CARE OF THE ELDERLY

HL Deb 13 December 1961 vol 236 cc325-416

2.53 p.m.

LORD AMULREE rose to draw the attention of Her Majesty's Government to deficiencies in the arrangements for the care of the elderly, both sick and infirm; and to move for Papers. The noble Lord said: My Lords, once more I have put down a Motion dealing with the problems of the elderly, but before I develop what I am going to say I should like to explain what type of elderly person it is to whom I refer. Most of the people to whom I shall refer in the course of my speech will be taken from the 5 million-odd pensioners, and, there again, most of them will be among those people who are in receipt of National Assistance as well as their pension and who number about one million. A large number of elderly live quite comfortably with their families or with their friends and therefore pose no problem at all; but we find this quite big number—although it may not be very large as an actual number, it is certainly very big from the point of view of their problem—which does pose a great difficulty. Most of the elderly sick will get their treatment in hospital or in their home in just the same way as younger people do.

I do not want to claim for a moment that those services which may be called the geriatric services should take up all people of pensionable age—that is, women of over 60 and men of over 65—but the people I refer to are those people who do require some sort of geriatric service. We must not think of that as being merely a hospital service. It is a service which has to include the care of them when they leave the hospital; the care of those who have no families or homes to go to; and the care of those who want some kind of assistance in their normal life, whether that may be continued in their homes or whether they need to go to some kind of communal home. That sets out the problem I want to talk about; and, because I have set it out in that way, I should like to take the hospital side of the question first. That may be looking at it rather the wrong way round, but I think it is the most convenient from my point of view.

One finds that geriatric departments have now been set up in about one hundred hospitals. They have generally been constructed in what were the chronic sick wards of the old Poor Law infirmaries. There, I should like to make the suggestion to Her Majesty's Government that we call them geriatric departments of hospitals and not geriatric units. If you call it a geriatric unit, that rather makes it appear as if it is something by itself and separate from the normal services, whereas if you call it a department it means that it is an integral part of a general hospital, and I think that that is the conception to which we want to return. We rather have the idea that the elderly sick are something special, whereas they are something exactly the same as the younger sick but they require a better kind of treatment.

One of the troubles about the fact that they are housed in what were, for the most part, the chronic sick wards of the old Poor Law infirmaries is that, in a way, they have not made a great deal of claim. Take the question of staffing—and I dealt with this point the first time I spoke to your Lordships' House, which was, I think, in 1946. One of the troubles is that there are these large hospitals with insufficient medical staff. There are a number of these geriatric departments which have improved a great deal, but a survey was carried out recently by the British Geriatric Society, of which I have the honour to be the President, in which we inquired about the staffing of these new geriatric departments. We found that in the areas of seven of the Regional Hospital Boards there was one physician in charge of 400 beds. Now that, I maintain, makes practical, good medicine almost an impossibility, because not only does the doctor in question have such a large number of beds under his care but, in quite a number of cases, he is not of consultant status. Therefore, he cannot talk equally to his colleagues. He is of a status called senior hospital medical officer, which is a junior grade to consultant; and that, as I have said, does not make it easy for him to get full collaboration from his colleagues.

The other difficulty in most of these areas is the shortage of ancillary staff. Here, I should like to join the noble Lord, Lord Taylor (and I am sorry I was not here for his debate the other day) in paying tribute to doctors from the Commonwealth and foreign parts of the world, to whom we owe a great debt. They are people who will take jobs in these geriatric departments and who will do their work extremely well, and if they were not there I do not know what would occur. The same remark applies to the other branches of medicine which one expects to find in a general hospital. We have not the right number of people in occupational therapy, in physio-therapy, in the almoner's department and in all those other departments of the hospital which we now regard as essential for the proper treatment of patients, whether they be young or whether they be old.

Another difficulty is that these departments are, in general, in what were the old Poor Law infirmary wards, and some of the buildings are buildings which should have been pulled down and demolished many years ago. Some of your Lordships may have seen a certain amount of correspondence in the papers during the summer. when Dr. Sheldon conducted a survey in the Birmingham Region. The conditions he found and the state of the hospitals where the aged folk had to be housed were really too shocking to be believed. About a fortnight or so ago there were two very good articles in the Sunday newspaper the Observer, a London paper, in which a woman called Susan Cooper gave a rather similar account, which again showed that a large number of these elderly sick or infirm people were housed in conditions which savoured of the worst sort of buildings of the nineteenth century.

I will not say that there has not been a certain amount of improvement, because the idea is spreading around that elderly people can be properly treated and must not just be firmly tucked up in bed the whole time. But although I will not say that there has not been some improvement, there is still a very great deal of improvement to come. What is rather sad about what has occurred with the new departments is that we have lost one of the good things of the Poor Law. Although there were not many good things about it, there were one or two and one of them was that a person in need of a bed was entitled to a bed. Whether that was a good or bad bed, I am not going to argue to-day; but a person was entitled to a bed, whereas nowadays people in need of a bed often cannot get into hospital. That just shows what some of these buildings are like.

Then, if some of these elderly folk fall sick and need to go into hospital, there is very great difficulty in finding a bed for them because of a shortage of beds. May I quote one or two figures to your Lordships? I have some figures which apply to the London area. They are supplied by the Emergency Bed Service, which is an organisation set up by the King Edward's Hospital Fund. If a patient is between nil and 50 years of age he has a 98 per cent. chance of being admitted to hospital. If he is between 70 and 80 years of age then his chance has fallen from 98 to 92 per cent. If he is over 80, the figure is down to 89 per cent. That shows that people who really need hospital accommodation find it increasingly difficult to obtain it as they grow older. Again, I think that is something which is rather to be deplored.

What has been found during the past few years is that if these elderly patients go into hospital they can be treated and cured. Of course, a large number of them will die because they are old, and they have gone into hospital to die. But, again, a very large number will eventually be fit for discharge. There we come up against another really big difficulty. It is not so bad if they have families or friends to take care of them, or have somewhere to go; in that case it does not really pose any particular problem. But what one finds—and, here again, I am talking about the big built-up area in and around London, because that is the sort of area where I myself work, and about which I have most knowledge—is that a very large number of people live by themselves, and when I say "live by themselves", I really mean by themselves.

In some parts of London as much as up to one-fifth of the people of pensionable age live by themselves. In the country areas, the figures are nowhere near as large as those for London, but so far as London itself is concerned that is certainly the case. There are various reasons for that. Because London is a great big sprawling area, members of a family may go to work in different parts of London. The family itself does not want to move—there is a very great housing problem in London, to which I shall refer in a moment. Therefore, a large number of people do live by themselves, and do not live in very satisfactory conditions.

One of the things which make it even more difficult is this. I have been going over some of the figures of aged patients admitted to my wards during the past five or six years, and I find a really rather frightening thing. In 1956, 60 per cent. of the people admitted to my wards were at least 75 year of age. In the first half of 1961, the figure had gone up from 60 to 70 per cent. That means that you have a very large number of elderly people coming into hospital, and more elderly people being eventually discharged. Supposing they live by themselves and are unable to cope that creates a very serious problem.

There are two alternatives to deal with that. The first alternative is provided under the National Assistance Act, 1948. If I may just read a brief sentence from Section 21, subsection (1), that Act provides: It shall be the duty of every local authority to provides— (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: For the London areas the local authority is the London County Council and the Middlesex Council. In those areas we find that the amount of accommodation available under that section is extremely limited; in fact, it is nowhere near enough. The accommodation they provide at present consists of two types. Quite a large number of extremely good, new, modern homes have been built, which are comfortable, pleasant to look at, and, I should think, comfortable to live in. But at the same time, several of the old workhouses still exist. There is one in Marylebone; there is one in Islington; and there is one in North London and one in South London. These are great big nineteenth century barracks of places, containing about 1,000 or 1,200 people, and although they have been considerably improved, they are not what you would call very good accommodation now.

The trouble about there not being enough accommodation available in these homes is that a large number of patients—or, rather, let us call them persons who have been patients and have recovered from the acute illness which sent them to hospital—have recovered enough to be able to lead a semi-normal, independent life but cannot do so by themselves, and therefore have to be kept in hospital at the present time. I have ninety beds, and in those beds I have fourteen persons who have been accepted by the L.C.C. as being entitled to have accommodation but who have been waiting for it for between four to eleven months. The longest wait has been eleven months; the shortest, four. That is a very serious state of affairs, because it gives rise to waste of medical staff and nursing and ancillary staff; and people who are sick in their homes and who should be admitted to hospital cannot come in because we cannot get the other persons transferred to other accommodation.

To come to a rather more mundane matter, this, in turn, costs more money, because in a hospital like the one where I work the average cost of a bed is about £41 to £42 a week, whereas if one goes to one of these homes the cost is about £7 a week. I do not want to stress that side of it, but I think it is a point to be taken into consideration; we are being rather extravagant about it. I have talked to officials of the L.C.C. They are extremely kind; I do not say a single word against them. They try their best in a very difficult situation indeed and try to do all they possibly can, but they are confronted with this grave difficulty. I think that for the complete L.C.C. area there is a waiting list of about 500 persons, of whom about half are in hospitals and half are in their own homes. Quite naturally, the L.C.C. first take people who are in their own homes, because they are in need of some kind of care, whereas those in hospital are certainly being taken care of already. Therefore, it means that if there is a long waiting list the future is a little difficult. I suppose that to accommodate 500 persons would require five or six new homes, because the new ones they are building take between eighty and ninety people.

Things are going to be worse than that in future, because one of these big workhouses, which is now called Luxborough Lodge, is going to be pulled down. I think that everybody would agree that that is a very good thing. Although it has been improved a lot during the last 12 or 15 years, it is still not an attractive place in which to spend the rest of one's days. It contains from 1,000 to 1,200 people and they have to be rehoused somewhere else. It is not a very difficult sum, if you know that the new places are going to have 90 beds, to get the result that some 10 or 12 new homes will have to be built over the next few years, and then Luxborough Lodge can be pulled down. But that means that there is going to be no increase in the number of beds. The type of bed will improve, but the number will remain the same, and the problem I am talking about will continue.

I do not want to criticise the L.C.C. at all violently, but this raises a point in one's mind when they are talking about building a National Theatre and the like. Although I am greatly in favour of building a National Theatre, and by the L.C.C., I think we have to get our priorities right somehow. Surely, building to deal with a great social problem like this is a greater priority than a National Theatre.

