Interview – the RCPsych 50 years ago in South West England

Dr Peter Carpenter (PC): Angela, I'm delighted that you've actually agreed to talk to us about life back in the 70s. I thought I ought to start with asking when did you actually start in psychiatry?

Dr Angela Rouncefield (AR): Oh, in 1963.

PC: Some time ago.

AR: Yes, yeah.

PC: And the college was forming in the late 60s, but I gather you were in North Wales during that time.

AR: Absolutely yes, yeah.

PC: So how did you get to hear of the College’s proposed model?

AR: I think from Professor Linford Rees who was Prof at Barts at the time, and Professor Ken Rawnsley, who was Prof at Cardiff at the time.

PC: And they presumably weren't too fond of what the College was proposing.

AR: They weren't fond at all of what the College was proposing, and they were finding it very difficult. It got very unpleasant I regret to tell you.

PC: Okay. So you got to join the group of junior doctors. How did you find out about that group?

AR: Almost certainly through Professor Linford Rees. I'm not sure whether he was at Barts or whether he was still at the Maudsley at the time.

PC: I have no idea I’m afraid.

AR: He may have still been at the Maudsley, I'm not sure.

PC: Okay, I was thinking, in that time, how did the group actually meet up? Because you didn't have email you didn't have phone easily. How did the group of trainees, how did you actually meet up together?

AR: Well, I was given the link to David Goldberg. So that was going on. The other thing was I also at that time knew another trainee who eventually became a professor. That was Jim Watson. So, I was in touch with him as well. And David told me that he was – with some others – organising a bus. This was the final meeting that we had in Plymouth. You see each time they seemed to try and hold the meeting further and further away from London in the West Country. In other words, putting it in the extremity of the country so it was very difficult for people from the north to come down. But it didn't work because, you know, we showed up at every meeting.

PC: So what did you want from the College at that time?

AR: Well, I'll make it simple. The College was mimicking the Royal College of Physicians and we felt that was a very bad system. That it was an old boys’ club, more or less. They only passed – no matter what people got in an exam – they only passed so many every year, which we thought was a pretty outrageous way of behaving, and to join the College you just had to pass an exam. You didn't have to give any other evidence at all. And we as junior doctors, especially some of us who'd had experience of being not in London or at the Maudsley or Bethlehem, that if you wanted to raise the whole standard of psychiatry throughout the country. If you had a curriculum that had to be followed and it was national and it was over a period of a minimum of two years, you had to have done with this curriculum, you couldn't sit your exam until you could give evidence about the training that you'd received. So this was to improve training throughout the country. And by that, we'd be raising the whole standard of psychiatry throughout the country. We thought it was very important to do this. We also didn't like this idea that only a certain percentage could pass each year, that it ought to be that if somebody had passed the exam, they passed the exam. We thought this was just a way of generating money for people to have to keep taking their exam. We thought this was quite wrong, so these were the issues that we had.

PC: So it was – I hadn’t really thought of that. So, basically you were wanting the College to actually have formal training schemes around the country and to inspect them.

AR: That's right, absolutely yeah.

PC: I hadn't thought of the fact that the College of Physicians was not doing that at the time.

AR: No it wasn't. At that time, of course there was the Royal Medical Psychological Association, the RMPA and very, very few junior doctors were members. It was quite difficult to get time off to attend the meetings. I was fortunate because as a junior doctor I was surrounded by people like Linford Rees, Ken Rawnsley and my immediate boss consultant had been at the Bethlehem and Maudsley and he was very keen, you know, on training he was already running a system at the North Wales Hospital to train junior doctors. So that was very, very good and through them I joined the RMPA, but I was very aware when I went to meetings that they were they were all consultants at the meetings, it was rare to have another junior doctor there.

PC: It's interesting because, as an aside, I've just been looking at the creation of the South West Division and it was created by Peter MacDonald who was the consultant at Dorset, and his argument was that the big central meetings were very inaccessible for junior doctors and having divisional meetings would enable junior doctors to attend.

AR: Right, right.

PC: So that's why the South West Division as the first Division of England and Wales actually happened.

AR: Yeah, yeah.

PC: Anyway, I'm very aware that the events about the creation of the College have been recorded in the book ‘150 Years Psychiatry’ and you recently made a fairly detailed video about it. So I'm pleased that the model that the trainees wanted arose and it won through. But I was interested in some other bits which weren't really discussed at that time. How did you find the College hierarchy when you actually discussed dissent?

