HL Deb 22 January 1957 vol 201 cc9-36

2.58 p.m.

LORD AMULREE rose to call Her Majesty's Government's attention to certain administrative difficulties arising between the working of the National Health Service Act, and the National Assistance Act in regard to old people; and to move for Papers. The noble Lord said: My Lords, speaking in your Lordships' House on April 6, 1948. when, as some of your Lordships will be aware, the National Assistance Bill was being given a Second Reading, I expressed some doubt whether there was going to be proper liaison between the National Assistance Bill, when it became law, and the National Health Service Act which had just become law. I was assured by the speaker for His Majesty's Government (it is true that it was not the same Government as we have now, but I think that what I am dealing with is entirely a non-Party matter) that there would be.

The noble Lord who spoke for the Government on that occasion said [OFFICIAL RFPORT, Vol. 154, cols. 1151–2]: In the first place he"— that is myself— stressed the need for liaison between the regional hospital boards and the local authorities. I am glad to tell the noble Lord that the Government are acutely aware of the importance of this. Obviously, it is necessary that there should be this closely-worked-out liaison, and that every effort should be made to get the old folk out of the hospitals where, as he said, they tend to stay and to retain beds which are needed for other people. It is also essential to encourage traffic the other way. On both those points the Government are at one with the noble Lord and I am glad to give that assurance to him and to other noble Lords. When I was told that, I did think that things were going to work out fairly well, but I am afraid that, as I hope to show your Lordships in the course of what I hope will be a not very long speech, things have not proved quite so successful and pleasant as I was then told they would be.

The first thing I want to point out is that what I have to say does not apply to the large majority of old people. The majority of old people of this country live perfectly contented lives with their spouses, families or friends, and therefore pose no real problem to the welfare home and hospital authorities at all. Nevertheless, there are a few—it is impossible to give the exact number, but they are a substantial minority—mostly pensioners, who cause a good deal of difficulty. That difficulty has been well expressed in the 1949 Report of the National Corporation for the Care of Old People, a large and responsible body set up by the leaders of the Nuffield Organisation, in which I play a certain part. The Report says: There is a category of old people which is the responsibility, apparently, of no one: those in it are on the border between health and sickness, being neither fit enough, since they may need days in bed, to look after themselves or to live in a Home for the able-bodied, nor yet sick enough to need hospital treatment. There appears to be an administrative gap between the National Health Service Act and the National Assistance Act.

I refer particularly to old people who live by themselves. It is an extraordinary thing (though I think this applies more particularly to London than to the rest of the country. and certainly to the Borough of St. Pancras, where I do most of my work) that about 40 per cent. of the old people who apply for admission to hospital are living alone. And when I say "alone", I mean really alone: I do not mean that they have friends round the corner or relatives in the same building, but that they are living by themselves in one or two rooms. There comes a time when they simply cannot continue that kind of life any longer. They have become too frail, too feeble, and tend to break down. If they are discovered before they break down, something can be done to stop them, but if they do break down, they have to be admitted to hospital, where they may recover up to a point. Then comes the problem of where they should go after their hospital treatment. It is very difficult to find out where they are to go, because they are not sick; they are suffering from profound disability.

That was one of the matters that we took up in the debate nine years ago, to which I have referred. In Part III of the National Assistance Act it is laid down that: It shall be the duty of every Local Authority,…to provide:— (a) residential accommodation for persons who by reason of age, infirmity or any other circumstances are in need of care and attention which is not otherwise available to them. That sounds a fairly definite statement, and one naturally thought that it would cover this substantial number of people who are on the borderline between being really fit and being in need of hospital accommodation. There has been a certain amount of improvement, I know, but it has not gone far enough yet. One result, which is very serious, is that many people are forced to remain in hospital, occupying beds which are fully equipped from a medical and nursing point of view and which are urgently required for the care of the sick.

Another, though perhaps not quite so material, point is that it is extremely expensive to keep people in hospital when they need not be there. The average cost of a bed in a hospital is £12–£15 a week. In the big London teaching hospital which I attend, the cost is £25 a week. It does not seem sensible or reasonable to keep people at that cost to the State if they do not require that kind of accommodation. Yet we find it extremely difficult at the present time to get people transferred from hospitals to welfare homes. I have about ten or a dozen patients who have been on the waiting list for a substantial length of time—six, nine or twelve months; and some since June, 1955.

It is sometimes said that there are sick people in the welfare homes who should come into hospital, and one way of getting people transferred to the welfare home is by exchanging a sick person for someone who is well. I have no objection to that form of admission, but I do not think that it should be done on an exchange basis. There should be some kind of accommodation for the people who require it.

It was pointed out several times during the debate in your Lordships' House on the National Assistance Act, both by my noble friend, Lord Saltoun, and by myself, that there were one or two things about the old Poor Law which were good things to be remembered. I do not advocate for a moment a return to the old Poor Law, but one principle in it which I think was valuable was that those people in need of care and attention, whether they were sick or well, were under the same authority, so that it was possible for people to be moved across from the "house" to the infirmary. Indeed, a large number of people would be in the infirmary during the winter months, and when summer came, they would be moved back again to the "house". It was no problem at all, because they were under the same authority and there were no administrative difficulties about it. They were in the same curtilage, the same people were about the place, and the patients did not mind being moved. Elderly folk, when we want to get them moved from one place to another, need a certain amount of encouragement, and it is a great advantage if one can say that it will be all right because they will be under one's care all the time and the same people will be looking after them. Then they are much more willing to go. That is why I feel it is a great pity that this principle was lost. From the point of view of the old folk at the present time, it is a pity that these services tend to run on parallel lines, because the definition of parallel lines is that they should never meet, and that is what is occurring in far too many cases.

