HC Deb 28 January 1955 vol 536 cc642-55

3.15 p.m.

Mr. Hector Hughes (Aberdeen, North)

I beg to move. That this House is greatly impressed by the inadequate provisions which now exist for the elderly sick and strongly urges the Government to take immediate steps to increase, improve and extend those provisions. I shall deal mainly with the health visitor service because members of that efficient and noble service are insufficiently paid and overworked, and the service is undermanned. I invite the Government to do something about it. For many years I have been pained and shocked by the insufficient provision made in actual practice for the visiting of the elderly sick. There have been statutory improvements, but they have not been fully utilised.

It is not sufficiently remembered that the old of today were the wealth producers in peace and the defenders in war of this great, rich, and civilised country. As such, in their old age, they are entitled to just as full an access to the amenities and to the wealth which they produced and defended as when they were actually producing or defending these things. The old, and particularly the aged sick, ethically have a right to the care and attention of their successors who are today enjoying the heritage handed to them.

I should declare an interest, because for many years I have been a member of the Board of the Church Army. I have been greatly impressed by this problem, and so I have been at pains to prepare my argument and to put it as clearly as I can. In doing this, I want to place on record the generous help which I have received from great humanitarian organisations, including the Church Army, the London County Council Health and Welfare Service, the Scottish Council of Social Service, the National Old People's Welfare Committee, and the Old People's Homes Committee, all of which are doing noble work.

I desire also to pay tribute to my hon. Friend and colleague the Member for Tottenham (Sir F. Messer), to Dr. Ian MacQueen, medical officer of health for the City of Aberdeen and to Mr. C. S. Petheram, of the London County Council. These people and organisations are all enthusiasts for health and welfare, and the tasks which they carry out could not be fully discharged without a keen sense of vocation and unremitting devotion.

This problem presents a striking paradox. Hospital accommodation would be adequate, quantitatively at least, in most areas, if the local health authorities developed their preventive services and domiciliary care services to the full; hence, with some exceptions, the regional hospital boards are unwilling to contemplate any large increase in the number of beds for the elderly. Local health authorities in general have not developed their disease-preventive services sufficiently, and this failure leads to a steady increase in the waiting lists for hospital beds. Many local health authorities, instead of putting their houses in order, simply blame the regional hospital boards for not providing more beds.

A most important feature of the health problem is that of bringing the full number of health visitors into operation. Their salaries, pensions, and general conditions should be so greatly improved as to encourage more recruits into that profession, which would enormously increase their numbers. I quote from the Scottish Health Services Council's Report on "The Ageing Population." It says: It must be emphasised that the problems of the medical care of the elderly portion of our ageing population are more domiciliary than institutional, and are more problems of social medicine and of medical administration than of clinical medicine. The essence of the matter is to assist elderly people to remain for as long as possible in health and comfort in their own homes. Hospital care and hostel or other accommodation for the infirm aged, though necessary, are only supplementary measures. The stress must be laid, not on hospital geriatrics, but rather on what can be done to stimulate eugeria—the condition of ageing serenely, slowly and painlessly. I agree with this diagnosis, and in order to present the needs of the elderly sick in a scientific and orderly way, I shall do so under three heads: one, that of warding off the onset of debility due to old age; two, attending the sick at home; and, three, attending the sick in hospital.

I do not at this hour intend to speak at great length, and I want to clear the ground of some matters on which I should have liked to speak if the debate had started earlier. First, I mention some things which affect those not ill; which help to keep the elderly out of hospital, to ward off the onset of debility due to age, and to maintain health and reduce disease.

I put them in schedule form for the sake of celerity. These include improvements in retirement policy, adequate pensions, appropriate housing, the health visiting service, chiropody treatment, the mobile meals service, the home help service, clubs for the elderly, geriatric clinics, registers of persons likely to need help, and a combination of health and welfare service.

I merely mention those, and I pass to the second head. I must mention the things which are needed by those who are ill but not ill enough to need hospital treatment. These include improvements in the district nursing service, the home health service, assistance by relatives, interchange of information between hospital and local authority staffs, and the after-care of those discharged from hospitals and hostels for the frail.

The third head relates to matters affecting the elderly sick actually in hospital, and includes the extension of hospital accommodation, proper use of hospital beds, and more up-to-date amenities and utilities. Obviously I cannot deal with all those now, and therefore I shall, perhaps to the relief of the House, concentrate on one—the warding off of debility due to age; that is the maintenance of health and the reduction of disease in the elderly.

