If Twitter has become the new barometer of the public mood, there were an awful lot of furious people watching TV last night. Most were effing and blinding at Britain’s Got Talent, or rather the lack of it, but for quite some time during and after the screening of Panorama on BBC1, indignance, rage and even tears appeared to be the order of the evening.
It isn’t often I start throwing metaphorical chamber pots at the television but if you haven’t yet seen ‘Undercover Care: The Abuse Exposed’ and don’t have too many throwable items nearby, this is surely a ‘must see’ piece of tele-journalism. It will have you foaming at the mouth. Here we have documentary evidence of cruel, callous staff supposedly offering care to vulnerable adults while actually doling out little more than institutionalised torture, bullying and assault.
Why does this happen?
It’s heartening to see the collective hive of Twitter so furious at the treatment of people who get precious little attention from anyone apart from those of us actually involved with learning disabled people or, like me, providing the training to help facilitate their care. But is it enough to simply tweat indignance about what we see on a secretly filmed expose? After all, by the time you’ve read this Panorama won’t be ‘trending’ anymore and we’ll all have gone back to ranting about BGT, Sepp Blatter, or Jeremy Kyle.
We may see some commentary in the left-leaning media as to how savage cuts to health and social care budgets are the inevitable precursor to many more instances of barbaric, privately run institutions like Winterbourne View. Well I can’t disagree with that point of view, and we’ll return to that theme later. But to really understand how ‘care staff’ come to be filmed aiming drop-kicks at learning disabled patients or acting out Nazi Officer fantasises in the faces of frightened young men, we need to dig a little deeper and go back a little further.
‘A Degrading and Odious Employment’
About seventeen years ago I published a research paper with a nurse colleague of mine called Chris Challoner. We had both worked in secure hospitals for some time, myself in medium secure units and Chris at Broadmoor Hospital. We were fascinated by the schism between two very different ideas of the term ‘nurse’.
The more public perception of the nurse was (and probably still is) the idea of the ‘angel’. The little girl who’d been given a toy uniform for Christmas with a big red cross on the front and a plastic stethoscope. She (for this remains a largely gendered profession) couldn’t wait to become a nurse. Having got her treasured qualification she guiltily scoffed chocolates on the Medical ward, the box of Quality Street left by just about every grateful patient as they left for home having enjoyed the tender ministrations of those ‘lovely’ nurses.
And then there was us lot. Much more testosterone, no nice uniforms, key-laden lanyards swinging from belts and certainly little in the way of a lifelong yearning to look after dangerous psychopaths behind electronic doors. We’d just sort of drifted into it, and with a bit of overtime it paid the bills. And our patients never left us chocolates.
Myself and Chris wanted to test whether nurses working in secure environments really were the sort of right-wing, Daily Mail reading lock-up merchants of the stereotype that abounded at the time alongside the notion of the ‘sandal wearing tree hugger’ found in more normal, open psychiatric units.
We were testing a stereotype and achieved what research nerds would know as a ‘null hypothesis’ – there was no statistically measurable difference between the secure unit nurses and those who worked in more ‘therapeutically inclined’ environments, at least on measures of responses to our standardised measures of political and therapeutic attitudes. But we did find out a few other things that didn’t show up in our number crunching, and which, I think, have a direct bearing on the horrors seen on last night’s Panorama.
Firstly, while doing a little research on the history of psychiatric nursing, we came across this little gem:
The evils arising from the generally indifferent character of attendants, and from the deficiency as to the resources they ought to possess, are so great that few things would benefit the insane more than devising some remedy for them.
Very topical. But this was written in 1847 by a Dr. John Connolly, Medical Superintendent at one of the Victorian Asylums, pioneering mental health reformer and a chum of Charles Dickens. It has often been said that psychiatry attracts both the best and worst of the medical professions. Mental health has never been a fashionable specialism, but does attract the intellectually curious doctor as well as those who got a medical degree but weren’t quite bright enough for a scalpel. And to some extent, the same could be said of some of those attracted to psychiatric nursing.
But Panorama featured a private hospital catering for a group of people whose care tends not to attract even the academic curiosity inspired by Bipolar Disorder or Anorexia. As a registered hospital, Winterbourne View provides secure care under the Mental Health Act for people with autism and other learning disabilities. Care doesn’t get much less glamorous than this. It’s a neck of the therapeutic woods which doesn’t attract the starry-eyed little girl with a plastic fob watch pinned to her nurses outfit.