The British Medical Association in 1947 set up a large and representative committee of which I was a member and which produced a short and sensible report, which advocated that it should be possible for the elderly who were not really ill, but were frail and infirm, to come under the umbrella of the National Health Service, rather than being separated under the National Assistance Act. Unfortunately, that was not done, and we are still labouring under the difficulties resulting from that decision. I should like to put this question to the noble Earl who is to reply. It is a case which occurs rarely, but suppose one has an elderly patient in hospital. The time comes when he has recovered and is fit to be discharged, but he has nowhere to go. He lives by himself and is not quite well enough to cope with independent life again, and he refuses to leave the hospital. I have never actually had that happen to me, but I have certainly wasted five or six months trying to cajole and persuade old people to go. When they refuse, what can one do? One can well see why they refuse to go to a welfare home, because they regard the welfare home in the same way as people in former days regarded the workhouse. To them, there is still a flavour of the workhouse hanging around the welfare home. I do not mean to say for one moment that welfare homes are like the old workhouses—they are greatly improved inside and they are run more humanely—but the buildings are the same, and the nineteenth century workhouses are not attractive buildings to approach. Therefore, one finds from time to time that people refuse to go if they are discharged from hospital. If they do refuse, I wonder what is done.

Another trouble as to accommodation arises under Part III of the National Assistance Act because it is difficult to get a large number of patients accepted by the welfare authority, although they appear to be quite well enough to be so accepted. I have a few patients of my own whom I cannot get transferred. I was talking to a friend who works in the Midlands who told me exactly the same story. He said that he has about twenty-five to thirty people who were sick and have now recovered but are left with a profound disability because of which they cannot attempt to live anything approaching a normal life. They can get fully dressed and be up in a chair all day, and they can feed themselves, but they have to be carried from bed to toilet and from toilet to table, for example. Those were the people for whom I thought, in my innocence, when I first came up against this problem, accommodation under Part III of the Act would readily be provided. But no; it is impossible to find anywhere for them to be taken care of except in an expensive bed in a hospital.

It may be—I should like to know whether the Government have any views about this matter—that there is difficulty in finding staff for these places. I wonder whether some attempt could be made to solve that problem. The only inducement which suggests itself to me is that staff might be paid rather more than they are. But one does not like to suggest expensive measures at the present time, and one would like to think it possible to get people interested in a job like this not purely for the sake of the money they receive, but from an interest angle and a vocational feeling about the work in general.

It really comes back to the difference in the two authorities. There is the local authority, working under the National Assistance Act, who have one standard of fitness—and in some of the homes that I visited in the country the people seemed to be able to do so much and appeared to be so fit that one wondered why they were not living a normal life in their own homes. Although I agree that if the world became much more settled and prosperous it might be a pleasant thing for people to live in a communal home, if they wanted to, when financial conditions are so straitened and there is not a large amount of accommodation available I feel that such accommodation as there is should be earmarked for people who really require it. The number of people living in welfare homes in the country has gone up substantially since 1945, when, according to my information, there were about 47,000, whereas in 1954 there were 65,000. Those, I take it, were elderly people, and that seems a very high figure for the country as a whole. I may say that those figures are merely for England and Wales and do not include Scotland.

Looking further into the matter, one wonders whether there are more people living in these homes than is necessary. That may sound rather paradoxical, in view of what I have previously said, but it all comes back to my main contention that we want to get the right kind of person in the right accommodation. One wonders, therefore, if the fullest use is being made of the domiciliary services available under the various Acts of Parliament for local authorities to employ. One knows that in some areas the domiciliary services are extremely well done. The Borough of St. Pancras, where I work, must be one of the best in the country, because we have a co-operative local authority who do as much as they can. However, I have visited other local authorities where the figures given me are so different that one cannot help feeling that nobody bothers much about the matter. I wonder whether enough work is done to encourage local authorities in this direction. Some of the services are, I think, mandatory with them, and some are permissive; but one wonders whether there should not be more of an effort to encourage local authorities not merely to pay lip service to the domiciliary services, but to put their whole heart into them.

One thing which is particularly lacking, and where I think the position is completely chaotic in the country, is the provision of the mid-day meal service. One hears a lot about good work done by various bodies in providing a mid-day meal service, and no doubt it is true. But there are some places where a meal is provided on five days a week, and others where one is provided on only two days a week; in some the food is good and suitable for frail elderly persons, and in others it is not suitable at all. There appears to be no common policy about the provision of a mid-day meal service. Under Section 30 of the National Assistance Act it is possible for a local authority to contribute to a voluntary body providing, amongst other things, meals for old people. There is, so far as I know, no statutory authority under which the local authority can provide a specially prepared invalid meal for people who cannot take a full normal meal but want something rather special. So far as I know, there is one body in the country, again a body with which I am connected, called the Invalid Meals Service, which is a partly voluntary body but gets a large grant from the county council. In a struggling way, we just manage to provide dietetic and chosen meals for a few people in London. If a service such as that could be expanded an enormous amount of good would be done to a great many people.