I am bound to say that things are not so bad in the country. In Scotland, for instance, as the noble and learned Viscount on the Woolsack will appreciate, things are very much better. The average waiting time is about two weeks, and if old people have to wait longer the doctors are very surprised and shocked. They do things better there than they do down in England.

One of the great problems we are up against is what to do with people who have recovered, who have been rehabilitated in hospital, and who yet cannot go back to their homes, particularly when they have no home to go to. This is the third problem, the question of housing. Again I must refer to London entirely. A lot of people could go home if they had some reasonable house to which they could go, but we have the old story in London of tenement houses which were built in the middle of the nineteenth century as family dwellings and, because a change of population has occurred, have been cut up into single rooms and small flats, but not improved inside. They are often four-storeyed houses, with maybe another storey in the basement, and one finds even now that in these houses there is only one w.c. on the ground floor or frequently across a little courtyard. The old folk generally go to live in the basement or on the top floor, because the rooms there are cheaper, and that does not make it very simple for them, if they have to come down several flights of stairs and cross the courtyard every time they want to go to the w.c. It is quite common for old people not to be so continent with their urine as younger people and they need to visit the w.c. more frequently.

One would have thought that, if a person was well enough to be discharged, it would be easy to find a house for him, because a great deal of building is going on now in London; but during the last 18 months I have managed to get only three people rehoused out of quite a number who needed rehousing. Sometimes I do not even think it worth trying, because I know there is absolutely no chance of getting a new house for them. They have to go on living in these most uncomfortable conditions, which lead to their health breaking down again and to the recurrence of long-term degenerative diseases, and they need to come back into hospital again for treatment, which is both expensive to the country and uncomfortable to the person concerned. The principle was enunciated by Edwin Chadwick, the great social reformer in the nineteenth century that if we get proper houses, proper mains, proper drains and good environmental condition, we are going a longer way to stopping infectious sickness than we think possible. If we want to prevent old people from becoming sick and causing a lot of difficulty, we should press on with getting more and more houses for old people. I know that I shall be told that a lot has been done. I agree; but it is not nearly enough. When one sees housing accommodation being torn down to make way for the building of new blocks of offices, when there is this crying need for all sorts of people to be housed, it makes one wonder whether there is not something wrong somewhere.

There is one question I should like to ask the noble Lord, Lord Newton, who is going to reply, of which I have given him prior notice. I would ask whether the Government can tell me the number of people who are at present bedfast in their own homes and the number who are permanently housebound. This is information which is difficult to find, but perhaps figures have come in from regional boards from which it might be possible to give some idea of what the total may be.

Supposing old people do go back home, many can cope perfectly well by themselves, but a certain number cannot. There are a certain number of domiciliary services available. The first, and most important, is the home help service, which consists of somebody going to the homes of old ladies, old gentlemen or old couples, to keep the place clean, cook meals and do the shopping. There is also the home visitor, who is very important. These services should be expanded, but that is not so easy, because the home helps are volunteers and obviously volunteers are the most suitable people for this kind of work. It is a service which, I think, can never cover all needs, but I think it can be extended, if more propaganda were done and more encouragement were given to people to take on this extremely valuable job.

The home help service was started from the maternity and child welfare service. I see the noble Baroness, Lady Swanborough, shaking her head. I am sorry if I am wrong, but I think that that was one of the important aspects of health visitation which produced the home help service. It happens sometimes that home helps are taken away from old people to visit younger persons who are ill and the old people are left by themselves. Another valuable service is the district nursing service, which does an enormous amount of excellent work and keeps a large number of sick people comfortable in their homes. What we should do without it, I simply do not know. I should like to see it encouraged and increased, if possible.

The next important question is the supply of a midday meal. I do not want to go into this in detail because we had a long debate on this during the summer, but I should like once more to stress the importance of the midday meal. A great deal is being done by voluntary service, which is doing a fine job of work. They are serving more meals now than they were a year ago, but we cannot say that the country is properly covered until it is possible for everybody who needs a meal to get one five days a week. I do not say that all will want this, but a five-day-a-week service of meals should be possible so that old people and the sick can really stay at home and be properly fed. A six-day week, with the weekend, can be difficult, but a five-day week service is perfectly possible. At the same time, one would like it if some of these meals could be given in the form of rather simple diets—I do not mean an elaborate form of dietetic service—so that it would be possible for people who need special feeding to have the food provided. That is why, if you are going to have the big meal services going, you must have some kind of medical advice attached to it so that the diet question can be solved. However, there is a Private Member's Bill in another place dealing with this matter and I will not go into it further.

There is one other point on which I should like to touch, and that is the question of the health services and the welfare services. One of the difficulties which occurred when the National Health Service Act and the National Assistance Act came into force was that they ran on parallel lines and there was little point of contact between the two. It appeared to be all right on paper, and the Government of the day told me during the debate on the National Assistance Bill that they were fully conscious of the need for a close liaison between the health and welfare services, because otherwise matters would not be satisfactory. Things were not satisfactory for quite a long time, but I am pleased to say that they have improved now, because the Local Government Act, 1958, made it possible for county councils to delegate their powers to authorities with more than 60,000 members; and most of them have taken advantage of this and have put the medical officer in charge of the welfare and health departments. I am sure that will make for simpler and easier running and for a far better service not only for the old but for younger people as well.

At the same time, some eleven of the county councils have put their medical officers in charge of the welfare committees; and some of the county boroughs—21 out of a very large number—have done this, too. Once again I am afraid I must say that things were done better in Scotland, where the large burghs, which cover a very large part of Scotland, combined the services under the health authority. That is two occasions to-day on which I have said that they do things better in Scotland.

LORD TAYLOR

They have a higher infant mortality rate.

LORD AMULREE

Never mind. To continue, that again was one of the great advantages of the old Poor Law. I said that there were two; I have quoted one, and now I will quote the second. It is that if you got people in the old workhouse they had an infirmary attached and it was possible in winter for the sick and frail people to be transferred to the infirmary, with no question of administrative difficulty, and in the spring they went back again to the house. I am not wanting to get that system back, but it was important that there was no trouble in getting sick people into hospital and fit people into some other kind of accommodation.

Finally, I want to put to the Government that what we have never really known is the total number of beds required for the elderly population who are unable to live in their homes. We have some idea of the number of hospital beds required; but there is an enormous number of different kinds of beds wanted, some with a good deal of care and attention and others with not so much. But for people who cannot live alone, we just do not know what number is wanted. That is something I should like to put to the Government, to see whether we can get some figures out of the total number of beds required in any one part of the country; and it will not be the same all over, because parts of the country differ widely in their social structure. It would be a good thing if we could get some figure as to that, because we could then really begin to think about a proper co-ordinated service for those old people who require it. As I said before, housing is the crux of the whole matter. If you have your population well housed in appropriate housing you will not require so much institutional and hospital accommodation and your people will be much more comfortable and happier. We are going to have more old people, and I hope that what I have said to-day may help them in the future. I beg to move for Papers.

3.26 p.m.

LORD TAYLOR

My Lords, any of your Lordships who wish to see the Welfare State at its best cannot do better than go and visit the geriatric department at the University College Hospital which is looked after by my noble friend Lord Amulree. It is housed in what was one of those terrible old workhouse buildings, and any of your Lordships who knew St. Pancras Infirmary as it used to be in the Poor Law days, overlooking the coroner's court, and not the most cheerful of spots, between St. Pancras and King's Cross stations, would hardly believe your eyes if you went there and saw what beautiful geriatric wards have been created out of those old wards by spending public money really sensibly and intelligently. I think there is a lesson there for all of us when we look at old buildings and wonder whether they ought to be pulled down or converted. It is surprising what can be done by conversion, and very often conversion is cheaper.

I agree with almost everything that the noble Lord has said—perhaps not everything about Scotland, and I would make one or two other provisos which I shall come to in a moment. I am sure, however, that we are all grateful to him for drawing our attention to the problems and difficulties and deficiencies in the services for old people. I count it my good fortune that I have spent a good deal of my life with people who are much younger or much older than myself. It is very nice to be with young people, because they are so full of vigour and enthusiasm; but I almost enjoy the company of older people more, because one learns so much from their experience and wisdom. There comes the point when one's young friends suddenly start calling one "Sir" and one realises that one is getting old. That is the time, of course, to enter your Lordships' House, because all of a sudden you become "My boy" again. That was one of the most delightful things that happened to me when I arrived here.

In the fifth chapter of the first book of Aristotle's Rhetoric he describes what he calls Eugeria, which is the art and science of growing old healthily and sensibly, and I think that is nowhere better exemplified than in your Lordships' House. I am sure that this process has to start when one is young. You cannot start to grow old when you are getting old; you must learn about it when you are young. It involves having the capacity to amuse and occupy oneself, by oneself it may be, because old people have to spend a good deal of time by themselves in their own homes. They do not mind this, but it is a great help if when they were young they learned to do things for themselves and to enjoy doing things for themselves. For it cannot all be done by other people, however much they may try.

Inevitably very old people live in some measure in the past, when they remember with advantage the feats they performed in other days. I feel that the B.B.C. could do more for them by having perhaps a special programme once or twice a week for the very old, enabling them to live again the days of the 'nineties, hearing the old songs and old stories again and the old music they like. The B.B.C. do many good things for the blind and other special groups. The very old, with an exceptional point to which I am coming in a moment, merit their special consideration.

When I was thinking about this debate, I went to visit one of the old buildings to which my noble friend Lord Amulree was referring. It is a building called "Hillside", and is at the bottom of Highgate Hill. I am sure the noble Lord knows it well. It was an old workhouse, and it is now one of the large L.C.C. homes for old people. While I was in there I met a dear old lady of 105 who had broken her femur, which is the large bone of the thigh, when she was 102, and had had a satisfactory operation. There she was, not perhaps hail, but not too had. When I got back home my children said, "Did you ask her the 64 000 dollar question?" I said, "No, I forgot." It was just a sign that one was getting old. The 64,000 dollar question was, "Do you get a telegram from Her Majesty The Queen on your 101st, 102nd, 103rd and subsequent birthdays?" I subsequently found out that you do not; you get it only on your 100th birthday; therefore, if you whack up a good score you do not get another one. It is not usual, and one can perhaps understand the difficulties that might arise.