Even a few decades before Dr. Connolly’s scathing attack on ‘attendants’, another Medical Superintendent was waxing lyrical on the same subject:
Although an office of some importance and great responsibility, the role of the attendant is held as degrading and odious employment, and seldom accepted but by idle and disorderly persons
John Haslam’s observations probably weren’t featuring in the 1809 equivalent of a Job Centre. The typical interview of the time was a quick twirl in front of the asylum boss to prove you were a) a bloke and b) a big bloke with muscles.
So hospitals dealing with learning disabilities and challenging, aggressive behaviour have hundreds of years of historical form in recruiting nurses/attendants who are more adept at ‘decking’ aggressive patients than providing any semblance of ‘care’. But two questions remain to be asked. Has anything changed, and what other reasons are there behind such appalling abuse?
A Question of Management
Our research was partly inspired by the ground-breaking 1979 documentary ‘The Secret Hospital’ which investigated the systematic abuse of learning disabled patients at Rampton maximum security hospital. Older readers may remember the horrifying story (among others) of a male patient with a particularly large penis who provided ‘entertainment’ for the nursing staff by way of a snooker table and a cue. If you didn’t see the programme you can guess the rest as I’m already traumatised by last night’s revelations.
As a separate but recent finding on the sometimes appalling state of elderly care in hospitals has shown, the NHS is certainly no grinning standard bearer of quality care. But last night’s damming evidence did make me think of the private sector organisations with whom my company now refuses to work. In these organisations we see ridiculously high staff turnover, with the few minimum wage staff who actually show some signs of competence being quickly promoted to management as a kind of ‘golden handcuff’. They leave behind a floundering workforce struggling with the demands of what are often difficult and challenging circumstances, often with a limited command of English and barely a passing awareness of the cultural norms and unspoken rules so important to working with vulnerable adults and challenging behaviours.
For our blacklisted companies (several of which were started by entrepreneur property developers suddenly made aware of something called ‘Supporting People’. Kerr-ching!) the level of training required to work with challenging adults is often summed up by the following management-speak: “Oh shit, we’ve got an inspection next month. Somebody book a course for Christ’s sake!” If anyone from CQC happens to be reading this, no. We cannot infer client abuse or malpractice from the comfort of the training room, but on at least one occasion my classroom suspicions have been proved well founded.
Fortunately, for every vision of Gothic Bedlam I come across in my travels, there are many more examples of very fine care providers who do actually commit to training and prioritise the support of staff who do what is a bloody difficult job. So why the difference?
Let’s return to the research study for a moment. Our data gathering involved travelling to various different NHS units. Acute psychiatry, drug and alcohol and secure units all came under scrutiny. We met the managers of each unit to discuss the purpose of the study, meetings which, with hindsight, told us more about the attitudes and therapeutic orientation of our sample than the wads of questionnaires and measuring tools we brought. The managers ranged from the bright and enthusiastic sorts who exuded a culture of care from every pore, to the sort of indolent, world-weary pen pushers who, then as now, are so sadly common in NHS management. We were there to measure the effects of therapeutic environment on our nurses, not the impact of management culture. But as we debriefed and analysed our data after each visit (let’s just call it having a pint before anyone asks) the parallels became obvious. The attitudes and therapeutic orientation of the nurses in each unit were far more a reflection of the management of that unit than the environment itself. In research nerd language, positive management correlated positively with positive patient care.
So we reach a conclusion that those among us requiring the most complex, skilled care are being left to the support of those who, often through no fault of their own, are most poorly equipped to deliver that care. This is not a mitigation for the water torture, assault, bullying and abuse of vulnerable people, but in my mind at least it’s a hell of a lot more satisfying to try and understand why these disasters happen than to simply press the ‘disgusted and appalled’ button on my Twitter account.
We’ve been left with a legacy of front-line care donated by a New Labour obsessed with installing layer upon layer of Blackberry wielding apparatchiks constantly on the look-out for the next strategy group or working party to fill that long post-lunch window. We’re left stripped of the coalface people not wearing suits, who are now in turn getting their P45’s leaving an ever dwindling workforce to deal with problems of mental health, autism and learning disability showing no signs of declining in either quantity nor complexity. Companies such as Castlebeck will be invited, along with the property developers and former used car dealers, to pick up the slack. So-called care providers will carry on using celebrity detox as a front to their profit-yielding minimum wage efforts at managing some of the most vulnerable, difficult and disturbed people in the health care system.
Thank you, Panorama. You may just have stopped the rot for a little while. Not for long, just a little while.
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