If you are going to look after people in their homes it is not very expensive. The current Report of the National Corporation for the Care of Old People says that, provided they do not want care at night—and that, I admit, is very expensive and hard to come by, and is almost not worth while, simply as a matter of possibility—a great amount can be done for between £5 and £6 a week, depending on what services the old person requires. Assuming that he or she does not want too much, it seems to me that £5 or £6 a week is not an unfair amount to pay, and it compares well with the cost of looking after people in a well-run home.

The Guillebaud Committee, set up to inquire into the cost of the National Health Service, reported in 1956 that they were very worried about this particular problem to which I have referred—namely, the old folk who seem to fall neither into the lap of the National Health Service nor into the lap of the welfare authorities. They rather attributed the difficulty to the fact that there was not enough accommodation available. I have never been entirely sure about that. If the beds we have in the country were administered properly, and the right people kept in them, I doubt whether a big increase of beds would be needed. In some parts of the country, where services have not been well developed, it might be that a certain increase would be required, but until we have the beds properly filled I think it extremely unwise to say that one wants an enormous expansion of hospital and welfare beds. I say that in the hope that it will induce Her Majesty's Government to look at the matter more kindly, because I am not demanding an immediate expenditure of a vast amount of money.

The position is largely bedevilled by the retention of that curious phrase, "the chronic sick." Even the Ministry of Health are keeping that phrase in being. They have been carrying out an inquiry—it may be finished now, but it was being carried out about two months ago—into the state of the chronic sick of the country. I would put forward the suggestion that there should be two categories, those who are sick and who need medical care and treatment, and those who are disabled—the category under which most of the chronic sick cases come—and need something entirely different in the way of care and attention. I am sure that it is wrong to keep up these phrases of "acute sick" and "chronic sick." It means that two classes of medicine are required. The chronic sick are mainly the old age pensioners, and it seems wicked that they should be worked against in this kind of way.

I saw a result of that in one of the local papers the other day. There were two old ladies, one aged ninety-four and the other aged eighty-five, who were living together in the country, and who both got acute bronchitis. You cannot call that "chronic"; they were acutely sick. It was impossible to find a bed for them for the quite long time they were sick. They were sick for a week or ten days, and then both of them died, in great discomfort and misery, in their cottage. The comment made by the authorities was, "Well, the number of chronic sick beds has gone up quite a lot in this part of the world." But that does not seem to be helping poor old ladies suffering from acute bronchitis who might have recovered, although I do not say they would. But it does seem to me that if we could get away from the terms, "acute sick" and "chronic sick," it would go a long way to ensuring that this gap between the National Health Service Act and the National Assistance Act is closed.

One can put forward various suggestions about how to improve things. The first way is to have amending legislation to put the matter back under one authority. I do not think we need consider that suggestion seriously, because it would entail a great deal of work, requiring a complete change of all we have in the country now; and I doubt whether such a step would be justified at the present time. Another possibility is that the regional boards and the local authorities should make a joint appointment, when they appoint doctors to take care of the old people in their hospitals, so that they would have charge of the people under Part III of the National Assistance Act. That has been done in at least one case which I know, and it is working well. That seems to me a matter which might be encouraged. It would at least stop the rather absurd situation which occurs in some towns.

Let me quote one example. On one occasion, I had two old ladies in hospital—I forget what was wrong, but they were rather seriously sick, and they were in bed quite a long time. After a great deal of trouble, we managed to get them out of bed and walking up and down stairs. They lived by themselves and could not go back to their home, so they were transferred to an institution. About six months later, I was approached to see whether I could take them over. I found my two old ladies tucked up in bed. They were rather cross and said, "They have put us to bed. Can't you get us up again? I asked why they had been put to bed. It had been discovered that they were eighty-five and were shaky, and because it was thought they might fall down, they were put to bed. That does not seem an economic way of dealing with this problem, and certainly it is not a humane way. That might be stopped by some kind of joint appointment such as I have mentioned.

The third suggestion I should like to make, which I think was also suggested by the Guillebaud Committee, is that the welfare services might be transferred to the health committee of the local authority, which would mean that the medical officer of health would be in the chair and they would have a medical side to them. I am sorry to keep on stressing the medical side, but I feel that it is largely a medical matter. I do not want to push myself in front of your Lordships too much, but I do think it is a medical matter, and the more we can keep that kind of balance, the better it will be. There have been one or two good schemes worked out in some parts of the country, but unfortunately they were badly done on a personal basis. Although one admires persons who can work together amiably, one does not like to see a whole Service dependent on that, because if you cannot get people to work together it leads to trouble. These are merely a few suggestions I put forward, and I shall be, extremely interested to hear whether Her Majesty's Government have any further suggestions. I do not say for a moment that mine are the only ones—I am sure there are a great deal more. I trust that I have drawn your Lordships' attention once more to what is rather a bad blot on the welfare services of this country. I beg to move for Papers.

3.28 p.m.