This old lady is in one of several wards for bedridden people, the great majority of whom are incontinent. There is no smell, and no bedsores. It is a very nice ward, although it is a very old building. There are four-hourly changes of linen by the nursing staff, and in the laundry of that home 16,000 articles have to be washed every week. The average age of people admitted to that department—it is not an institution; it is a home—is 72 to 85; some are 95. The average age of death is 79 for men and 86 for old ladies. They live for years and years, up and about, most of them, although some are in bed. They live a very simple, sheltered existence. They are warm, clean, and well fed. There is a gradual closing in of interests as they get older. There are plenty of games, cards and handicrafts that they can do. There are books in the library, but as time goes on they do not want these things. They just gradually close in. The very old ones do not altogether like the radio, partly because they are deaf and it muddles them up if they have a deaf aid. So their lives become simpler and simpler. They just sit and think, or perhaps sometimes just sit and watch the television. As long as they can watch the television, that is a very good thing.

This sort of cabbage life of some of the old is not necessarily an unhappy one, for with the blunting of the senses there appears to go a blunting of sensibilities, which is a good thing. They have no reason to die. They do not very often become ill. They appreciate their food very greatly, and at "Hillside" one of the nice things that have recently been done is that they have a trolley from which the patients—they are not really patients, but old folk—can buy things. They have 11s. 6d. a week pocket money after they have paid for their accommodation. Three months ago they started having Guinness on the trolley, and I am pleased to say they are taking 80 dozen bottles of Guinness a week off the trolley, which is a very good thing indeed.

BARONESS SUMMERSKILL

That is advertising.

LORD TAYLOR

This is not the B.B.C., my Lords. I still think it is a very good thing indeed. If these old folk cannot organise their money, if they are too confused to hand it out, it is kept for them. An account is kept, and if they want any little things they just ask for them and get them. I think we should all agree with what the noble Lord, Lord Amulree, said: that old people should be able, with help if necessary, to look after themselves in their own homes. I know my noble friend Lady Summerskill is going to say something about those homes in a few minutes. But in the attainment of this ideal everything depends on those services which my noble friend Lord Amulree was mentioning. There is the home itself. It should be small enough, and within the capacity of the old person to cope with. There is nothing sadder than to see old people landed with houses too big for them, and yet, because it is their home they do not and will not move out of it. Yet they cannot cope, and you see a gradual deterioration. It is much better if they can move into accommodation within their capacity.

Secondly, relatives and friends should be near at hand. I entirely agree with what my noble friend Lord Amulree was saying about the tragedy of the lonely old people in London and other great conurbations, where loneliness can be far more real and terrible than in the smaller towns and in the countryside. Then there are the home social services to which my noble friend referred. To the first line of detection, which very often is the general practitioner, one would add the parish priest. I hope the right reverend Prelate, the Lord Bishop of Sheffield, will say something about the work of the parish priest and the old people, because I think the parish priest has a very important part to play, not only in knowing where they are—because that is one of the problems—but in this simple act of being a friend to them.

I would join with my noble friend Lord Amulree in paying tribute to the district nurses. They do the most remarkable and wonderful jobs with these old folk. They nurse them at home with never a mark on their backs, and it is quite remarkable how they do it. The Lambeth Borough Council run a special laundry service for those old folk who are incontinent in bed at home. That is another wonderful service, and a very good thing. I am sure many other borough councils do the same, but it just happened that I came across that instance to-day. Now the home helps. Again I endorse all my noble friend has said. With regard to "meals on wheels" we cannot say enough for them but, alas! there are many areas where they are not yet available. When my friends say that, I always reply, You write to Baroness Swanborough, and all will be well we hope"—and often it is.

There are other folk who ought to be available in a home. There are the chiropodists. Old people need a chiropodist very much indeed. More and more local authorities are providing chiropody clinics for old people, cheap or free, but not necessarily a mobile service. I do not know of any, but I believe there are one or two services where there is a mobile chiropody service to go to the old people who cannot go to the clinic. Then there is home physiotherapy. There is a great shortage of physiotherapists, and the hospitals have said that they must concentrate these physiotherapists in the hospitals. I am not sure that that is right. I think there is a great deal to be said for bringing a physiotherapist to the old people in their homes, particularly those people who are not necessarily bed-bound or room-bound.

As my noble friend Lord Amulree has said, some of them are stuck at the top of a house for life. It is an awful thing. There they are, at the top of these high blocks in St. Pancras and Islington, unable to get down. One of the great jobs is to keep old people mobile. It is all too easy to let them take to their beds and stay there—because they want to, very often—and of course it makes the care of them easier in the home. It makes them easier to look after if they are in bed. One of the dangers is the danger of mental apathy because by being in bed and doing nothing there follows circulatory enfeeblement due to muscular disuse, difficulty with the bowels and all sorts of other difficulties which may make the job of the geriatrician not difficult, but sometimes impossible.

We are all agreed about the value of holiday homes and holiday periods for these old people, either in a hospital in a geriatric department, or in a welfare place where they can go for two or three weeks just to give the relatives a break. Very often by doing that it is possible for the family to carry on with their home care. May I express my own personal gratitude to the noble Lord, Lord Amulree?—because he, in his unit, gives just that kind of help, and my family have actually had experience of it. But there comes a time when home care becomes impossible. Often a widow carries on for a year or so after the death of her husband but, being a very old person, she finds she cannot cope. Or an old man is without a wife or relations. They, in the words of the circular which the noble Lord, Lord Amulree, quoted: … are in need of care and attention which is not otherwise available, and are not sick. Then they become eligible for Part Three accommodation—and what a horrible phrase "Part Three accommodation" is. But there it is; that is what it is always called. But 'Part Three accommodation is not as bad as it used to be. It is getting better all the time, but I quite agree with my noble friend when he says we have still a lot to do.

He put the number of places on the L.C.C.'s waiting list for Part Three accommodation (that is, for old people who are not ill but in need of care and help) at 500, although I spoke to the Chief Welfare Officer a little while ago and learnt that it is actually 1,000. His breakdown was not inaccurate, because 400 of them are waiting for selective vacancies; that is to say, people who only want to go to vacancies in small homes, and it is not absolutely urgent that they should go in. That 300, as he said, are in hospital. Again, exactly as he said, the welfare officers are inclined to say, "Those old people are being looked after all right; we will not worry too much about them," but by not worrying too much about them, they are blocking the way for other old people. Again, precisely as he said, there are 300 urgent cases in the L.C.C. area.

The L.C.C. has 8,000 places for these old people; 4,000 in the large homes, which are being upgraded to small home standards; 2,000 in the small homes, mostly of the excellent new variety which my noble friend is talking about; and 2,000 in voluntary homes, which are paid for in part or wholly by the welfare authority and which are making a very real contribution. To each of these there are as a result of the natural course of events—that is to say, because of death—about 100 vacancies a month, although the figure varies with the time of year, and that is what the L.C.C. in the County of London area can accommodate. In 1948 they had 6,600 places for old people, mostly in very unsuitable condition. Now they have 8,000 places, and there are another 700 in the pipeline—that is to say, up to 1965. But I agree that I do not know what the answer to the closing of Luxborough Lodge is, because this will knock out 1,000-odd places and will produce a very serious and difficult situation. Again, I agree so much with my noble friend that it would be very valuable if we could have a real estimate of the whole problem. Nobody knows how many more old people's places are required to meet the need. It cannot be an enormous number because, with a waiting list of 500, not a tremendous number of places would be required to get rid of that waiting list.

A word about conversion or new building. Each new place in a new home costs £1,500; in hospital it costs say £3,000 to £6,000 per place, so it is obviously much more economical to provide such places in welfare authority homes where a smaller measure of nursing care is given than in hospitals. But if we take the conversions, the upgrading of old workhouse buildings, some is very good indeed and the L.C.C. have done a remarkable job. For example, the frightful old corridors and great high rooms have artificial ceilings fitted across them. They all have Parker Knowle chairs, delightful modern furniture, modern little coffee tables, and so on, and they are very homely and nice, even though outside the old building remains an awful old building. Most expensive of all, of course, they have to fit in an entirely new heating system. That sort of thing costs about £900 per place, usually with small dormitories or rooms for couples. There are increasingly places for one old person by his self or herself, but many old people like to sleep two together, just in case something happens in the night and there is somebody to lend a hand. For these the maximum charge is £7 a week. The great majority of the people, however, are getting N.A.B. pensions of £2 17s. 6d., of which they pay in £2 6s., and all must have, as I said earlier, 11s. 6d. a week for spending and pocket money after they have done that.

L.C.C. places have gone up by 25 per cent. in twelve years, and the quality has gone up very greatly, but as the noble Lord, Lord Amulree, said So much has been done, so much remains to be done," and they are my sentiments, too. What has been done is a tremendous achievement. When one looks back to before the war and how we did not look after our old people, one realises that it is a wonderful thing that has been done since the war. We ought to be proud of what we have done, though we still have to do a great deal more. However, matters are moving in the right direction, especially in geriatrics. The subject is new. If we take the country as a whole, the figure has gone up to 84,500 places, an 82 per cent. increase since 1949, since the Health Service came in. But that is not all old people, for one must knock off 11,000 of these places for other welfare cases, such as the blind, deaf, epileptic, physically handicapped, and so on.

As my noble friend said, there is the problem of the margin where the line is drawn between the hospital and the welfare home, though the position is much better than it was. The difficulty is that there are too few beds for both, and so we get the hospital's beds blocked up. The noble Lord quoted his own department. Your Lordships may have seen a letter in the Guardian from Dr. James Andrews, Geriatric Consultant to the South-West Middlesex Group: it is the same situation, only worse. In this hospital his geriatric unit alone has 38 patients, accepted by the Middlesex County Council Welfare Authority, whom they are unable to take. Some of these patients have been waiting over two years—two years in a hospital bed at probably three times the cost of a welfare bed. This, in turn, stops the admission of sick and elderly people who are in urgent need of care in hospitals.

One of the things which strike one when one goes round these beds for the care of the medically sick, whether in hospital or in welfare home, is that of the people who are looking after them half come from the Republic of Eire and the other half come from our Commonwealth. They are coloured folk from the Commonwealth, not only from the West Indies. I met a very nice boy who was a young male attendant and who came from British Honduras. I do know how much we owe to the patience and kindness and the good nature of these people, and the supervisory nursing and lay staff who train them and help them to give of their best, and get so much out of them in terms of efficient and good service. It is incalculable. Are we sure that the position will not be prejudiced by the legislation which is now before another place? We have to be very sure, when that legislation comes to us.