In my submission the key to that is the health visitor. It is obvious, with the vast continuing increase in the numbers of the elderly, that a reduction of disease is essential in the interests of the whole community, young and old. Unless we can so improve health and fitness that a man of 70 remains as active and as useful as his father was at 60, our whole national economy may be swamped by the rising tide of the elderly sick.

The clear implication is not that we should retreat from our obligations of welfare for the old people but that we should make a real and sustained effort to improve health and to prevent disease in the older age-groups, in addition to providing for the comfort and welfare of those no longer capable of looking after themselves. We must help them in their homes. We must help them to keep out of hospital, and that is where the health visitor is the key. In common humanity, we must help those who have become incapable of fully independent existence, and let us also be vigilant to prevent those who are still fit from descending needlessly into the stage of unfitness.

How is this to be done? There are many answers to the question and I wish that I had time to give them. Today my one answer will concentrate on the enlargement of the health visiting service, which is below standard in numbers. Gaps should be filled, standards should be raised, the salaries should be increased, the pensions and general conditions should be improved, because this is an essential service affecting the vitality, the mortality, and the happiness of the whole community. The health visitor is the key worker in the disease-preventing service. In the phrasing of the Royal Sanitary Institute, She is the spearhead of the social services. The official Report on "The Ageing Population" states: The sphere of work of the Local Health Authority has been extended to include the prevention of disease (not merely of infections) among all ages (not simply among children). An outstanding contribution to the undoubted success of the Child Welfare Service has been made by the public health nursing staff. By their training and experience, health visitors are well fitted to contribute to the well-being and comfort of people at the other end of life. We recommend that the Local Health Authorities examine the possibilities of extending the sphere of the health visitor staff to deal with the needs of the aged and of increasing their quota of health visitors as and when these become available. The rôle of the health visitor is the health care of the elderly.

The best analysis published on this vital aspect is probably an article by Miss D. J. Lamont in the "Medical Officer" of 24th September, 1954, which I ask the Minister to study and act upon. I have not the time to quote from it today. Meantime here are some points to emphasise the great importance of the health visitor. For the prevention of disease and for the promotion of health in the elderly, the health visitor has unique qualifications. I name four.

First, her nursing training and hospital experience make her aware of the degenerative conditions that accompany age. Second, her training in public health enables her to realise the importance of delaying for as long as possible physical and mental deterioration. Third, her constant association with normal families gives her an unsentimental and practical outlook. Fourth, she is already accepted in the home as a welcome visitor and adviser who, unlike other medical and social workers, does not have to delay her visit until summoned in time of emergency.

The health visitor can and does help in many ways in this connection. She can and does reawaken the interests of the middle-aged women who have hitherto been preoccupied with young children, and who sometimes tend to drift into premature old age when the children no longer need care. She fosters the development of outside interests and leisure activities as an armour against the dreariness of old age. She maintains and promotes physical health by advice on diet.

It is well known that many old people eat too much and do not take enough exercise. When activity is lessened they continue, as regards diet, the habits of youth. Hence they suffer from obesity and coronary troubles. Many others find cooking wearisome and subsist on the "tea and toast" type of diet—hence lowered resistance to infections. They need advice on a proper balance of diet, rest, and exercise. Some try to behave as though they were still young, and they have sudden heart attacks in consequence, or they regard themselves as less fit than they really are and thereby cause needless invalidism.

The health visitor can and does help in those ways, and also in other ways. She helps to maintain morale and cleanliness by her visits, and sometimes these make all the difference between the dear old gentleman and the dirty old man. She can and does help in the prevention of home accidents. This is just as important in the case of old people as in the case of young children, though causes and types of accident are different. The skilled health visitor can do an enormous amount here. She can also help in the maintenance of mental and emotional health by raising morale, alleviating loneliness, removing the prevalent fears of death, of poverty, of illness, and of being unwanted.

She can help in co-ordination of services by bringing to the notice of the mobile meals service the old lady to whom cooking is now a weariness; arranging for a home help for the woman whose failing physical powers can no longer match her pride in the spotlessness of her home; assisting the old man in dealing with the complexities of pensions and allowances; and persuading the person who is ill but reluctant to summon a doctor that medical treatment is necessary.