My Lords, I am glad that the noble Lord, Lord Amulree, has thought fit to raise this matter. The arrangements for ministering to the care and wellbeing of old people are of great and increasing importance in an ageing population, and unless we can get them on to a satisfactory footing now the problems will become greater and the difficulties of overcoming them more severe as time goes on. Great advances have been made in recent years in the techniques of the treatment and rehabilitation of the aged sick—advances to which the noble Lord, Lord Amulree, who has made a particular study of these problems, and such people as Dr. Marjory Warren, who has an international reputation in this field, and many others, have made notable contributions. We shall not obtain—or rather. I should say, the old people will not obtain—the full advantage of these new techniques unless the administrative system under which they are applied works smoothly and efficiently.

In the main, the administrative difficulties in this field arise—and I think this is comon ground—from the dichotomy under the Acts, the National Health Service Act and the National Assistance Act, by which the hospital authorities, the regional hospital boards, are responsible for the aged sick, while the welfare authorities, the county councils, are responsible for the welfare of the senile and the infirm. I need not weary your Lordships with the precise terms in which the Acts define the division of responsibilities, or with the rather long memorandum that the Ministry of Health found it necessary to issue in 1954 in an attempt to clarify it. The fact is that in this field of the old people. however neatly and clearly defined a line between those who are sick and those who are merely senile may appear to be, and wherever that line may be drawn, there will be many old people who are borderline cases and many who change from one side of the line to the other. And the movement across the line is not a one-way traffic; it is a two-way traffic. It is to easing the movement of that two-way traffic that we should direct our efforts, so that the senile who become sick can be taken into hospital without delay, and the aged sick who are rehabilitated in hospital can be enabled to resume a normal existence, whether in their own homes or in the homes for old people administered by the local authorities or by voluntary organisations.

It may perhaps be helpful to your Lordships if I give you the experience in this matter of the regional hospital board of which I have the honour to be at the present time the Chairman, the North West Metropolitan Board. It is a board that administers a region partly rural—there are parts of Bedfordshire, for instance, that are remarkably bucolic—and partly urban; and it includes a segment of London where the administrative problems are in some ways different from those elsewhere. In general, the problems are most severe in the urban areas, and it is in the County of London that they are found to be most difficult and intractable. They are conditioned by the fact that in 1948, when the National Health Service was brought into being, neither the hospital authorities nor the welfare authorities had enough accommodation to meet their requirements for old people, and that there was a lack of balance. There were in welfare homes many old people—I was going to say "chronic sick" but perhaps I had better not use that term; your Lordships will know what I mean—who should properly have been receiving hospital care; and many hospital beds, in general and particularly in mental hospitals, were occupied by old people who really needed only the care and attention that welfare homes could give them.

The shortage of accommodation for old people that existed at that time, both in the hospitals and in the welfare homes, has been eased by increased provision, both in the hospitals and under the local authorities. There is still not enough, but there is much more, and what there is is now of a better standard, though there is still great room for improvement in the standard in many places. But some lack of balance persists, and will perhaps always persist. The mere passage of time must carry more old people, hitherto healthy and in welfare homes, into the category of "chronic sick" than we can reasonably hope that all the efforts made and the new techniques developed can restore from hospital to welfare homes.

In London, the position, always more severe than elsewhere, has been bedevilled by the fact that the welfare authority, the London County Council, has to deal with four regional hospital boards. A machinery was established some years ago for exchange, in suitable cases, of old people between hospitals and welfare homes; and with a good will and understanding on the part of all concerned, to which I should like to pay warm tribute, this machinery has, on the whole, worked pretty well. Other steps have been taken. The provision by the hospital service of dispensers in welfare homes and the development of physiotherapy are two examples. In other local authority areas in the region similar local schemes for exchanges and for co-operation were developed, and hospital officers have been greatly helped in the work of rehabilitation by a knowledge and use of the welfare authority services, such as the provision of home helps and of home nurses for old people returning from hospital to their own homes.

There has thus been some improvement, but much more remains to be clone, and we cannot afford to regard the existing state of affairs with any complacency whatever. There are still, on the one hand, considerable numbers of old people in welfare homes who should more properly be in hospital; and, on the other, not only old people in hospital suitable for discharge to welfare homes, but—and these form, to my mind, the greatest ground for concern—very substantial numbers of mental hospital patients who should never have gone into mental hospitals at all but should have found a place in the welfare homes. Those patients, it is our experience, however wrong it was in the first place that they should have gone into mental hospitals, are better not transplanted again. The transplantation back into a welfare home, into a different environment, is very apt to produce a breakdown that sends them back again to a mental hospital. I think we have to be very careful that for the future no more patients who are not really mentally sick, old people who are merely a little confused, do not find their way into the mental hospitals as they did at one time in very large numbers.

The opinion has been expressed that these matters cannot be administered successfully unless the dichotomy in the responsibility for the care of old people is removed and legislation is so amended as to make a single authority, either the local authority or the hospital authority, responsible for the care of all the old people in each area, whether they are sick or whether they are merely infirm and senile. That is, of course, a nice, tidy theoretical solution if one looks at this problem as an isolated problem, but it is not and can never be an isolated problem. It is bound up, on the one hand with the provision of medical and hospital services for other purposes, and. on the other, with the provision of domiciliary services generally. It is not really a practical possibility that the welfare services for old people should be detached from the other welfare services of the local authorities and transferred to the hospital authorities; nor did the widely canvassed proposal that the National Health Service should be handed over to the local authorities find any favour with the Guillebaud Committee.