Another piece of impending legislation which will affect this subject is the Government plan for Greater London. I am going to say one thing only; in the distribution of these homes for old people, the L.C.C. has built them where there were sites available. The result is that if you take Wandsworth it will have a very good supply indeed of old people's homes when they all go back to borough status, but other boroughs will not have one home at all. I think we shall have to do some adjusting there; there will have to be a great deal of interplay if we are to get by with it.

I have three more points. The first is the presence of ill-health in the elderly and the importance of dealing with it early. One of my friends who is a general practitioner makes it his business to go round his old patients in the summer when he is not too busy and have a look at them, and give them a general checkover to make sure things are not going on that he will miss in the winter. That is a very sensible thing to do. One of the things which easily gets missed is a condition called chronic glaucoma, which is a gradual increase in tension in the eyeball, which comes slowly and which results in blindness; and yet if it is detected early it can be dealt with. There are a number of conditions where early detection in the old can save a mint of misery and really put off the process of ageing.

Perhaps I may say one word about private nursing homes. These make a contribution, but I am not sure that it is altogether a very good contribution. Certainly the women who run them—and they are mostly nurses; some are run by doctors—are doing a service, but it is not altogether satisfactory. Some of your Lordships will have read the National Corporation for the Care of Old People's Report on Nursing Homes in England and Wales. A great many of them are looking after old people. One defect is lack of sitting rooms. Although 62 per cent. of the elderly patients seen in this survey in private homes were not bedfast, few proprietors seemed to provide sitting or dining rooms. They had single rooms but no sort of social mixing. Ten to twelve guineas a week was the average charge, though many were more expensive and there was no clear relationship between the price paid and the quality of care received. I know that many of the old folk who go into Part III accommodation, having been in private care, say it is better in the new circumstances. One cannot blame the excellent folk who try to run these nursing homes. These homes have grown up because of the demand and because we are not meeting it properly, but it is not really a suitable form of private enterprise, because one cannot do this sort of thing really well and make a profit; the better you do it, the less money there is to spare.

I would say one word about the role of charitable bodies. I am delighted to see that immediately after me the right reverend Prelate the Lord Bishop of London is to make his maiden speech. I used to be the Member of Parliament for the Barnet constituency and he used to be the vicar of High Barnet. He went up and I went out; he was promoted and the Barnet electorate rejected me. It is very nice indeed to see him again after all these years, and we are delighted that he should have chosen this occasion to make his maiden speech. I want to say one word about the valuable work which the churches can do and in some cases are doing for the care of those who are slowly dying. The Roman Catholic Church has done most in this sphere; they do a very remarkable and wonderful job, not necessarily for old people though often for old people.

Some of your Lordships may know a very remarkable lady called Dr. Cecily Saunders, who started as a nurse and was impressed with the plight of those dying in these circumstances that she became first an almoner and then a doctor. She has now set out to try to build a hospital for the dying and has got to the point of raising £50,000. She will succeed, I have no doubt, and if any of your Lordships can help her it would be a fine thing. It is a wonderful effort she is making for patients of all denominations, but actually within the Church of England—what the Catholics are doing so well for their people. She is now our greatest authority in this country on the care of the dying. I commend her activities to your Lordships.

I would say one last word, and that is about research into ageing and the differential rates of ageing of tissues. It is an extraordinary thing, this business of growing old. Human tissues repair and replace themselves throughout our lives, and if you take human tissues and grow them in tissue cultures outside the body some will grow for ever, so far as we know. There was taken from a lady called Helen Lane many years ago a tumour which has been sub-cultured and grown in laboratories all over the world. She has been dead for years but her tissues are going on growing indefinitely. They are know as Hela tissues. This apparent agelessness of undifferentiated tissues makes one wonder whether old age as we know it is a normal process or a disease.

There is a clue here. I mentioned at the beginning of my speech a word called "eugeria". There is a condition called progeria, which is very rare. I have seen only one case. It is premature senility occurring in children. The one' I knew was a sweet little girl aged 13, but her body was that of a woman of 70 or 80. She had advanced osteo-arthritis, arterio-sclerosis, and her mind was the mind of an old person. This premature ageing gives one a clue. It must be a disease. It must be that something has gone wrong with that little child and made her tissues grow old far too fast. It may be that in due course we shall be able to prevent this disease so that we shall grow old in years but not old in our minds and bodies; and what very excellent things can follow from that! The question of Life Peerages will have to be thought about again, because goodness knows how long we shall all go on being Peers for life.

A country general practitioner friend of mine, on analysing deaths in his practice over the past four years, found there had been 84 of them among his 2,000 odd patients. The peak age was 80 to 85; there were 7 deaths over 90. He summarised his conclusions in these words: If you can avoid cancer and severe high blood-pressure, you have a very good chance of living to ninety. If, in addition, you can avoid all disease of the heart and blood-vessels, there seems no particular reason why you should die at all—if you are wise enough to live in our village. Here, surely, is a plain case of Back to Methuselah. Your Lordships will remember this excellent play by Bernard Shaw. I thought it was his best. A couple of gentlemen called the Brothers Barnabas lived on Highgate Hill, and they were really prophet biologists. They spotted that it might be possible for people to go on living, because they wanted to go on living, for 300 years without deterioration of the tissues, and then, and only then, would good government of mankind become practicable. To learn wisdom in the conduct of our affairs we need not one lifetime but four. The follies of youth weigh heavier than its achievement; the true wisdom of age more than balances its rigidity and conservatism.

In broad principle, I think the Brothers Barnabas were right. The coming of the antibiotics, modern anæsthesia and modern surgery on the old, has started to make longevity the rule. In the next twenty or thirty years I think we are going to see fresh biochemical advances which may have even more spectacular results. It is true that the Barnabas postulate of isolated peninsulas of longevity is not being realised, but in fact we are achieving a broad advance on a wide front. The advantages which we enjoy in consequence are already showing themselves.

It is interesting to examine the obituaries in The Times and to strike out everything that happened to persons before they were fifty. It soon becomes apparent that we are already a gerontocracy. Both power and influence are largely in the hands of the over fifties. Indeed, our chances of earning an obituary in The Times depends almost on our capacity to earn a living and to work until well into the seventies.

In British politics in particular, a measure of gerontocracy has been established for close on a hundred years. The physical basis for this is to be found in the very arduous conditions of life in the House of Commons. Only the toughest can survive. The banging, slanging side of politics, the glib and fluent rhetoric, and the demagogy are easy enough in one's twenties, thirties and forties, but they are aspects of political childishness, embarrassing and perhaps sometimes even pathetic when they persist into one's sixties and later. By then the elements of the art of politics should have been learned. Here most of the superlative craftsmen are in their sixties, often their late sixties or early seventies. It is part of the art of politics to know not only when to act but also when to take no action. Sometimes action must be swift and ruthless. Sometimes calculated procrastination is the secret of success. At these high levels, often the right thing is the dull thing. To the outsider, the doughy platitude may seem no more than a doughy platitude. Yet it is in fact nicely calculated to mop up a lot of explosive emotion, which could do a lot of harm.

It may be objected that gerontocracy tends to negate the creative or artistic side of politics. Yet experience does not bear this out. If we take three great pieces of political imagination, the liberation of India, the creation of the National Health Service, and the inception of the New Towns, we find that all the principal performers were in their fifties or their sixties. One has always believed that the best hope for mankind lies in more science rather than in less. In recent years this naive belief has been somewhat knocked about, but it has survived and now it is justifying itself. Virtue is a slowly growing plant. To be truly good one must have known evil and survived, and it takes time. For the exercise of the greatest virtue, one needs the greatest capacity to keep on keeping on to the end of the road. By pushing back that end, we increase the sum total of virtue in geometric progression.

4.3 p.m.

THE LORD BISHOP OF LONDON

My Lords, it is with considerable reluctance and hesitation, not to mention nervousness, that I rise to speak to your Lordships on a subject on which I cannot claim the professional knowledge of the two noble Lords who have just spoken. But, as the noble Lord mentioned, the parochial clergy do know rather a lot about the needs of old people and they do communicate those needs to their bishops. Therefore, though some of what I know on this subject is second-hand, the source is pretty reliable.

The impression that one gets of the situation as it is to-day, and particularly in the London area, is that almost everything which is needed for the care of old people is there, but nowhere is it present in adequate size. The various units or departments are doing extremely good work, but nowhere are they adequate to the need. So we have the problem of lack of hospital beds; we have the problem of old people returning home too soon for lack of sufficient post-hospital homes for them, and sometimes going back to conditions which are appalling. I had brought to my notice recently the case of an old lady returning from three weeks in hospital to the room in which she lived alone, which was itself damp, to the bed which had been unmade since she left it three weeks previously to go into the ambulance to go to hospital. The home help service, "meals on wheels" and the district nurses are all doing magnificent work, but nowhere do they seem to be adequate to the need. The home helps in particular, so often themselves at the mercy of their own domestic needs, cannot always guarantee to be there, and often old people are left for almost days on end, seeing practically nobody and having no contact with the outside world.

There is one aspect on this side of the problem to which reference has not been made, but which I think should come into our calculations—namely, that there seems to be a real need for more places in which the senile and mentally infirm old people may have the right kind of care and treatment, preferably not in large mental hospitals, of which they are inordinately afraid, but in small homes where they can keep something of their sense of independence and of being persons.

There are two other points which I want to pick up and which have been mentioned by the two noble Lords who have just spoken. One is the need for dwelling units of the right kind. I am told that in the course of 1960, 39,000 dwelling units specially designed for old people were provided, and that the same number approximately may be expected to have been provided in 1961. With the increase in the percentage of people over the age of 65, it would seem that that rate of progression is quite inadequate. There is a further point which has been borne out clearly by experience: that old people are happier when they can be accommodated in houses or flats suitable for them, not too far away from where their children and their grandchildren are. That is an aspect of the care of old people which is of vital importance in any properly planned housing developments.

Almshouses perhaps should be mentioned, because they have their own part to play in this subject. I know quite a number of almshouses which cannot be modernised through lack of funds belonging to the trustees. When I was rector of the parish to which the noble Lord referred I was also a trustee, and in two cases the sole trustee, of no fewer than eight sets of almshouses and in one case I was practically reduced to putting the slates on the roof with my own hands because there were no funds at all which the trust could draw upon. Something like 35,000 old people are, I am told, in almshouses at the present time. That number could be raised, perhaps not inconsiderably, if the trustees could have access to funds which are not theirs now, or could obtain further charitable donations and perhaps almshouses (though the word is not a popular one nowadays, but something of that kind), if these could be more the object of charitable gifts and legacies than they appear to be at the present time.