I turn to another aspect of the virtues and activities of the health visitor. Research is of course, an essential service. We get knowledge of the prevention of diseases from the study of established cases in hospitals and from the study of cases by general practitioners, but also from the health visitors who are experts in normality and skilled at recognising early deviations from normality. We can expect from them useful new knowledge on which to build social policy for the future.

I turn to another aspect of the matter. The National Health Service Acts are not fully utilised in this respect. They impose on local health authorities a duty to provide health visitors to visit persons in their own homes, and to advise, to quote the Acts, as to the measures necessary to promote health… and so forth. An adequate health visiting service could do much to improve the health of the community and to reduce the present crippling cost of hospital care. The sad fact is that the health visiting service remains in many areas in almost skeleton form. I invite the Government to do something about that.

The present scarcity of health visitors places on the comparative few unduly heavy case loads. This scarcity is infinitely greater than the scarcity in any other profession. Before 1948, when health visitors were concerned only with expectant and nursing mothers and young children, the standard case book was 100 to 120 births per health visitor per year. With a normal birth rate of 16 to 17 per thousand of the population that represented a pre-1948 loading of one health visitor to every 6,000 to 6,500 of the total population.

With the extension of the health visitors' duties it is quite impossible for her to cover a population of more than 3,000, and many experts have publicly advocated smaller case loads. The Department of Health for Scotland, in its official Health Bulletin, over the signature of the Deputy Chief Medical Officer, has suggested that the minimum for adequacy is one health visitor for every 2,500 of the population. Professor Fraser Brockington, of Manchester University, has argued for the same number of health visitors as of general practitioners, and that is roughly one for every 2,200 of the population.

Sweden has vital statistics showing high standards of health there. She certainly has no better hospital services than we have. Sweden has far fewer medical practitioners per head of the population, but considerably more generous staffing of health visitors and district nurses than we have, and that is reflected in her vital statistics.

Every local authority in Britain is short of health visitors, although in many areas the shortage is masked by the fact that the local authority has not increased its establishment of health visitors. In Aberdeen, where we have increased our complement, we have 25 vacancies in a total complement of 85 health visitors. The national shortage is at least 30 per cent. and probably nearer to 50 per cent.

Local health authorities that try to obtain an adequate quota of health visitors find that recruits are scarce, and the reasons are not far to seek. I shall mention some of them. High among the reasons is that health visiting is the only profession in which full-time study for obligatory additional qualifications is followed by an actual diminution in pay. What an anomaly; what an anachronism.

The health visitor, like the hospital ward sister, starts by undertaking general nursing training for three years. She then works as a staff nurse for, say, two years. The ward sister needs no further training or experience, whereas the intending health visitor spends a further 1½ years in midwifery and health visiting. Before 1948, health visitors were paid a little more than hospital sisters. But since then the positions have been reversed, and so continue.

The ward sister today receives a salary of £425 to £550 a year. The health visitor, on the other hand, with two extra qualifications, with the responsibility of working unsupervised in the homes of people, and with the unpleasantness of having to be out of doors in the most inclement weather, receives only £420 to £545 per annum.

Again, health visiting is one of the few professions in which virtually no promotion outlets exist. For every four or five ward sisters there is at least one senior post to which they can aspire. In health visiting, on the other hand, there is about one senior post for every 25 or 30 health visitors. Also, the senior posts are woefully underpaid. The health visitor tutor with yet another qualification, the Tutor's Certificate, requiring another year of full-time study, that is, with a total training longer than that of an ordinary doctor, receives £560 to £660 a year.

The salary of a principal health visitor tutor, and there are only six in the United Kingdom, rises to a maximum of only £760 a year. Contrast this with the salaries of lecturers in teacher-training colleges, which are comparable posts. Even a junior female lecturer gets about £800, and a male over £900 a year; and the person in charge gets about £1,800 a year. A superintendent health visitor receives, according to the population, a maximum varying from £635 to £915 a year.

But the salaries of matrons in large hospitals rise to over £1,100 a year, and an assistant dental officer in a local authority gets a maximum of £1,400 a year. The health visitor is the key to the prevention, or warding off, or delaying, of disease in elderly people. The reasons for the shortage in this great and noble service are those to which I have referred.