Nor, if these suggestions were within the field of practical politics, would they, to my mind, offer any full or effective solution of the problems of which I have spoken. What is needed is not a tidy, theoretical, paper solution; what is needed is a real understanding and knowledge of the problems and needs of the individual old people on the part of the hospital officers, on the one hand, and the welfare officers and the wardens of old people's homes, on the other, and the closest possible measure of co-operation and liaison between them locally, each knowing the needs and problems of the other and each knowing how he can assist the other. That is, as I believe, the course that we should pursue in our search for the best solution of these problems; and we have already progressed some way along it. We have, I am glad to say—we should be most grateful to those who have helped to bring it about—the closest and most friendly co-operation between the regional board and the local welfare authorities, certainly in the region that is my particular concern, and I believe that is true generally. What we should now do is to concentrate our energies upon ensuring that that close and friendly cooperation, with all the give and take that it implies, is fostered and flourishes at all levels, and especially between those who have the aged hospital patients, and those who have the old people in welfare homes or in their own homes, under their personal supervision. In that I believe that we are already beginning to succeed.

My Lords, the genius of this nation is not a genius for logic; that is the genius of the French—and look at the pass to which it has sometimes brought them! The genius of the British nation is a genius for compromise, for making things work. If that were not so our National Health Service, which is full of illogical anomalies, would not work at all, let alone progress, as with all its faults it undoubtedly has progressed in the last few years. I hope, therefore, that in this field of the care of the old people, rather than trying to turn the existing system upside down, as well-meaning people have proposed, we shall direct our efforts to making it work, and work well, for their benefit, as I firmly believe that it can and will be made to work.

3.43 p.m.


My Lords, let my first words be words of congratulation to the noble Lord who has just spoken with such authority, because it springs from actual knowledge of the conditions. I belong to the same profession as he does, and have had a great deal of experience in all parts of London, particularly, as well as in other parts of the country. I see quite clearly that what really requires to be done is that some people should sit round a table, with all the facts before them, and try to achieve something which will make the arrangements work.

The noble Lord knows a great deal about this problem—more, in fact, than I do. He would no doubt tell me that there are great differences between the treatment given to the old and infirm in various parts of the country. I know myself how different parts of the country vary, and I feel it rather extraordinary that we should have gone on for such a long time "pottering about" (if I may so describe it) with a problem of such grave importance, especially to the old people who are subject to the "pottering," and that there has been no general, complete inquiry into the whole subject over the different areas of the country, so as to get a rational knowledge of what is required to be done in the country as a whole. It is no use going on as we are, pottering. We must have something much more definite, much more precise and much more thorough than has been the case up to the present.

I think it is quite impossible for us to continue to talk of what should be done in this part of the country and what should be done in another, because everyone who knows the country, as I have no doubt many noble Lords do, knows how different customs and manners prevail in different parts of the country. It does not follow that because a system is working well in one area it will work so well in another. I believe that we have to attack this matter by the simple procedure of applying common sense, and by inquiry, in different parts of the country, as to what are the numbers concerned, and how far the treatment is being successful, even if only provisionally successful. Then we should seek to get on with a general plan which, though not the same all over the country, because of the differences that exist between one area and another, will at any rate enable the authorities concerned to see that elderly people, whether infirm or actually in need of medical attention, have the treatment they need.

I cannot for the life of me see why we should not set up a Committee, not composed wholly of medical men and women but also including others, to survey the situation in the country as a whole and see what can be done. I have had a great deal of experience, particularly in London, of what can be done in these matters. I know how much can be achieved by persevering and by sometimes being obnoxious to one's administrative superiors. I was for a long time employed as one of the inspectors of schools in London, and I was constantly being obnoxious to my superiors—and, by being obnoxious, constantly getting things done. I believe that if we could have a commonsense survey of the situation it would be a good thing. Never mind what has been done in the past; let our objective be to see that infirm people and the sick are looked after; that there are no boundaries between one group of people and another, but that there are only differences in the methods of treating them, in whatever areas treatment may be found necessary. I should by no means agree that these areas must necessarily be the present areas that are used for administrative purposes, whether with regard to welfare or with regard to medical treatment.

It seems to me that there might well go out from this House a proposal that there should be set up a Committee to examine the whole question thoroughly and systematically, with a view to providing a system which will ensure that those who are infirm are looked after, and those who are sick are looked after, in all circumstances, whatever they may be, and that we should not have what appears to be the quite ridiculous situation which exists at present. We have had a bad situation in the past. Noble Lords, especially those who are doctors, will remember that in London and in other large cities, before the medical treatment of schoolchildren was introduced, children were not being treated at all. At the same time, children were not having adequate meals. It was found possible to do this in the London County Council area (I was one of the people who brought it about), and we now have a good feeding system, as well as a very good system for the treatment of ailments, of whatever kind they may be—sometimes difficult ones. But we should not try to make one plan for one place and another plan for another, and then try to add them all up and make them into a coherent plan which will suit the whole country. I do not believe in that.

In my view, we ought to have the whole country surveyed, not in detail but in outline, and a plan laid down for the country as a whole. It should not be done from district to district, but should be a plan for the country as a whole, differing in its treatment according to the circumstances of the individual district. I do not think that it is necessary to provide statistical details of what is dietetically necessary for each particular meal, nor do I think that the whole of the details that have been mentioned today need necessarily be considered. We ought, however, to see that the difficulties are surmounted; that we are guided by plain, ordinary, common sense, knowing that old people, and especially sick old people, need to be looked after; and we should get this scheme into operation in a comparatively short period of time.