Reference has been made to the work of the voluntary agencies. It is to this that I should wish to draw your Lordships' attention more particularly. On the side of providing suitable accommodation, the voluntary societies are doing a great deal, and are stepping up what they can do. The Church Army itself has, I believe, in the last two years provided no fewer than 57 units for old people. They take over large houses, convert them, put someone in charge who has some nursing skill, and eight or nine old people can live quite happily together. Other societies, such as the Abbeyfield Society depending entirely upon charitable gifts for the capital for the conversions, are able to do a great deal. Perhaps more can be done in this way. Perhaps this illustrates, also, that in the care of old people the voluntary element is of very great importance, for what we do for old people we must, I believe, do out of a sense of respect for them, and not out of a sense of something that must be done because there is a social problem to be solved.

I think it was J. A. Froude who, in one of his essays which I had to learn as a schoolboy, said: In the old man nature has fulfilled her work". In the sense that old people have contributed to society, society, in looking after them in their old age when they can no longer look after themselves, is only repaying a debt which one generation owes to another. But it must also do so out of respect for them as persons, and therefore it is only persons who can care for persons in the ultimate resort.

The desperate shortages, which occur in all parts of the services for old people, are shortages of people. "Meals on wheels", home helps, and all the rest, are all short of people. Even more, we are short of a sufficient number of people to relieve the loneliness of the old. Visiting, which is so badly needed and so much appreciated by the old people, is itself not an easy thing to do. Every young clergyman learns in the first three weeks after his ordination that visiting is about the most difficult part of his job, and the part of his work in which he can drop the largest number of bricks in the shortest possible time. Sometimes those who go to visit old people might well have gained something from the sort of training which a parish priest can give to his curates. But the good will exists.

There are just two other points which perhaps I might mention to your Lordships and which are related to this subject. The first is that there seems to be a crying need for closer liaison between the voluntary and the statutory elements in the service of old people. Both respect each other but, perhaps through shortage of manpower and womanpower, they are not sufficiently closely in touch with each other in many cases. The pilot research project which was carried out by the Birmingham Council of Churches, the Report of which has been published under the title of Responsibility in the Welfare State, shows by a great deal of practical inquiry how difficult it is to create a really effective liaison between voluntary and statutory elements in any part of social welfare, not from any lack of goodwill or good intention, but sometimes because the facilities are not there.

Perhaps both centrally and locally a good deal could be done to make sure that those who want to help can find the old people who need their help, and can help at the points and with the skills which are most needed. For instance, one finds youth clubs doing odd jobs of great importance for old people, like a little house-decorating, going round visiting, or weeding the garden—work of very great importance to the young and of no less importance to the old whom they serve. Other youth clubs hear of this and they think what a very good idea it is, but they have the utmost difficulty in finding any old people to practice on, because the liaison does not exist to put those who want to help in touch with those who need the help.

I believe that here is something that, without any great degree of administrative control, might be made much more effective than it is at the present time. In saying that, I should not wish to appear in any way critical of the services which the local authorities give and of their desire to co-operate with the voluntary services. It is sometimes due just to a lack of someone whose business it is.

Along with that goes another problem which old people experience, and that is, in a sense, the multiplicity of those who can help them. The old people do not know to whom to turn. It is the borough for this; it is the county council for that; it may be the National Assistance; or they may be going to the wrong place. They are not very mobile, if they are mobile at all, and something of the kind of service which the W.V.S. supplies so well seems to be particularly needed to assist the old people to get the help which they require. But, my Lords, this is essentially a personal problem for the old people.

The Lord Mayor of London is in process of trying, with the help of the mayors and lord mayors of the boroughs in the country, to make this Christmas, as he calls it, very specially an old people's Christmas, in which the younger generation bring something of the family life to old people, particularly those who are lonely. That is a splendid thing, but it would be a disaster if on January 1 we forgot all about old people again.

One can only hope that, as a result of the thinking, the action and, perhaps, the publicity which may spring from a debate such as this, more volunteers may be forthcoming, and more people may accept the challenge to be volunteers, to assist all that the medical and other services can provide, in making sure that as many old people as possible are happily independent for as long as they can be.

4.17 p.m.

BARONESS SWANBOROUGH

My Lord, to me falls the extreme privilege of telling the right reverend Prelate, on behalf of the House, how deeply we have appreciated his speech, and especially of saying how thrilled those of us who are keen on this particular subject are to have him speak with so much authority and so much deep understanding of things which, of necessity, cannot be under his immediate jurisdiction. From my own point of view, having heard the right reverend Prelate in other places, I feel that we shall be very fortunate if we have the opportunity of hearing him again and again, even if that removes him a little from his diocese.

I feel there is a very great deal that has been written in the newspapers and said in speeches about the care of old people, which is not absolutely fair. The amount of work which is being done for old people hi this country to-day is greater than it has ever been before, and I believe out-distances anything which is being done anywhere else in the world. But I think that a great deal more must be done, and I think that in examining how those things are to be done there is one thing which perhaps comes well from me, because I am an old person myself, and that is that old people do not like to be termed as "old people". This generic grouping of everybody who is over a certain age level can be hurtful to some of the people who come within that group. Although as yet I am ready to give as good as I get, I am sure that the moment I feel incapacitated I shall feel it extremely strongly myself.

I am quite sure that old people want to remain in their own homes, and there, fore I should like to address myself to a different aspect from the one which was taken by the first two speakers in as much as they spoke mostly on the hospital angle. I should like to speak from the point of view of the old persons living in their own homes, and I should like to do so as someone who has done a good deal of work with human beings, which has made me absolutely convinced that domiciliary care is the thing we must look to on a long-term basis. I think we ought to do this, rather than consider the institutionalisation of the individual, although, of course, it is going to be necessary to have redress in the way of homes or places where nursing can be given, in addition, naturally, to the extra beds which we should like to see in hospitals. I feel that this is one of the most important things we can consider. I should like to see domiciliary care made as perfect as possible, so that we can achieve the maximum results with the least dislocation to the individual we are trying to serve.

I believe that old people of to-day require services on a modern basis, not on a charitable, patronage basis, and I think that the statutory aid of to-day means care by many people in addition to the professionals. To my mind it is necessary to have a subtle and intelligent integration of voluntary services and statutory aid; and I would disagree with the right reverend Prelate in thinking that the most necessary thing to-day is extra volunteers. I think the volunteers are there if one calls for them in the right way, but I think that finance and the opportunity to serve are both very necessary assets if you are going to use the volunteer to the full extent.

I think that we must admit that the one who has the ultimate responsibility is the statutory body which has to accept the difficult case; it has the hardest job of all, and I am quite certain that this debate would be of little value if we were not able to put into practical words what we should like to see the responsible people doing as a result of the debate. Those of us who are involved on a national basis know that the shortage to-day is for homes where old people, destitute or with an income, can have nursing, care and attention because they are too frail, either mentally or physically, to be cared for in their own homes. Anyone who, like myself, has endless requests for help knows how sad it is not to be able to answer the people who write to one as to where they can get relief for their problem or where they can get admission for the patient.

My plea to-day would be for more accommodation for the really elderly who need some form of skilled care because of their mental or physical state. But I feel it is tremendously necessary, if we are going to get help for old people, to see that help comes in a shape in which it can be useful to the younger ones. However devoted a daughter, a granddaughter, a son, a niece or a sister may be, there comes a time when, for mental or physical reasons, residential care must be available for certain people. To-day the inadequacy of the provision is very evident to those of us who get letters from people about their mothers, their mothers-in-law or their fathers who have to be looked after in their homes while, at the same time, the writers are trying to bring up a young family. Often the three generations suffer, and again and again a breach comes between husband and wife and between parents and children because the house is too small, the situation is not possible for nursing, or the old persons themselves present too great a difficulty.

In the past, it was generally accepted that the sick and the handicapped could go to a hospital and that the lonely would be far better off in a home. That theory survived until the 'fifties. Then the realisation came that men and women are happier and maintain their strength and their health much better if they continue in their own homes with such services as are necessary available to them. From this has developed a special series of efforts such as housing, domiciliary care and all sorts and kinds of other services for the elderly. It is within this cadre of services that the "meals on wheels" service, which is at present being debated in another place, has come into day-to-day acceptance as a necessity for those who cannot arrange for their own feeding. The figure for the "meals on wheels" service, which was debated in this House not very long ago, has once more gone up, and, although national figures are not available, I know from the point of view of my own organisation that we are now delivering meals at the rate of three million a year. More could be done if more backing were available in the way of finance, the tools with which to do the job and the premises in which to do it.

Like everybody else, I should like to pay my first tribute to the district nurse. I think that the district nurse is a most wonderful woman who can be called upon to do any job in the country, and her work for the old people on the domiciliary basis is completely indescribable. The district nurse obviously works through the doctor. And the district nurse, the doctor, the health visitor, the home help and the "meals on wheels" service together provide very valuable props to those who wish to remain in their own homes as long as ever it is possible. But all these services are in short supply in regard to the trained people who are operating them, and local authorities are not always willing to incur the expenditure necessary to provide more home helps and more "meals on wheels". Where home helps are used imaginatively, they can go in the morning and in the evening, and the old person is in this way kept ambulant, and they have already been shown to be a tremendous strength to the community.

During the 'sixties there was much more realisation that people living in their own homes do not need constant care and attention but need only the props I have just mentioned, which can be provided through the Health Service. In addition, as the right reverend Prelate and others have mentioned, there are the other things that help so much to keep interest, and therefore health. Occupations and interests which can be supplied by those who wish to help and are ready to assist exist all over the country. The necessity to invoke these depends on the personality of the liaison officer, or the person who is going to link statutory aid to voluntary services; and, as the right reverend Prelate has mentioned, this is a delicate but nevertheless a very necessary function for them to perform.

