Barton, Martin Roth, Norman Exton-Smith and Doreen Norton, about the mental and physical health of older people (Anon. 1968e).

Abel-Smith and Rolph tried to fathom out the reasons for Robinson’s hostility to the situation on the long-stay wards and to Barbara, AEGIS and Sans Everything.¹²⁷ Rolph (1968) thought that his complacency was ‘a mask for anger’, but could not work out the cause for that. Crossman claimed to have identified a cause that stemmed back to Barbara’s student days: Robinson’s wife, Elizabeth, was an alumna of Chelsea College of Art, contemporary with Barbara, Brian and Strabolgi (Cochrane 1990, p. 397),¹²⁸ and at some point a personal disagreement arose. Barbara and Crossman discussed this when they met in April 1970, a dialogue that Barbara rapidly committed to paper:

BR::

What can I tell the press?

RC::

Tell them that I will not investigate the White Paper but will investigate the hospitals. The White Paper arises out of a family quarrel.

BR::

What are you saying?

RC::

Well, it’s linked with a family quarrel.

BR::

What family are you talking about?

RC::

You and the Robinsons.

BR::

I beg your pardon, Sir. I am not related to or connected in any way with the Robinsons.

RC::

They’re old friends of yours.

BR::

I have known Elizabeth Robinson for a long time. I have nothing whatever against her. I have only met Kenneth twice.…

BR::

Am I to tell the press that you regard the White Paper as part of a family quarrel between the Robinsons and the Robbs?

RC::

No, you are not to tell the press. If you were warm-hearted you wouldn’t be bothering about the White Paper. You’d be concerned only about investigating the hospitals.

BR::

Can’t you ask one of our mutual friends about the state of my heart?

RC::

I’ve discussed you with Bea Serota. When things go wrong and we’re very depressed, she and I often cheer ourselves up by asking one another what you would say about the problem.¹²⁹

The dialogue revealed as much about Barbara and Crossman as about Robinson. It demonstrated her wittiness, her uninhibited confidence to contest people in authority and her immediate response to ‘tell the press’. It also indicated Crossman’s characteristic frankness, and a mixture of impertinence, humour and respect when he described Barbara’s effect on Serota and himself. Crossman described the same meeting in his diary. He said that Sans Everything

was her pound of flesh to destroy Kenneth Robinson. I said it is a pity to have a personal squabble, (this is the only time she got really angry) because of course it is true she and Elizabeth Robinson were bosom friends together until Kenneth Robinson failed to give Mrs Robb’s husband the key appointment he thought was his due, whereupon she turned against the Robinsons. At least that is what Brian Abel-Smith tells me and I can well believe it.¹³⁰

The likelihood of Robinson having a post to offer Brian, an artist, seems remote. In an internal memo at the DHSS, Abel-Smith referred to the importance of his confidential discussions with Barbara,¹³¹ but whether he broke a confidence or if Abel-Smith was in fact Crossman’s source of information or if there was any foundation to the rumour is unknown.

Despite a reputation for his interest in psychiatric hospitals,¹³² Robinson was complacent about the older people in them. Crossman tried to justify Robinson’s approach, speculating that he took little action on their behalf because he expected that the ‘new hospitals would have a fair proportion of geriatric and psychiatric beds’,¹³³ which would solve the difficulties. New facilities in most places, however, were beyond the horizon. Crossman (1977, p. 727)¹³⁴ did not criticise Robinson in public but wrote in his diary: ‘he mishandled her [Barbara] and instead of treating Sans Everything sensibly Kenneth set up committees of investigation into her charges and then published a white paper as a non-controversial document to answer her, which it didn’t. This left a very dirty impression.’ Robinson seemed oblivious to public opinion and he misjudged Barbara’s tenacity and strength of character, even in the face of public humiliation.¹³⁵ Crossman (1977, p. 134)¹³⁶ stated: ‘I feel he has done nothing whatsoever to silence Mrs Robb because the bare picture [that psychiatric hospitals are adequate] is not terribly convincing.’

In an oral history interview in 1991, Robinson clung to the conviction that his stance towards Sans Everything was correct, and still sounded exasperated by Barbara:

I thought at the time and I still think, that it was very much exaggerated and emotionally weighted. She was a very strange and almost hysterical woman…maybe I resisted it too strongly, but this was a terrible slander on the mental nursing profession.…It conveyed the impression that they were a whole lot of sadistic people who were only concerned to make life hell for the patients. Maybe I over reacted, I don’t know.¹³⁷

Robinson did not like Barbara, but whether an element of personal animosity fuelled a conflict about Sans Everything is unconfirmed. If Robinson behaved in the manner Crossman described, it was unprofessional.