To end, may I just point out to your Lordships that it is not long ago since there was no feeding of school children in London or in other great cities. I am afraid that I must state this personally, for it cannot be avoided, to be truthful. It was achieved very largely as the result of an experiment which was carried out in London, partly by other county council medical officers and partly by myself. I was the promoter of the proposal. We prepared a diet for school children and arranged to have it supplied. It was not a plan for theoretical discussions on the subject but simply for feeding children properly and seeing what that did for them. It was really wonderful and interesting to find that when children from poor areas were properly fed they gained in weight, intelligence, activity, and in every other way, and became like the other ordinary children in the country.

I believe that we ought to apply ourselves to the proposal to set up some kind of national Committee to look into this whole question and to see whether the extraordinary difficulty which exists at the present time between those who are welfare cases and those who are sick people can be overcome. We ought to see that we solve these problems by common sense and straightforward thinking, based on actual up-to-date medical knowledge. We should see that we get rid of this ridiculous situation in which a large number of people in this country are suffering all kinds of inconveniences, sometimes in very grievous conditions, simply because we have not a general national plan which can be modified as necessary for local conditions and applied to the country as a whole.

3.53 p.m.


My Lords, I should like to join the noble Lord, Lord Haden-Guest, in congratulating the noble Lord, Lord Cottesloe, whom we have heard for the first time, and to express the hope that we shall hear him often again, particularly on this subject, which is one of the most important that your Lordships can ever have to consider.

I rise principally for the purpose of saying one thing which has not been said in this debate. Owing partly, no doubt, to the economy of which the noble Lord, Lord Amulree, complained, and perhaps to other causes, about eight years ago the various authorities who had to administer the Welfare and Health Services, being appalled by the magnitude of the problems and their difficulties, rather reluctantly called in volunteers to help them. Since that time the work done by those volunteers in various areas of Britain has been so useful, so enormous and so utterly admirable that I feel that a debate of this kind ought not to pass without public tribute being paid to them. If it were not for them the difficulties which the system encounters would be much more manifest and many people who are now looked after and cared for probably would have passed undiscovered and died in unpleasant circumstances.

The fact is that to-day the death of any old person, neglected and uncared for, is reported in the Press only as a very rare occurrence. I feel that that is largely, I am inclined to say principally, due to the entirely voluntary charitable work of people in the various areas, who themselves saw the duty, formed committees, trained themselves and submitted themselves to discipline in order to carry out the task. That is the more admirable because we in this country are very independent; and if one considers the various charities of different kinds in the area of London one sees how very independent we are. Yet here we have an enormous number of people voluntarily putting themselves under a State system and working to make it a success. I hope your Lordships will agree with me that that effort demands the highest thanks that Parliament can bestow.

There are one or two small points on matters raised by the noble Lord, Lord Amulree, to which I should like to refer in passing. I do not want to alter the system; the thing is to make it work. But I have always been of the opinion that welfare would be much better administered by the boroughs than by the counties. They are nearer the ground, nearer to the people and nearer to the problem. There are many things which happen in the Welfare Services and which probably cannot be avoided but which would be much more easily avoided and remedied if the authority was at borough and not at county level. However, it is too late to hope for that: it is a county business, and the only thing one can do is to point to some of the dangers.

I believe one danger is that in many cases old people's homes built by committees are probably rather more expensive than they need be. If I were to try to build a home in which to take in old people, I would have grounds as beautiful as I could get and would take steps to get the old people themselves to look after the premises so far as they were able. I think it is a great mistake not to make every effort in old people's homes to keep those people on their legs, doing something. I am inclined to think that in some of these homes that aspect is not studied quite as much as it should be studied. The example of the two old ladies given by the noble Lord, Lord Amulree, rather bears out what I have said.

There is another point which I have mentioned before. I know its difficulties. It is a purely welfare matter which affects others besides old people. I refer to the home-help service. The best welfare officer that I know begins the real business of the administration of the home-help service at five o'clock in the evening and goes on until any hour; because, as I have pointed out to your Lordships on more than one occasion, one cannot run a home-help service from an office, for most of the important work is done out of normal hours. May I give your Lordships an example which came to my notice only a short time ago? The wife of a working man fell sick. He had to go out to his work and was compelled to call for a home-help. This particular home-help was so dirty and impossible that he had to send her away again. The man found that his wife was better off without that home-help. I realise perfectly well that it is a very difficult service to organise, but no man can know how his people are working unless he is visiting the people who are being helped after they return home from their own labour.

That is the kind of difficulty which the Welfare Services encounter. I know that everyone is trying to make them work well, but that is one of the things which make me think that the borough level is much better for Welfare Services than the county level. Perhaps one day there may be some system of delegation which will enable some effect to be given to my views. In the main, I have carried out the task to which I principally set myself—that is, to draw the attention of your Lordships to the enormous debt which we owe to the voluntary welfare workers in this country.

4.0 p.m.