From the voluntary angle, I have had the experience of working with the biggest single organisation in the whole of the world operating for old people, and from this experience I have gained a vast amount of knowledge about what old people need and what old people like. A great deal is done in the way of clubs for the able-bodied and for ambulant old people, which keeps them well. My own organisation is responsible for some 2,000 of these, and people of good will and understanding run these clubs and do endless things in the way of providing occupations, interests, hobbies and diversions, as well as friendships, holidays and all the things that are necessary. But the people we are all worried about are those who are a little frail but nevertheless are very often ambulant. Clubs with special interests and special facilities are run, but more—much more—attention needs to be paid both by the statutory services and by the voluntary services to the sick and handicapped in their own homes. They do not need to be institutionalised, but they need not only nursing but general care and friendship. which means the extension of good neighbourliness so that the little jobs can be done for them and they do not feel alone.

Under Part III of the National Assistance Act—which, as my noble friend Lord Taylor said, covers care and attention—a superb piece of work has been done throughout the whole of Great Britain, and this has not been an easy task to carry through. National organisations have done a great deal, but I should like to state quite categorically that the great credit for accomplishment must go to the local authorities. They have achieved a most remarkable total throughout the whole of the country; and if you travel, as I do, up and down, North, South, East and West, you cannot but marvel at what has been achieved in the time to transform yesterday into to-morrow.

What I should like to see is all the existing services interlaced so that co-operation results in the team working really together. Where teams work together they work well with the hospital geriatrician and his assistants, with the almoner, the medical officer of health and his staff, the health visitors, the home nurses, the home help organiser and the voluntary services. In those places where the team works as a whole, it is possible to get so much more comfort to those who require it. But co-operation is specially needed between the hospital and the local authority. Within the local authority area the different departments of the local authority co-operate well together, but distance and different municipal boundaries are apt to make a dislocation in handling machinery, and too often co-operation between hospital and local authority health and welfare services is not as good as it could be. This is partly because of ignorance and partly through lack of information being passed from one person to the other.

On the everlasting problem of finance, there is the fact that one lot of finance stems from the national purse and the other from the local. This is a very serious and a very difficult thing, and it is something which must be recognised by all those who are working in this field.

In some areas where the co-operation is good, volunteers are asked, very often at a moment's notice, to get the home ready when a sick, old person who lives alone is to come out of hospital. In this case the almoner rings up the voluntary service and asks that the room or house be prepared and aired, a fire put on, and that a lot of help be given during the first few days immediately following the day when the old person comes out of hospital. The number of places where this service is used is not as many as it should be, and unfortunately, when it is not used, it means that the nurse does this work when she is needed for much more important work in true nursing, instead of doing what could be termed domestic household jobs.

"Meals on wheels" are delivered to old people at the request of just the same authorities as I mentioned in the team. An example of co-operation is the way in which it is arranged that old persons coming out of hospital can have their home prepared for them, and have a home help on the days when "meals on wheels" are not delivered, and in consequence can be sure of a hot meal each day of the week. Another great avenue of service through "meals on wheels" is that it means that someone calls regularly at the house and can report at once to the authorities if all is not well. This is also the advantage of what we all hope to see become a real fact—namely, an organised visiting scheme. Volunteers are not anxious, indeed are not capable, to take on the jobs of those people who have trained professionally; but unless a home help, district nurse, or doctor—all people highly skilled and in short supply—is used to best advantage, we shall not be giving the maximum service to the old people themselves.

I think we must face the fact that we shall never have enough staff, whether at local authority or at hospital level, to do all the jobs which have to be done, and many of us feel that much work, such as visiting, ought to be done on the basis of good neighbourliness by religious bodies, voluntary organisations and individuals, whether they live in the vicinity or not. Too often I find people pontificate, blaming and parcelling out to others the opprobrium which, perhaps, they ought to take upon themselves. What should be done, I am quite convinced, is that each community should undertake to do, both professionally and voluntarily, the things which are required within the community, never losing sight of the fact that neither professionals nor volunteers can take the place of the family. There are many people available who could do this work because of their experience of life and also because of their readiness to help; and if only they could he called upon to do this, I am sure that they would answer the call.

I feel that freedom of living, of decision and of action, is strengthened to a great degree by providing domiciliary care for people, instead of institutionalising them. I would rather anything happened than that we started thinking of putting the elderly into homes. I would rather that old people had slightly less scientific care given to them, and that they could live their own life in their own way, than that they have to live away from the things they love. Surely it is not beyond our capacity to have in this country, on a local basis, sufficient places for those who cannot remain in their own homes, but to have such places more on the basis of attention and care in a practical way, rather than imitation hospitals, with rules and regulations and all the things which are necessary in a hospital but which are not necessary in a home-from-home which exists merely to give extra care and kindly nursing help.

It is time that we faced this problem more courageously. I beg that we do not imitate those nations which are more flamboyant than we are, but which are not, I believe, our equals in this field. Can we not have an understanding of what the outlook of human beings really is? Do we need to be so bemused by the little triumphs of science in a vast world of suffering that we pay too much tribute to rules and regulations and standards and not enough to the human beings we are trying to serve? The shortage of a place to which a person, whether destitute or with an income, can go to have ordinary care and nursing attention is very great, and the absence of such a home is a real tragedy. It always seems to turn on the question of standards and diplomas. The keynote is always the same—shortage of trained staff. But if old people are in their own homes, life moves on steadily to its close, and the end is viewed with dignity and with courage, without feeling that it is necessary to have a clinical atmosphere and a required standard of assistance against the final moment.

The people I talk with and the places I visit make me more and more confident that man is not doing a service to man if, by his scientific discoveries, he sets himself to extend the breathing period of a man's life when, in fact, that man is no longer "alive"; and although I must make it clear that I speak only for myself, I would plead that it is better to make life peaceful, as the human machine runs down, than to use artificial means to back up scientific discoveries. After years and years of work with old people, I would beg that everything be done which is at all possible to let them live their lives out in their own homes; that a sufficient number of places be available for those who need some continuous skill in their care and that the end may be allowed to come peacefully, rather than that it should be a clinical extension of a painful period. If emotionalism were got rid of and a real feeling were to ride supreme, it should be possible to give real support to those who are approaching the last stage of their journey. And because the men and women of this land are worthy of their country, I feel we should endeavour to supply the ways to strengthen their courage and uphold their dignity in the shape they would wish.

4.37 p.m.

EARL FORTESCUE

My Lords, I should like to offer my humble tribute to the right reverend Prelate for a remarkable maiden speech which, I am sure, will be very helpful to your Lordships in considering this problem. The noble Lord, Lord Amulree, has done great service in raising the question, because it is a very important problem and one which is going to get larger and larger. Modern science has succeeded—I was going to say admirably, but I am not quite sure that that is the right word—in prolonging life, but it has not succeeded so far in prolonging vitality (I am not sure that that is the technical word). There is an increasing number of elderly who are going downhill, but going down so slowly that they cannot die. It is for these that the nation has to find some solution.

I venture to think, although I have no statistics on the subject, that the average age of noble Lords in this House is higher than the average age of those in another place, and so it is only appropriate that the start and the prod on behalf of the old should come from here. Much of the ground has been covered by previous speakers, but there are one or two points which I should like to raise. In the rural areas, there are in many villages many houses quite unsuitable for old people to hang on to in their old age. The houses are bad, but they hate to be turned out of them in order that the houses can be improved. However, they are keeping young couples out of those houses.

It has always struck me that there is an obvious solution to this problem. In every village there are now many council houses, but it has rarely occurred to the councils concerned to think that, when they put up, say, two council houses, they could put up something for the elderly in between. If, when each pair of council houses is erected, another building on ground floor only was put between them, comprising a bed-sitting room, a kitchen and a bathroom, an elderly person or an elderly couple could continue there. It is an admirable feature of country life that neighbours will look after the old and then they do not feel in any sense isolated or dependent.

I have had the advantage of a conversation on the subject with an admirable local general practitioner, who is a man not only of wide experience but also of a very warm heart. He tells me that neighbourly sentiment towards the elderly is as strong as it ever was, but family sentiment is not what it was. The younger generation no longer take it as a matter of course and as a happy duty to look after their parents in their old age, and there is a certain reluctance on the part of parents to inflict themselves on the younger generation. Something needs to be done about that, and if these (for want of a better word) maisonettes could be provided, they would go a considerable way towards a solution in rural areas.

One aspect which has not been touched on in this debate so far is that of the elderly of the professional classes. There are many pensioners on an old-scale pension which has depreciated. In that connection, I would mention the Army pensions after the First World War, which were reduced. There are many widows of pensioners who find themselves in straitened circumstances. There are public servants of both sexes who have spent their lives doing admirable work and in their old age find themselves unable, because they have very limited means, to "make a do of it". Despite what the noble Baroness said on institutionalisation, I think that many of these people are better and happier in homes of some sort.

There are a good many such homes already. My noble friend Lord Mackintosh of Halifax, to whom I was speaking this morning, is appealing for the Methodist Homes for the Elderly. Many professional bodies, including the clergy and doctors, run homes for the elderly or give assistance to them. There is an extraordinary demand for voluntary homes. These homes have many advantages. Old people need some help, someone to come in and see to things every day. That can be done with a good deal less labour if the units are of a certain size. If 100 elderly people want some assistance every day in their own homes, the number of man-hours or woman-hours required to look after them is considerable, whereas if there is a unit of about 50, much less labour is required—something in the proportion of 25 for running an establishment of 50 to 75 persons—and it is a good deal easier to get.

I have to do with one such home (for want of a better word) and when I go into it, I am often reminded of the hexameter of Virgil: Tempora mutantur, nos et mutantur in illis. My Latin pronounciation is out-of-date, so may I render it this way?: Times do change hut who would ever have thought we should finish up like this. No, my Lords, it is not a matter of laughter; it is very sad. I think that we must do all we can to help these people.

One of the major problems is finance. Many of these people can afford to make a contribution which covers housekeeping, but the renting or purchase of buildings and their maintenance takes a great deal of doing. The institution with which I am concerned, and a number of others, have had enormous help from charitable trusts, but, as an instance of our difficulties, a few months ago, we had an excellent opportunity of extending by buying a freehold nearby at a figure in the neighbourhood of £80,000. A quick look round showed us that a number of charitable trusts would help quite a bit, so we made a bid for it and bought it. But how were we to raise the rest? Just at that moment, the "squeeze" came, and although we have been very fortunate in getting the money we needed, it has been a matter of great difficulty and, in these times, of considerable expense. I think that the Government could help the elderly enormously if, for recognised bodies such as the one I have described, there was some ready source of finance, either charitable or at a reasonable rate. That is all I have to say.

4.47 p.m.