AR: Well it was very threatening actually. I mean really threatening. There was an occasion which I personally wasn't at, but my colleagues that were in this group told me they were more or less lined up against the wall and told that if they didn't behave themselves they wouldn't be getting jobs in the future. It got to that. Very interestingly, when we met up recently, it turned out that those of us who are in that video, we all went to the States, we all got ourselves jobs in the States in case the worst happened. But, you know, that was very sad really, but that's the level it got to.

PC: Okay. When the College was formed, I mean, do you think you were actually welcomed into it?

AR: Well, whether my experience was the same as others, I don't know. But remember I already, you know, had these professors that agreed with what we were doing and were very, very supportive so I think I probably was shielded from quite a lot, but people like David Goldberg, who had been a junior doctor with Will Sergeant. I mean, I think he, you know, was really under threat and very unpleasant. But when the College actually formed, the people that had wanted to be president weren't successful in being president and their influence evaporated quite quickly.

PC: Okay.

AR: Because they hadn't got their way and so that that was good, that that's happened. I mean we were sad. We didn't want to be unkind to older colleagues, but unfortunately it had to happen.

PC: Yeah, okay.

PC: Okay. So in the end, do you think it affected you getting your consultant job, what you’d done?

AR: Well, interestingly, I actually – believe it or not – got my consultant job before the College was formed. I actually got it during the process. Very unexpectedly, although looking back, I suppose it wasn't. At the time when I got it, my boss encouraged me to apply because he said it would be really good experience for you to go through that process, never expecting to get the job. But when I look back on it – and I have to tell you – three people that were on the Appointments Committee were the people who were already supporting me. And I was the only woman that applied against about eight men. So you know, really, I have to say I was very fortunate that the men that I was involved with because Linford Rees and Ken Rawnsley jointly were supervising my research and then my own boss had worked with Linford Rees in the past. He'd been a junior doctor with Linford Rees, so I think I was really fortunate they were not against women at all. And I may have been almost appointed because I was a woman. I don't know, I hope not. I hope I was the best candidate.

PC: I'm sure you were.

AR: So in actual fact, it's just before the College where I was appointed. Very soon before the College was actually formed. Much to my surprise and delight I have to say.

PC: So you became a consultant at Bodmin in St Lawrence’s Hospital, and certainly from our initial descriptions and discussions about it, it’s clear to me it hadn't changed for many years, and the attitudes then that you met then probably reflected much of what had been happening for the last 50 years.

AR: Oh yes, absolutely yeah, yeah.

PC: So I wonder if we can talk a bit more about what St Lawrence's was like when you first joined it? Roughly, how big was it, do you reckon? How many patients?

AR: Oh, well over 1,000 beds and there was always empty beds. There was never a problem for a patient to be admitted.

PC: Okay, and on the wards, I mean, how individual was it? Was there any privacy there?

AR: There was no privacy and people didn't even have their own clothes. I was absolutely horrified by the lack of privacy. I mean, this sounds shocking, that you didn't even have your own knickers or your own underpants. I mean things were washed, don't get me wrong. That was one of the joys of the hospital. They had the most fantastic laundry and lots of patients worked the laundry. In fact, it was 90% of the laundry were the patients working there, working the laundry. So, the people’s clothes were clean but they didn't have their own clothes.

PC: And my normal experience is that then you found that they were often boil washed and they shrank.

AR: Yes things were shapeless and colourless and so it was very difficult for people to make themselves smart and attractive.

PC: Okay. And what was the food like?

AR: The food actually was very good, and in fact I I don't know if you know Camborne College at that time was one of the leading catering colleges in the country along with Torquay and Westminster. And St Lawrence’s was an absolute beacon for people training in catering for large numbers. So we always had placements from Camborne, so we were regularly inspected by the examiners. The food was excellent and a lot of the food was grown in the market garden and we had a farm at that time as well. So, a lot of the meat would have gone to the local abattoir and was local meat. The food was very good.

PC: I know the patients basically ran the hospital.

AR: Well, they did, they worked in every department.

PC: But when you went to the chronic wards, would patients still be sitting around a lot?

AR: It was a whole mishmash. The only division was between men and women. There was all female awards and all male wards. And the nursing staff likewise, you know, there'd be a chief male nurse for the men, and a matron for the women. But there was no separation through diagnosis, except there was an elite part of the hospital where people with new depressive illnesses would be admitted. And this was, you know, completely different. In fact, it was even a quarter of a mile up the road away from the big main hospital and was, you know, very elite, but the rest of the hospital down the road was these great big wards with no separation of diagnosis at all.

PC: Did any of the staff actually live on the wards?

AR: No, the staff didn't live on the wards. It was it was the biggest industry in Bodmin and whole families would work at the hospital. The nurses all wore uniforms, doctors wore white coats.