My Lords, your Lordships always readily recognise the consistent and personal interest which the noble Lord, Lord Amulree, takes in the health of the people, and the care with which he always presents facts to prove his case. This has been just such an occasion. It has been enriched by the maiden speech of the noble Lord, Lord Cottesloe. He spoke from a position of authority as chairman of a regional hospital board, and I would echo what others of your Lordships have said: that we very much hope he will speak to us on many occasions in the future, on these and other subjects, and will give us the benefit of his wisdom. I have found only one thing unconvincing up to date in this debate, and that is the claim of the noble Lord, Lord Haden-Guest, that he got things done only by being thoroughly obnoxious.


That was quite a long time ago—before the present Government came in.


I was going to say that I looked forward with apprehension to a further intervention from the noble Lord, but to-day, at any rate, we have escaped his censure.

Lord Amulree to-day has pleaded that more should be done for those elderly people whose disability does not require full hospital treatment but who have to be kept in hospital because no help is available for them, either in their own homes or in residential homes provided by the local authorities. The policy which he and other noble Lords have advocated is clearly good common sense, because if proper co-ordination can be achieved in this field between hospital authorities, on the one hand, and welfare authorities, on the other, then, clearly, beds will be released for those whose need is more urgent. And, of course, it is a wise policy, too, in the interests of the old people themselves, as Lord Amulree pointed out. Indeed, this has been pointed out to the country in an authoritative way on several occasions. The Phillips Committee came to the conclusion that, wherever possible, old people should continue to live their lives as members of the community, and that domiciliary services should be developed and co-ordinated between the general practitioner service and the hospital and the local authorities. That is what we all want—old people enabled to live happy lives as members of the community.

The Guillebaud Committee went rather further, and, as your Lordships will remember, they laid down a Future pattern of development for the hospital domiciliary and residential homes services to meet deficiencies which they, like the noble Lord, Lord Amulree, regarded as being real in the present situation. The programme they laid down was to be put into effect, to use their own words: as and when an increased proportion of the country's resources is made available to the Health and Welfare services. I will return in a moment to the question of the nation's resources and the proportion of them devoted to these services. I think it might be useful to inquire and to satisfy ourselves whether there are any defects in the Acts which govern the situation which might limit the expansion of these services.

Of the principal services provided under Statute the first is a hospital and specialist service, under the National Health Service Act, for those who are in need of hospital treatment, either as inpatients or out-patients. Then there is a residential homes service, under the National Assistance Act, for those whose age and infirmity make it impossible for them to look after themselves. Further, under Statute, services can be provided in the home by local authorities, as local health authorities under the National Health Service Acts. Then there is the home-help service, the home nursing service and a health visiting service. As the noble Lord, Lord Amulree, said, there is no direct power for a local authority to provide a meals service for old people, but under Section 31 of the National Assistance Act a local authority is empowered to contribute to the funds of a voluntary association which gives meals to the elderly. We should not be satisfied, for it may be that in this last respect there is a gap in the legislation. Of that I am not sure, but it is worthy of consideration. In general, I think we may say that existing legislation is comprehensive and covers those requirements which can be broadly classified as "the care of the old". It is then a question of the amount of money which the nation can spend on the Health Services in general, and the proportion of that total amount which can be given to this particular section of health and welfare work, and of the efficiency and co-ordination of hospital and local government services achieved within the amount of money available to them.

It might be useful—and I do this in response to Lord Haden-Guest in particular—if I were to give your Lordships a few statistics under the headings of the background against which we must look at this, the actual position as it is to-day, and the progress which has been achieved over the last few years. The background to this question which we are discussing is that of an ageing population. In 1911, those who are classed as "elderly" numbered one in fifteen of the population. In 1954 they were two in fifteen of the population and in 1979 it is estimated that they will be three in fifteen of the population. So the demands made on the active producers, the younger generation, are increasing all the time, in that it is from their earnings that the expenses of caring for the elderly have in a certain measure to be met. And, of course, there are increasing demands, both on accommodation and personnel, as the numbers of the old grow greater. So there really is an enormous problem here. As one elderly person is removed to live the life of an ordinary citizen, nature probably provides that there is one more elderly person who becomes a hospital case.

Now for an illustration of the situation described by Lord Amulree today. There were in 1955 some 4,500 elderly persons occupying hospital beds who could be moved—who no longer needed full hospital treatment if alternative facilities could be provided for them. They should be moved out of hospital to another form of welfare care, if that could be provided.

On the other hand, according to our calculations there were 2,000 old people who would be better in hospital than in the premises in which they were housed. So, by transfers, and if additional premises and home-helps were all there—in other words, if everything were working perfectly—we could free some 2,500 beds which could be used to better purpose for others in more urgent need. Of course, that is an over-simplification, because it takes no account of geography, and obviously one cannot remove somebody from hospital in, let me say, the North-West of England, and put him in a residential home in the South-East; but, broadly speaking, there are some thousands of beds which could be freed.

The noble Lord, Lord Cottesloe, said that in the face of this challenge, and against this background, undoubtedly great efforts had been made by many people who were giving devoted service to this work. That is perfectly true. I can give your Lordships one or two illustrations of what is being done. In the last nine years, some seventy units for the assessment and active treatment of the chronic sick have been set up. Summoning the remnants of my Greek, I believe that they are called geriatric units. This treatment revolutionises the prospects of old people. The number of elderly out-patients who are having regular attention in clinics has increased largely. Five years ago the number was 7,000; in 1955, there were 27,000, and to-day there are a good many more. Local authorities have opened some 900 small homes and as a result of their efforts some 23,000 places have been added to the 48,000 already available.