LORD BEVERIDGE

My Lords, I should like to begin by adding my welcome to the maiden speech of the right reverend Prelate the Lord Bishop of London. I do so with all the more pleasure because I found myself agreeing with nearly everything that he said. My noble friend Lord Amulree, who sits beside me on this Bench, formally drew the attention of Her Majesty's Government to deficiencies in the arrangements for the care of the elderly, both sick and infirm; But I am glad that he did not limit himself to considering things which should be done for the sick and infirm, and I was particularly glad when he emphasised housing and "meals on wheels". For even those who are not sick or infirm, housing and meals are needed. My noble friend did not limit himself to the formal words of his Motion and I shall not limit myself either.

Old people all over the country although they may not now be sick or infirm, are living in conditions which will undoubtedly lead to sickness or infirmity. In dealing with sickness and infirmity, prevention is infinitely better than cure, and prevention, no less than cure, means understanding the causes. We all know pretty well the main course of the trouble with old people today. It is, first, the growth in their number. Whether it is their fault or that of the doctors that they go on living in such numbers I will not say, but more than anything else this growth puts before us the vast deficiency in housing all over the country. That has to be tackled somehow. Then there is the second cause of inflation, destroying savings and making assistance rather than pensions seem indispensable. Then there is the disappearance of what used to be called domestic service, and what is now called home help. That is altering enormously the life of old people and the possibility of their having comfortable lives, and is one of the problems of the old which cannot be exaggerated. Those three things that I have mentioned are common to all old people.

There is one other that is common to old people in Britain, and it is that they are not confined to one part but are to be found all over Britain. Some help for dealing with old people is needed everywhere, though it is not by any means the same help that is required everywhere, and still less the same help for all old people, because the actual needs of old people differ greatly, just as the action needed to help them differs.

I had the good fortune of realising how great is the work done when about a month ago I paid a visit to Belfast in Ulster to learn what they were doing about old people. I was enormously impressed with what I saw there. I think that if every town in the country could do as much good for old people as Belfast does—not necessarily the same things—where very happy circumstances surround them, and there is agreement between all the interested people in the city, the solution to the problem of old people would take a great step forward. I realise, of course from talking to the chairman of the body that provides institutions—perhaps 30 or 40—for old people who are sick, that there are some people who need recurrent nursing. You cannot put them in ordinary small homes, and you do not want to fill up the hospitals with such people. In Belfast they have several homes, each for 30 or 40 people, and the moment they need full nursing care they can get it rapidly without putting an end to the work of the hospitals. That, I thought, was an excellent institution. From what I heard, I did not think it necessary to visit them, but I went to see some houses that have been established within the last year for housing old people who had really nothing wrong with them except loneliness.

I welcome the emphasis put on loneliness by the right reverend Prelate, because this is one of the main troubles of old people: loneliness coming perhaps through their having no children or careless children, or the loss of a wife or friend, so that in effect they have no home. That loneliness may easily lead to infirmity and to much worse. It so happens that I am concerned with the Abbeyfield Society mentioned by the right reverend Prelate, and I am glad to say (I hope this may also please the noble Earl who spoke last) that this Society wishes to be able to cover everywhere where its work is needed. It is worked by local committees. In Belfast there is a most vigorous Abbeyfield Society. I went to see what they were doing, and I saw three homes for lonely people with nothing wrong with them except loneliness. But loneliness is a horrible thing for old people. In Belfast they were in homes established within a year, completely furnished, and good homes in every possible way. There, for some fortunate reason they seem to have much more money to spend on this than, say, in Oxford, the city in which I live; and also let me say that I am sure the houses in Belfast do not cost as much as do the houses in Oxford.

In Belfast, as I say, there were these three homes; there are two more on the way, and they are going to spread them all over Ulster. I had a meeting with all the representatives of the neighbouring towns which were going to do exactly the same thing. They provide homes for people, limited in number to four or five or four to six, because if the number goes beyond that they may become something like small institutions. These homes provide a separate room for each person without any furniture, unless they ask for it. They can bring their own furniture and be surrounded by their own possessions. They have the feeling of privacy when they want it, but they can call on somebody else and get companionship if they want it. They have lighting, heating, food, home help and occupation—all these things are thought of for them. I will not go into the finance of it, but will only say that if they cannot pay themselves we find the National Assistance Board very sympathetic indeed when they know that these people are being put into good and not bad conditions. I was deeply moved by what I saw there.

I saw, among other people, an old man of 84—much older than I am—who had fought against the Boers in 1899, had gone on being a soldier and had lived very happily indeed with his wife. They had no children, but his wife looked after him until she died about a year and a half ago. Think what happens to an old soldier whose wife dies and he has no one to look after him. What happened was that he went into an Abbeyfield home. There are four old ladies there, and I think the four old ladies and the housekeeper between them compete as to who shall best look after the old man. I am making a plea for old men; they want to be helped by old women, although there are relatively few of them. After a married life without children the death of your wife is a terrible break unless there are other children or friends who come to the rescue.

I want to urge upon your Lordships that the unhappiness of old people to-day—and there is plenty of it—is a disgrace to our affluent society. The only question is: Who is going to wipe this disgrace from our British record; and by doing what? It cannot he done by any one body. The Government must obviously be greatly concerned with housing generally. The old people have made the housing shortage. You cannot cure the housing problem by leaving them without homes. You have to build more homes and it is no good building them for anybody. Somehow you have to get a priority for the old people, and you have to fit the homes to old people. I am an old person, and I know I could not live anywhere and everywhere with perfect happiness as I live in Oxford to-day. There are some advantages, even in Oxford. The Government should seek every co-operation from the local authorities and any voluntary organisation. I put housing as the first charge upon the Government, whatever it is.

I do not want to talk about inflation, but, of course, the Government, the employers and the trade unions among them could combine to halt the further destruction of the value of money, because inflation makes saving for old age seem nonsense; and it is nonsense for many people. I have always believed that happiness for the citizens of this country should come partly from the State, partly from voluntary organisations, partly from people helping others and partly from people helping themselves. I was glad to note one particular society on my visit to Belfast. Let me say at once that the last thing I would suggest is that this is the only possible society; there are many excellent societies working for old people.

It so happens that we had invented for us a few years ago a particularly good idea as to what solitary old people, not in ill health, needed in order to live and to be saved from ill health. Although we do not normally put a nurse into an Abbeyfield home, there is no chance of an old man or old woman in an Abbey-field home falling ill and not seeing a doctor until it is too late to be cured. That is one of the common evils of old people. It may well be that as the numbers grow some kind of help (not full nursing) for people when they are beginning to be ill is a thing we ought to develop to prevent their illness from going further.

That is all I have to say, except how thankful I am that this House, concerned so deeply with social problems, has once again called attention to the unhappiness of old age and to the need for joint action to end it. I think I may say that practically every speaker, in one way or another, referred to both those points and supported joint action to end unhappiness and to prevent the trouble that we have to-day from leading to something worse in the shape of illness and misery. Let me return to my thesis: that prevention of infirmity is better than cure. In order to get prevention, we have to deal with the problem of old people as a whole. If the Government, the local authorities and the various voluntary organisations, without any jealousy or quarrelling one with another, will take this debate to heart and do together all they can as a result of this debate, then I think we may say that the House of Lords has once more done a great service to Britain.

5.6 p.m.

BARONESS SUMMERSKILL

My Lords, we have all listened to the noble Lord, Lord Beveridge, make his plea for the aged and lonely. If he will forgive my saying so, I think it was a poignant speech, and when his voice goes out to the old and lonely at least I can assure him that they will derive some comfort in knowing that he, whose name is known all over the country, has spoken on their behalf. I must admit that I cannot understand why he says that women should look after men, and not men look after women, but we will not cross swords on that.

LORD BEVERIDGE

Because women can, and do, look after men, and men only make a mess of trying to look after women.

BARONESS SUMMERSKILL

I must confess that we women like looking after men. But I cannot offer my services to the noble Lord, because I have a very nice man to look after, and the noble Lord will realise that I have not time to look after both.

LORD BEVERIDGE

I have two nice women and four children and stepchildren, all looking after me.

BARONESS SUMMERSKILL

The noble Lord makes me suspect that he is a polygamist. However, we did not think that at this stage of our lives we should be crossing swords on the question of feminism.

The noble Lord has emphasised the point that the matter we are discussing to-day, the needs of the aged and infirm, is not spoken about enough in either House of Parliament. Indeed, what has happened to-day is that the noble Lord, Lord Amulree, has focused attention on the needs of a very large group in the community which does not possess a pressure group in either House of Parliament. I would say that in the last few years their voices have been heard more often, for reasons which the noble Lord will realise. There are in this country to-day more than 2 million people aged 75 and over whose needs cannot be ignored. My noble friend Lord Taylor talked about the physiological condition of the aged. I observed that the noble Lord, Lord Beveridge, tended to talk about the middle classes when he talked about domestic servants. He will realise that home helps help the classes who never had domestic servants in their lives before.

I would say that the real tragedy of old age, in all income groups, lies in the fact that, as a rule, physical deterioration precedes mental degeneration. Consequently, there is a growing aged population, physically incapable of conducting a normal life but sufficiently agile mentally to suffer profoundly from the apparent desertion of relatives and friends, and from the frustration and inadequacy which dependence on others instils. In my opinion, that is the real tragedy of old age. Only if this important aspect of ageing is kept in mind can plans be made to meet the real needs of the aged and infirm.

It is not always recognised that privacy is very important to an old person although he or she is physically enfeebled. The description by Dickens of the workhouse of the 19th century is deplorable to our modern way of thinking. Then masses of people of all kinds were put into large rooms and just left. The importance of privacy is that to the aged poor the only status symbol remaining is a humble home, with its simple belongings, and it is a tragedy to be deprived of that state in one's few remaining years. Therefore I would say that the present need is for more accommodation for those who are anxious to remain independent but who need some supervision.

I have arrived at precisely the same analysis as the noble Lord, my noble friend, Lord Beveridge. He is quite right, of course, in his decision that a room of one's own is what is needed generally in old age for the reasons I have given. He has described buildings which he has seen. Here I would remind noble Lords of the unit opened at Mansfield this year, which would seem to meet this need. There, there are double and single bed-sitting rooms provided in bungalow units, each providing accommodation for ten residents with a housekeeper in charge. There is a housekeeper, my Lord Beveridge, a woman.