Robinson and Hackett mishandled ‘Diary of a Nobody’ and Sans Everything, fuelling Barbara’s campaign. Both men were authoritarian and patronising. Hackett’s self-righteousness in the media, his hand-in-glove working relationship with Robinson (Hackett 1965b), his probable underhandedness with staff at Friern and his complicity with Friern’s shortcomings, did not enhance the well-being of patients, despite his claim to ‘guard and protect’ them (Hackett 1965a). Hackett and the RHB ignored criticism rather than using it to seek ways and resources to achieve improvements, a pattern mirrored by the Friern HMC. He was heavy-handed with staff who might spoil his, or his RHB’s, reputation. Hackett appeared unaware that belittling complainants, rejecting genuine concerns and accusing critics of ignorance and exaggeration, inhibited improvements and antagonised the public, some of whom saw through his methods (Field 1968). Others disliked his leadership style, including the distinguished advisory body, the South-East Economic Planning Council. Hackett was appointed its chairman while his brother-in-law George Brown was in a related role of Secretary of State for Economic Affairs. On the Planning Council he ‘upset a fair proportion of the leading academics, lay planners and men from industry…by a curiously unendearing brusqueness in the chair and a proneness to cut off respected experts in mid-exposition’ (Anon. 1967).

Hackett was knighted for services to the RHB and to the Planning Council (Anon. 1970c, 1970d). Undoubtedly some positive events happened in the region under his leadership, such as building and opening Northwick Park Hospital. However, one wonders how much his knighthood related to who he knew rather than what he did and how much he sought recognition for himself rather than benefit for those he represented, particularly the most vulnerable and stigmatised people in the psychiatric hospitals. Crossman described Hackett as ‘gloomy’ and a ‘bore’.¹³⁸ In Shearer’s words, Hackett was ‘an idle jobsworth’.¹³⁹

Robinson and Hackett contrasted with Crossman in their responses to Barbara and to the issues that concerned AEGIS. However, like them, Crossman also knew how to manipulate the system, revealed by his nicknames ‘Tricky Dicky’ (Cochrane 1990, p. 120) and ‘Double Crossman’ (Rolph 1987, p. 183). Abel-Smith (1990, p. 259) later reflected:

I’ve always been slightly puzzled…and never really satisfied myself as to why it was that Richard Crossman made this such a personal crusade.… it was definitely as much a personal crusade to try and get things right as it was for Barbara Robb to draw attention to what was wrong. Most people don’t realise the extent to which the change was initiated by Crossman, but he started a movement which, once the Department had got on to it, took on its own momentum. This was what a great minister can do. Long after he had died, the ripple effects of the whole thing were still going on. I don’t usually go for the ‘great man’ thesis in history, but he will be remembered, or ought to be remembered, as a rather unlikely person to have done something like this.

Crossman was more perceptive about Barbara’s determination and public influence than Robinson. Crossman described her as collecting ‘ammunition for an attack on us’,¹⁴⁰ and that

She is a dangerous woman because people go to her, people write to her, the most terrible stories about the hospitals are collected by her. She is always ready with some great scandal to break, and there are, God knows, enough scandals to break.¹⁴¹

On one occasion, on her way to meet Crossman at the Commons, an usher escorted her to his office. Barbara remarked to the usher that the Commons was a labyrinth, to which the usher replied: ‘and at the end of the labyrinth you meet the Minotaur.’ Barbara relayed the comment to Crossman during their meeting.¹⁴² Rolph (1987, p. 182) commented that Barbara’s sense of humour was ‘effervescent and mischievous…without ever giving offence’. Crossman said about Barbara: ‘I happen rather to like her.…it’s better for us to have her investigations useful and her on relatively friendly terms with me.’ He described her as ‘a curious little thing, terribly neat, precise, cold, venomous, with a certain serpentine charm’.¹⁴³

Crossman’s approach to NHS complaints contrasted with Robinson’s. Crossman gambled with his reputation by publishing the Ely Report, and survived, by committing himself to, and implementing, policy changes. When Crossman became a back-bencher in 1970, he returned to journalism, editing the New Statesman. He commissioned a series of articles, ‘Snakepits of the seventies’, which declared in large print on the cover of the New Statesman that in overcrowded ‘asylums’ patients were still ‘stripped of self-respect along with their personal property and clothes’ (Anon. 1971a). That was probably the nearest Crossman came to criticising Robinson in public for rejecting Sans Everything. At the end of the snakepits series, Donald Gould and Ann Shearer (1971) wrote: ‘To the medical profession’s shame, it was a politician, Richard Crossman, who made us take notice of the ugly state of the mental health scene.’ In view of his short period as Secretary of State (twenty months) it is likely that his impact would have been far less without Barbara’s groundwork, expertise and influence.