PC: There was very much a medical institutional feel to it.

AR: Oh absolutely. Having said that, there were some very good things about St Lawrence’s even at that time, and you know, because there was the farm there was the market garden, there was the laundry, there was the printing works, there was the baby pants manufacturers, there was the name tape department that made name tapes. And so there were these sort of industrial things. There was another department that packed screws and nuts and bolts and all that sort of thing, so some people had quite nice jobs that were able to function and of course the laundry and the kitchen and cleaning was all done by patients. And then they also had clubs like Women’s Institute, you know, and then they did have things like table tennis and billiards. They had an entertainment hall. So I think actually St Lawrence’s probably provided a lot more useful occupation giving a quality to life, than a lot of hospitals.

PC: Yes, yes. My impression is that a lot of the hospitals were still running those sorts of departments, certainly the farming and so forth, because it was a way of keeping the prices down, the cost down. But it does raise how much people were kept in occupation then.

AR: I mean, in a way, they weren't paid so it was slave labour really.

PC: Oh totally, totally.

AR: You know so, I mean ethically, there were things about it that weren't right at all.

PC: Okay, that's very true.

PC: Was there a doctor’s mess?

AR: There was a doctor’s mess and I think that's a really good thing. You know, it didn't matter what people were doing at 10:30, everything stopped and we went for coffee. Everything stopped at 1 o'clock for lunch and we had our own dining room, afternoon tea. It didn't matter what you were doing, it stopped and the doctors all met together. And I think that was really good because it was good both from a medical point of view of discussing things and also socially. I think it's been a real retrograde step not having a doctor's mess.

PC: Was there any formal teaching for the trainees at that time?

AR: That was one of the things that I introduced because I'd had that benefit myself, and so I actually started that when I went to the hospital and only once a month I would get colleagues that I knew from upcountry to come down and do a special teaching session all day. So we did start that.

PC: But before then, there was no formal teaching.

AR: Not really, it depended on if a consultant was interested to teach their junior quite frankly.

PC: Okay. How were the wards arranged in the hospital? Was there any specialisation on the wards?

AR: No, there wasn't, only in the elite part of the hospital, where people would come with, say, major depressive disorder and have ECT and have a period in the hospital, but no otherwise there were these large chronic wards with no differentiation so you could have people with what we would call dementia now and schizophrenia and a chronic, treatment resistant depression all in the same ward.

PC: Okay, and I gather you were given the chronic wards to look after.

AR: Oh yes, I mean for me, I think they were very surprised because my coming along as the most junior consultant was given what they considered to be the dross. But for me, my personality, it was perfect, you know, to sort this out. So I was very happy they couldn't understand why I was so happy.

PC: Did you manage to change much, do you think?

AR: Oh yes, I did. The first thing I did. It did it a ward at the time and I would separate people by diagnosis and start to have active treatment, because by that time we did have quite a few treatments. I enjoyed that and I started the first supported domestic house via the local branch of Mind. I was very lucky, the only place with a branch of Mind was the area that I looked after and so, you know, that was exciting to do that. And then the Medical Superintendent’s house was empty and so I got a group of patients – you couldn't do this nowadays of course – to go in and decorate it and clean it. And we pinched furniture from all around the hospital, and that was our first rehab ward. So, you know, for a young doctor full of energy and enthusiasm, it was all very exciting doing this.

PC: And you almost had the power to do it.

AR: Oh yes, I was very fortunate. The hospital Secretary was enjoying it and he was pretty powerful and one of the other things I did was I said, look, this library we have here is 100 years old and these books are interesting – we don’t want to get rid of them – but they're not what we need now. And I said, we need money to buy so many books a month and we need to start getting modern journals and he was all up for this and I don't know where he pinched the money from, but we started a library both for the doctors and the nurses, I have to say, so we got books for them as well. And so we started to build a library and all that was exciting for somebody, you know, a new consultant. So to me, it was lovely that there was all these lovely things to do and one of the other first specialisms I started was the psychogeriatric service. And that that was exciting because in my particular area which was mid Cornwall we had a lovely consultant physician and he and I set up a ward which wasn't at St Lawrence’s but in the local cottage hospital for want of a better word which was a joint assessment unit so that when elderly people presented we would they would go in for three weeks to have a complete medical and psychological overhaul and that was enjoyable for both of us. That was an enjoyable thing setting up a psychogeriatric service. I mean, it was endless, you see, and then you could go on to formally say, well, we'll have a community nursing service and it was just creating one interesting thing after another really. So I think I was really lucky to be appointed at that time and nobody interfering and stopping you doing what you want to do. You couldn't do all that now, you just wouldn't be allowed to.