I will give your Lordships two final illustrations which do something to measure progress. The home nursing service, of which a large part is devoted to attending to the old, makes 12½million visits to old people during the year, and the proportion of visits by the nurses who do this work to the old, as compared with visits to other sections of the community, has risen from one-third to one-half. The number of home-helps has risen in seven years from 11,000 to 36,000. Therefore, as the noble Lord indicated, it is true that there are great difficulties—in the expanding number of old people, in the provision of accommodation, in finding money and personnel—but, as the figures broadly show, over the last seven years there has been great progress and much devoted work is being done. I think we can conscientiously say that the country is not neglecting the old.

As the noble Lord realised, it would be unrealistic against the background of the national income to expect that there should be a great increase in capital investment in this sphere. if that be accepted. then we come down to this: progress in the field of helping the elderly must rest on greater efficiency in organisation, on greater co-ordination of the efforts of hospitals, doctors and welfare authorities and on greater appreciation by the local authorities of the needs of the old. These are the factors on which we must rely to ensure progress. Can more be done? I think that all noble Lords who have spoken, although looking back rather nostalgically, have rejected the solution that we should scrap the services as they are and put them all under one umbrella. So I will not deal with that. The noble Lord, Lord Amulree, asked me whether the hospitals have power to send away an elderly person who no longer needs hospital treatment but refuses to leave hospital. The answer is that a hospital has the legal power, for what it is worth.

Can better co-ordination be achieved? In spite of all that has been done, I think that the answer must be an unqualified "Yes"; that there is room for much better co-ordination between hospital authorities and welfare authorities. While I am inclined to think that the root of the trouble is the lack of accommodation we are able to supply for those people who no longer need to be kept in hospital, and that part of the trouble is the lack of personnel to look after these old people in their own homes, nevertheless there are certain things which could be done with advantage, and I believe that one of them is a suggestion which the noble Lord, Lord Amulree, made about the joint appointment of geriatric physicians. That has been done in one or two cases and has been successful, and it seems to me that that system might be extended.

So far as meals are concerned, as I have said, the local authorities have in general no power to provide a direct service, but they are empowered to assist the voluntary associations who give meals to the elderly, I think it is true to say that these voluntary associations know perfectly well that often they are not able to give meals of the standard they would like, but they are doing their best. This aspect of the legal powers of local authorities to provide meals directly, and the consequent need to rely entirely upon voluntary associations, is one to which I think further attention ought to be given, and I will recommend the point which the noble Lord has made to my right honourable friend. I can tell him that the Minister of Health loses no opportunity of conveying to local authorities that everything possible should be done for the old to enable them to live independent lives.

The noble Lord, Lord Haden-Guest, asked if we could not have an inquiry. Happily that has been done between 1954 and 1956 by the Ministry's officers, who have made a survey of the services which affect the elderly sick throughout England and Wales. The results have been assessed on a national basis and I think that this method of inquiry is as good as any other. My right honourable friend proposes to issue memoranda with suggestions arising from the survey, and to send them to all hospitals and local authorities so that they may be aware of the findings, which I think broadly support the conclusions to which the noble Lord, Lord Amulree, has come and many of the points which noble Lords have made in this debate. Certainly they will give both health and welfare authorities practical suggestions by which they can improve their services in this respect.

The noble Lord's speech was designed to be constructive in its criticism and to encourage those who do this responsible work rather than to criticise them, to exhort them to achieve higher standards and above all to work more closely together, in a common-sense way. No Government can compel co-ordination and co-operation, nor can an Act of Parliament do so. But if common sense is applied, great improvements can be made. So I would say that the Government sympathise with the aims of the noble Lord, Lord Amulree, and within the nation's means we shall do our best, so far as we can, and my right honourable friend will do his best, to further these aims and to promote them in this important section of the national health and welfare services.

4.20 p.m.


My Lords, before I say one or two words in reply to the noble Earl, Lord Home, I should like to thank all noble Lords who have supported me in my Motion. I was particularly gratified that the noble Lord, Lord Cottesloe, made his maiden speech on this important subject. It was a most valuable contribution to our debate, and I trust that he will come to the House and speak on similar and other subjects on many occasions in the future. I should like to thank the noble Earl. Lord Home, for the kind words he said at the end of his speech. We are all working towards the same end, and the last thing I want is to be destructively critical; one wants to be as constructive and helpful as possible. I am pleased to find that some good may come from my drawing attention to the curious anomaly about the provision of a meal service, because it is not only for the elderly but also for the sick, for whom such a service is particularly important. I think that if the Minister can see his way to increase that facility an enormous amount of good can be done.

One thing that always makes me rather melancholy is when people talk to me, as the noble Earl has done, on the basis that if the number of elderly persons in the country is going to increase, therefore the same number of problems will persist. What one is trying to do—and I think with some success—is to prevent people, when they grow old, from needing as much attention as old people need to-day. One does not want more homes and hospitals. If I have one ambition in this life, it is one day to see the number of hospital beds in this country decrease. I am sure that it can be done, although of course it will take some time. I cannot help feeling a little gloomy that we are still confronted with these 60,000-odd beds in the country full of the chronic sick. I should like to know why they are there and what is being done about the matter. However, I will not detain your Lordships further, except once again to thank the noble Earl for his reply. I beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.