Comment

Many people including Townsend, journalists and psychiatrists, and organisations such as AEGIS and the PA, were not deceived by the ‘sacred cow’ image of the NHS as propagated by Robinson, Hackett and others in authority. Fear of adverse publicity about the NHS, and reproach by the Ministry to those, including the BBC, who spoke out, supported the notion that the NHS sought to protect its workforce from criticism, over and above the needs of patients. Robinson doubted that such a ‘conspiracy against the patients’ existed.¹⁴⁴ However, some in NHS positions of authority indicated little respect for the ‘man on the Clapham omnibus’, whether as patient or as healthy member of the public, corroborating Cohen’s What’s Wrong with Hospitals? (1964) and the PA’s and AEGIS’s experiences. This attitude jarred with changing public perceptions in the 1960s, such as about personal autonomy, paternalism, and public ownership of the NHS.

Various factors contributed to the authorities ignoring or concealing bad practice, including believing that the problems were insurmountable, hoping they would go away (MoH 1961, p. 98) or, more positively, that developments already under way, such as the Hospital Plan, would overcome them (MoH 1962, 1963). The Ministry believed that criticism of the NHS would lower morale and adversely affect staff retention and recruitment, but evidence suggests the contrary. The Ministry did not perceive that openness about deficits could inspire hope, raise morale, lead to improvements for patients and make mental health service employment more attractive. Fear of the effects of negative publicity was associated with defensiveness, deception and coverups in various NHS settings, from individual hospitals to the Ministry, including Robinson’s announcement of Findings and Recommendations in the Commons.

Sans Everything and subsequent inquiries revealed unhelpful patterns of NHS administration, such as seniors denying allegations of malpractice, rejecting criticism from those without formal qualifications and victimising whistle-blowers. Barbara, Abel-Smith, Baker, Crossman and Howe, discouraged, and probably lessened, these methods during the period covered in this chapter, such as by improving complaints guidance, creating the ombudsman and by the HAS encouraging staff to speak out. Nevertheless, ongoing vigilance remains necessary to prevent defensive responses creeping back (e.g., NHS 2016).

In 1969, the NAMH reflected that recent events marked a turning point in the history of the psychiatric hospitals:

When the history of the treatment and care of the mentally ill and subnormal in England in the twentieth century comes to be written, there will be a chapter devoted to the last 12 months.…

Everyone concerned may want to forget the causes célèbres—Sans Everything, Shelton, Ely, Farleigh—the public because it is distasteful, the government because it cries out for a massive reallocation of funds and the hospital service because it damages their image—but we believe that the time has come when everybody should be urged to remember, to think and to discuss a subject which inexorably will become a major medical, political and social problem in the ‘seventies’ (NAMH 1969, pp. 5, 7).

Barbara heavily influenced many aspects of this, publicly or behind the scenes, from supporting and encouraging individual nurses and doctors, to face-to-face meetings with the Secretary of State. Sans Everything inspired clinicians, such as psychiatrists Arie, Enoch and Whitehead, and nurse Peter Carter, later Chief Executive of the RCN, for whom ‘it made a life-long impression’.¹⁴⁵ The Ely Report took the policy proposals raised in Sans Everything beyond the walls of the mental illness and ‘subnormality’ hospitals into the broader NHS, including creating a health service ombudsman and better complaints processes. However, the effectiveness of top-down policies and guidance was, and is, variable, as with the stripping guidance in 1965 and complaints memorandum in 1966; committed clinicians who adopt a bottom-up approach dedicated to ensuring improvements in the care of patients and morale of staff (Arie 1971) are likely to increase the chances of policy success. Thus by inspiring individuals and influencing policy, Barbara, despite the odds stacked against her, achieved her goals. As Enoch reflected in 2015: ‘Her effect was far more than Robinson’s in the end.’¹⁴⁶ In Abel-Smith’s words (1990): ‘For one woman who had really very little background in the mental hospital area…to suddenly do so much in such a short period—and tragically, to die so soon—is a remarkable story.’