Normansfield: vacuum of management in the NHS.

Perhaps the most extraordinary, and certainly the most dis quieting, revelation offered by the Report of the Committee of Inquiry into Normansfield Hospital1 is that of a breakdown in the NHS's system of management. The vocabulary of manage ment?with its emphasis on monitoring and accountability?is shown to have been empty, incantatory rhetoric devoid of substance. The report convincingly demonstrates that if the situation at Normansfield had indeed been monitored effectively, if had been a determination to make those concerned accountable for their actions and policies, the explosion which precipitated the inquiry would never have happened. Some of the circumstances leading to the crisis were indeed unique to Normansfield, while others derive from the special problems inherent in caring for the mentally handicapped. But many of the more fundamental weaknesses in the system of management follow, as shall try to show, a pattern already evident in previous inquiries. The report therefore has some uncomfortable implications which go beyond this particular case?or indeed the field of mental handicap?and which are highly relevant for any future changes in the NHS's organisation. The strike which prompted the inquiry occurred in May 1976. This is when the nursing staff walked out, deserting their patients, so as to draw attention to their grievances against the consultant psychiatrist, Dr Terence Lawlor. But this was no sudden or unpredictable eruption, but rather the culmination of a long chain of events. The fact that the situation at Normans field had turned sour?and that the quality of patient care had deteriorated scandalously as a result?had long been known at all levels of the NHS's hierarchy of management. If ever was a preventable explosion this was it : to sum up the message of the report, this was the story of a train approaching a precipice with everybody concerned sitting on their hands, hoping that the worst would not happen. The report sets out some of the main incidents in the history of Normansfield. As early as 1972, Dr Lawlor was interviewed by three wise men, following disagreements between him and some of his medical colleagues. Their conclusion was that there has been a breakdown of the normal professional relationship. In 1974 followed a spate of resignations from the staff, a letter from the community health council to the area health authority expressing concern about standards of treatment, and a complaint from the chief nursing officer at Normansfield about Dr Lawlor's interference in nursing matters?so signalling the breakdown of the relationship between the consultant and the nursing staff which was at the root of much of the trouble. The same year a member of the regional health authority, Dr Ivan Clout, visited the hospital and, alarmed by what he saw, described it as a time bomb. In 1975 the CHC repeated its concern, further evidence of ill feeling between Dr Lawlor and the nursing staff was drawn to the attention of the AHA team of officers, and evidence of poor conditions continued to accumulate. In particular, a nursing officer from the DHSS reported, after visiting the hospital, I was greatly concerned that management was failing in its duty