PC: But this is very much a hospital job. Was there a community service?

AR: No, but I was very keen on us doing that. We used to have in every area of Cornwall, it was divided up into 10 areas. One outpatient clinic a week. So there was the start of a community service in Cornwall at that time because there was outpatient clinics and that was the start of it.

PC: But this was very much people going out from the hospitals.

AR: Yes, the consultants would go out and would go and hold a clinic.

PC: But there weren't any nurses out there.

AR: No, no, not at that time. It would have just been a consultant going out.

PC: So what happened for out of hours? I mean, if someone needed admission, what would happen?

AR: The consultants all took it in turns to be on duty and the GP would phone the consultant. No problem in admitting people there was always beds, no problem at all. You would just admit them and really just almost GP said you know they need admission. They'd come in and then be assessed.

PC: Okay.

AR: There was no problem at all.

PC: And would you be doing home visits to do that?

AR: Yes, we started doing domiciliary visits linked to the outpatient clinics. Yes, that started to happen.

PC: If the GP asked somebody to come in at night, for example, would they normally come in without someone having seen them before?

AR: Oh yes, you could easily come in the hospital without anybody seeing you before. If you were willing to come, if a GP said, you know, I think so-and-so needs to come in and they want to come in. No problem at all. But the GPs knew their patients extremely well, would know the whole family, whole social setup. You could completely rely on them that they would only be asking if it was necessary.

PC: Okay. And if they did come in, say at night, would there be junior doctors on call for the hospital?

AR: Yes there would. There would be somebody to receive them to make sure, physically, they were not going to die during the night.

PC: The real assessment happened the next morning.

AR: Yes, and then the assessment would happen later, yeah. I have to say we had some wonderful nurses – really wonderful nurses – who would have looked after those patients in their distress during the night, you know. So the junior doctor, it wasn't too onerous, they would just have to check them over physically, and then the nurses would take over.

PC: A lot of people have told me that at this time it would be very much the person would go on the ward, it’d be the nurses who dealt with things initially and the doctors did fairly minor stuff to start with, and it was really only later that the consultant and the junior doctors would do the assessment. It was very much the nurses who ran the ward.

AR: Oh, absolutely yes, yeah.

PC: Out of interest, did you have any other chronic wards where the patients ran the ward?

AR: No we don't.

PC: No. 'cause I know in some hospitals that did happen.

AR: No, no, we didn't have that.

PC: And finally, I mean, do you think that the patients and residents there got better or worse care than they do now? And why?

AR: Well…

PC: It's different.

AR: It, I mean, one of the things that was really good was the continuity of care. There was a real continuity of care, which was good. But when I first went to the hospital, there were people who, really, their care, I think, would now be considered to be abysmal. They'd only really be reassessed once a year. And, you know, that was quite perfunctory. So, there wasn't an attitude of people having treatment and getting better and leaving the hospital. There was an attitude of, well, you're in hospital for life. That was in the main part of the hospital, and I don't know if you know, but the first part of St Lawrence’s to be built was called the Radial Building and it was based on Dartmoor prison with a central observation unit and with spokes going off. So, a minimum sort of interaction, you know, really. So, there are some things about it that were very bad indeed.

PC: What was that like actually having patients on that radial system?

AR: It was pretty horrible because they were in a goldfish bowl so they were, you know, there was no privacy whatsoever. You were being, you know, watched the whole time, so that created a very unpleasant atmosphere, I think. It wasn't good. So, there were things that we would consider now to be absolutely appalling. And, you see, there was no consent to treatment or anything, you know, people weren't you know, things weren't discussed with the patients or they weren't involved in their treatment, you know. There were things that now we would just not even dream of. And, I mean, people were, their freedoms were limited with no checks or balances whatsoever.

PC: Were the wards still locked when you worked there?

AR: A lot of wards were still locked. Yes, yeah, not all, but a lot were. And people had these enormous keys, you know, which were a bit like a prison, you know. Quite ominous really.

PC: No, I can believe that it was.

AR: So, it was, and you know, trying to change people’s attitudes, you can't do it overnight. I found that very, very difficult, you know, I was quite sort of hot headed and, you know, initially I would imagine I was like a bull in a China shop to start with, but I soon learned that wasn't the way!

PC: All right well, thanks very much Angela for talking about this. Good luck with the rest of your career!

AR: Well, it's still very exciting and that's something I would always want to pass on to junior doctors, you know, it can be exciting forever and I think to enjoy your work, you know, if you're looking for that excitement all the time, you will enjoy it. You won't get burnt out.

PC: That's very, very true.