There are other keys on this humanitarian chain which I cannot detail at this late hour, and earlier I mentioned only some. Among the other keys is the chiropody service. If there is one thing from which many of the aged suffer it is bad feet. It is essential that they should have a better chiropody service. They need a mobile meals service, home help service, clubs for the elderly, geriatric clinics, and a register of old persons likely to need help is required.

These are but a few keys on this very important chain. I hope that I have con- vinced the House, particularly the two Ministers who are listening to me, that they are very important keys, but the most important key of all is the health visitor. Her emoluments and conditions should be improved to attract greater numbers into this essential, humanitarian profession without which the old will continue in bad conditions which they do not deserve.

I hope that I have said enough to convince the Ministers that it is urgent that something should be done in order to improve the attractiveness of the health visiting service, and to increase its numbers.

3.42 p.m.

Mr. Somerville Hastings (Barking)

I beg to second the Motion.

I shall probably deal with this matter from a rather different angle than my hon. and learned Friend the Member for Aberdeen, North (Mr. Hector Hughes). So long as two old people are living together they usually manage pretty well. Each helps the other in sickness and cheers and encourages the other in health. But the number of people living alone is increasing. Between the 1931 and 1951 censuses it doubled. There are at least 500,000 people more than 40 years of age living alone in this country. When old persons living alone become ill their condition often becomes most deplorable. They cannot go out to buy food, and often they suffer very much in consequence. They find difficulty in keeping themselves clean, and their condition is very dreadful. It can only really be appreciated if it is seen.

It is difficult to understand how such things can happen in a civilised country, because we have health visitors and other facilities, but I think these old people do not understand the facilities available to them. Above everything, they dread being taken to hospital. I know that local authorities have power of compulsory removal, but they have first to discover the old people. Therefore, I suggest to the Ministers that the first thing to do is to improve the services for finding out when old people—particularly those living alone—are ill and need help.

There are four possibilities which have to be explored and extended. In many areas there are preventive clinics for old people where they have physiotherapy, are encouraged to do exercises and play competitive games which they thoroughly enjoy, and where they are taught to do interesting work of different kinds suitable to their capacity. When the old person does not turn up at the clinic it may suggest to those in authority that they may be ill. In other areas, I understand, a register is kept of those who are 65 and the health visitors visit them at regular intervals to see how they are getting on. I know that in at least one place the youth club has left with old people a card which they put in their window if they need anything, and this idea has been used to some extent with modifications in other places. Then, when old people are ailing, kindly neighbours or health visitors look in to see them night and morning.

In my view, what we want to do for old people above all else is to keep them out of hospitals if we possibly can. Old people do very badly when they are moved to hospital. They often seem to die from some inexplicable cause. In this House, I have given examples before that have come to my direct notice where, in spite of every care, old people when removed to hospital have suffered badly. Therefore, what we must do as far as possible, is to maintain the health of the old people. I know that the chief difficulty arises when they live alone, but we should try to prevent them getting ill and, if they do get ill, deal with them as far as possible in their own homes.

First, I suggest that the way to keep old people, like the rest of us, healthy is for them to be kept busy. Old people like to be occupied. Dr. Sheldon, of Wolverhampton, who has written a great deal about the ills of old people, tells us that he regards them as not unintelligent, and he says that they have a great deal of what he calls "guts." The most important way to keep old people healthy is to keep them busy and to give them things to occupy their minds and their muscles.

In the past, too often when an old person became ill he was removed to some form of hospital and put to bed, and there he lost all interest in life and all hope. Too often he was tucked up tightly in bed, with the bed clothes so tight that he could hardly move and certainly could not keep warm. The result was that he bent up his knees to keep his feet warm and got more or less fixed in that position. Then, as there was nothing else to interest him, he was inclined to eat too much; and having lost interest in life and all hope, he did not bother about much else and incontinence soon followed.

The first thing to keep old people healthy is to maintain their interest. One of the best things in the National Health Service is that old people have been able to get spectacles really fitted to their sight and have not just used what was left them by a grandfather or uncle or aunt. Even more important than that, in my experience, has been the provision of hearing aids. Several old people have told me that this has meant new life to them, because instead of being cut off from everyone else, they were able to communicate with their fellows and get some interest in life. After all, old people are gregarious. I would even say that they are often garrulous. Anyone who is in doubt about this should go to an old persons' club and not only see them, but hear the noise they make and the way they enjoy themselves. We should keep the old people busy in body and mind.

The next thing is to try to avoid stairs. Old people do not get on with stairs. Therefore, what I want to see is more one-storey ground-floor flats built in housing estates for old people. Would it not be possible to give preference in the allocation of such ground-floor flats to old people who have daughters or granddaughters living near? Thus they could get the help they very much need. I know that there is such a thing as tyranny of the sick, and I know that the daughters and granddaughters who are helping to look after old people often find it difficult. In some places it is possible to arrange for home helps to spend the night once or twice a week with the old people so as to relieve the daughters. In order that the family may get away for a while, it is sometimes possible to take the old person into a hospital temporarily. Then that, in my opinion, is a very great help as well.

When old people get ill there comes the question of bringing the hospital to the patient instead of taking the patient to the hospital. We have, as has been shown by my hon. and learned Friend, the very valuable services of the health visitors and the services also of the home helps and the home nurses. Many local authorities lend various articles of nursing equipment to the old people when they want it, such as water beds and corn-modes, and I know of at any rate one local authority in London that adopted some years ago a scheme for providing baths for old people in their homes. A bath is taken to the home, and also a boiler worked by Calor gas.

There are meals on wheels, and other schemes which take hospital facilities to the old people in their homes. A very great problem, of course, is bedding, and that is sometimes lent, and the washing of foul linen is a very great difficulty, but it is not insuperable, and arrangements can be made and have been made for this in some places between the local authorities and the laundries of hospitals.

What I would stress is that although the provision of facilities is costly to the local authority, it is infinitely cheaper to the community than taking an old person into an expensive hospital, and the old person is happier and is much more likely to benefit by treatment at home. The doctor in charge of the case may feel that hospital treatment has to be considered. Some hospitals, with which I used to be associated, would send out a geriatric specialist who would consult with the doctor in the home. Between them they could judge of the conditions in the hospital, the facilities available, the pressure on the hospital beds, and in the light of all the facts arrangements could be made. Sometimes a health visitor accompanied the doctor from the hospital.

The time left for the debate is, I know, very short, and there are many more things one could say and would like to say, but there is not time. These are a few suggestions for the care of old people. I for my part do not believe that we shall have an efficient service for old people until the competition between the different authorities for health is removed and until in every locality there is a single health and welfare authority.

3.55 p.m.

Mr. J. K. Vaughan-Morgan (Reigate)

We have had two very interesting speeches which have ranged widely over the welfare of old people generally. I had anticipated that we should deal more with the narrow point of the elderly sick, such as matters concerning the shortage of hospital beds for the chronic elderly sick, about which I wish to say a few words.

Last week I visited a small hospital in my constituency which has been greatly affected by this matter. This hospital has been ordered, told or advised—I am not sure which—to allocate 10 per cent. of its beds for the chronic elderly sick. In a large hospital it is possible to have a separate ward for the elderly sick where they can have what most of them need, which is less nursing than is needed in the average ward and the proper services. In a small hospital matters become much more difficult, and the problem has hit this hospital very hard.

They have had to allocate 12 beds out of 120 scattered over the various wards. Appalling complications have been caused. Of the 12 elderly sick in the hospital, no fewer than six need no nursing at all. Were there a half-way house they could be looked after there. I have gone into these cases individually. I was given the full circumstances affecting each patient. I am sorry to say that in three cases there were relatives who did not want them back. These three patients were continuing to stay on at the hospital, for no other reason than that there was no home for them to go to, which I think is a reflection upon all concerned. In one or two other cases the patients were very old indeed. One lady was 99; obviously it was impossible to move her.

I suggest that there should be more attention given to the provision of halfway houses where assistance could be given to those who have no business to be in hospital at all. That would work in well with the geriatric clinics mentioned by the hon. Member for Barking (Mr. Hastings). We have lagged behind since the war, not so much in the provision of hospital accommodation, which is the least important part, but in the provision of places where such people could obtain lighter nursing and care.

There is one other kind of institution which needs developing, though I know that something is being done on these lines by various voluntary bodies. That is a home or—I hate the word "institution"—let us say a home, to which those families who have elderly relatives could send them to be looked after while the family had a holiday. That would help many families and encourage them to keep their relatives at home and not "dump" them in hospitals or institutions.

I was told of the case of a school teacher who works very hard and at the same time maintains two elderly relatives at home. She has not had a holiday for nine years—

It being Four o'clock, the Debate stood adjourned.