LORD BEVERIDGE

Of course.

BARONESS SUMMERSKILL

Furthermore, the residents have been allowed to bring their own furniture, which is a humane and wise provision. Now, if all housing authorities provided adequately equipped bed-sitting rooms in buildings where some supervision could be exercised, this would meet the need of many aged people desperately clinging to their independence, and at the same time, of course, release large numbers of flats for young people.

When you are old there is a curious psychological desire to get back to the womb, to get warmth, to get comfort, to get privacy. And that psychological desire is translated into a yearning for a place of one's own, small and cosy. Wonderful flats have sometimes been shown, with a bedroom, sitting room, kitchen and bathroom. But the aged want to be kept warm, they want to sleep in the room they have heated all day with their bodies and their small amount of fuel. These are the things which the housing authorities should understand.

LORD BEVERIDGE

You are describing me.

BARONESS SUMMERSKILL

That is a great compliment from the noble Lord.

The joint circular which I think has been issued by the Ministry of Housing and Local Government and the Ministry of Health and local authorities was an admirable document. Despite this circular, which has taken many civil servants many months and years, I have no doubt, to write, unfortunately there is no guarantee that the excellent services will be used by those in greatest need, for this simple reason: there is no register of the aged. That is why we occasionally read of tragic cases of men or women dying in a room, an old man or woman dying alone without companions and days elapsing before that tragic discovery is made. Therefore, I want to urge those in authority that there should be some system of notification in order to ensure that the large number of aged living alone are adequately cared for. Furthermore, this would facilitate co-ordination of the services and so prevent overlapping and consequent waste of effort.

I have heard the noble lady, Baroness Swanborough, who has devoted so much of her life to the question of voluntary services, and I am second to none in praising the home help, the meals service, the health visitor. They are indeed deserving of the highest praise, as is also, of course, the district nurse. Yet I would say this, and I say it very gently: that there is a tendency for each to be concerned solely with their own contribution. A large number of people living alone on retirement pensions and National Assistance try, uncomplainingly, to pay for their fuel, food and light—their rent is paid for. But they are quite unable to meet the expense of new bedding, clothes, and perhaps a new chair, because one regards that as capital expenditure. I have had occasion to visit a number of blind old ladies living alone and I have been surprised to discover that their pressing need was the renewal of some of these articles, none of which could be categorised as luxuries.

When I was Minister of National Insurance—and the noble Lord, Lord Beveridge knows a great deal about National Insurance—I recall that the National Assistance Board was prepared to make discretionary allowances to meet these large items, and I was not aware that the policy had been changed. I presume there is—I would point this out to the noble Lady—a lack of coordination. I am glad to see she agrees with me. But whereas these excellent people go into a room to see an aged person, none of them would say: "Could I turn back your bed and see your sheets or your blankets?". Indeed, some of them might regard it as an impertinence. Only if you go into these rooms and establish friendly relationships can this be done. Yet all over the country in this cold winter there are these people who are so grateful for the "meals on wheels," home help, and the other services as individuals, and who do not like to say. "May we have something more?". Yet the machinery is there; the National Assistance Board, unless it has changed its policy, will be quite prepared to make discretionary allowances for the capital items.

The noble Baroness, Lady Swanborough, discussed clubs. I have met welfare workers who claimed that no old person need be lonely in their areas as there were many clubs which catered for the aged. This showed a lamentable lack of knowledge of psychology. A person who has shown no aptitude for social mixing during his young days cannot change his inadequate personality in old age; consequently he suffers from loneliness and neglect. The lonely often need individual help, and to try to compel them to attend a club is only to add to their misery. I would remind noble Lords of that valuable Report, the Younghusband Report, which I hope everybody has read. It stressed the need for more social workers and hoped that the social needs of the aged would take an equal place with their health needs. The noble Lady, I think, rather decried the scientists, which probably included the medical profession, but I am sure she is with me when I say—

BARONESS SWANBOROUGH

My Lords, in connection with science I was merely talking about the expectation of life after a person has stopped living. I would never decry either doctors or scientists.

BARONESS SUMMERSKILL

I am tempted to digress, because what the noble Lady has said was quite startling and quite amazing. If she says the expectation of life should not be increased, at what stage does she say science should stop helping individuals? Because I would remind her that the expectation of life in India, I think, is 32 years.

BARONESS SWANBOROUGH

My Lords, what I said, though perhaps I said it badly, was that I was sad to see that people were kept breathing when they were no longer alive, by which I meant a person who was unconscious being kept artificially alive by the authorities although that person had no chance of coming back into normal life again.

BARONESS SUMMERSKILL

I am very glad I have given the noble Baroness an opportunity to explain herself, because that was not quite clear when she spoke. If she means that, she is of course limiting her view to a very small number of people who are already semi-conscious. I was under the impression that she was almost in favour of euthenasia. I would say this to her—I hope she will agree with this, and this came out of the Younghusband Report: that if voluntary workers give regular time to the work, they should have the opportunity of training which will equip them to do the job competently. A knowledge of psychology is a great help to these voluntary workers.

Now I want to say something about the aged sick. There is, of course, a tendency in the world of medicine to regard chronic sickness as of little academic interest. I think my noble friend Lord Taylor described the wards of the chronic sick which were nursed by the Irish and by Commonwealth doctors. I think the medical profession is the finest in the world, but I believe it is quite clear to your Lordships why that is. Those doctors who can get others to do this work, which they regard as less interesting than nursing the acute cases, of course will get them. I would say this: as the expectation of life is longer, the medical profession must reorientate, and the aged sick must be regarded as patients who should be given the treatment to which they are entitled.

Let us come to home nursing. Although I attach tremendous importance to the district nurse, I would say that the first essential is to get a home help. I think the noble Baroness said that there are plenty of voluntary workers but I should not say that there are; there are not enough home helps because they are not available. To be a home help to an incompetent person is not necessarily a congenial job. Unfortunately, society is so short-sighted that it underpays these invaluable women. I hope the noble Lord, Lord Newton, will convey that to his right honourable friend in another place. A consistently mean policy is pursued in the payment of women in all the work allied to medicine. That even includes the home help who is so important in the nursing of the aged. In consequence, of course, there is a universal shortage. I have a Motion on the Order Paper and I hope that when the House resumes I shall have an opportunity to develop this subject. It seems to me that only when the situation becomes really dangerous are the authorities prepared to increase the rates of pay. This is a most short-sighted policy, because it is always cheaper to keep a patient at home than to send him or her into hospital. The noble Lord, Lord Amulree, mentioned that the average cost of a bed in a hospital is £40 a week. Yet the local authorities and the central authorities haggle over 6d. an hour for a home help.

In many big hospitals in large congested areas there is no geriatric clinic. The geriatric clinic which we have heard about to-day—and I say this in the best possible sense—is one of the show pieces of London. But there are hospitals on the periphery of this "Great Wen" of London serving large areas without a geriatric clinic. I am thinking of the North Middlesex Hospital, where I served on the Committee for seven years, serving Tottenham, Edmonton, Wood Green—great congested areas—and there is no geriatric clinic.

LORD STONHAM

There is no geriatric clinic in my area.

BARONESS SUMMERSKILL

This is due to lack of central direction and again a short-sighted policy, because the services given in a geriatric clinic may help to keep the patient mobile. Assistance in the first stages of infirmity is of paramount importance. Therefore, my last plea is this: that the maximum publicity should be given to the available services and it should be remembered that unobtrusiveness in this field is not a virtue. If any one of the noble Lords listening today had an old relative or a poor friend and wanted to set the machinery in motion, he would probably look through the telephone directory and say, "What number do I ring?" Nobody yet has realised how important it is at least to devise a comprehensive term which will cover those services, so that anybody in need can 'phone a key worker. For this reason I welcome very much the debate today, because it gives us the opportunity of voicing the needs of the most patient, and often most deserving, in the community, the aged and the infirm.

5.25 p.m.

LORD STONHAM

My Lords, it has become a commonplace that on subjects dealing with the social services your Lordships' House always speaks with the greatest authority, but I must confess that in this debate, for which we are indebted to the noble Lord, Lord Amulree, I have never previously listened to a discussion which has shown such width and depth of experience and knowledge, and, indeed, of feeling. I am sure that this discussion must be of considerable benefit to the people that we desire to serve. I think that is how it should be, because, after all, your Lordships' House is the only place in the whole world where elderly people are encouraged and allowed to make their full contribution. Indeed, most of us before starting on this discussion ought to have declared an interest. Therefore, it is right that we should speak not only with the knowledge gained from work in hospitals or voluntary organisations but from the fact that we have actually felt these things, or at least that they are going to affect us very soon.

LORD NEWTON

My Lords, may I ask the noble Lord what he calls "very soon", because I am wondering whether I ought to declare an interest when I come to speak.

LORD STONHAM

I did not quite catch what the noble Lord said. Did he say something about "his cup of tea", or was he suggesting that what I was going to say was not worth listening to and he was going to have a cup of tea?

LORD NEWTON

I wondered whether the noble Lord would tell me how long we were to wait to receive the services about which he was talking, so that I may know whether to declare my interest when I come to reply.

LORD STONHAM

My Lords, I think that is a matter for the noble Lord's own conscience and his birth certificate. I must leave that to him. I do not particularly want to labour this point. A number of speakers, including my noble friend Lady Swanborough, have mentioned that there has been an enormous and welcome increase in the services for old people, and I think that is right. But in my view the improvements are entirely incommensurate with the need. We have to remember that fifty years ago there were some 2¾ million elderly people in the country, which was 7 per cent. of the population; to-day there are 7¾ million, which is 15 per cent. of the whole nation. No one can pretend that the volume of the services has been stepped up to such an extent that they are adequate.

I feel that the time is ripe, and particularly that it should be done in your Lordships' House, to attempt to place on the Statute Book a Charter for the Aged. I know that my noble friend quarrelled with the use of the term "aged" or "elderly". I wish there were some other expression, because we all know how much it cheers us up when somebody says, "You are looking very well, and younger than ever". You have to use a genetic term. You just cannot refer to these people as "autumn leaves" or something like that; you have to use the words "aged" or "old people" or "elderly". Certainly it is time that this experienced one-sixth of the nation, who still have so much to contribute, were treated otherwise than as passengers—and non-paying and undeserving passengers at that. If the Government cannot find time for the coordinating measure which I think has been recommended by most noble Lords who have spoken, I hope it will be possible before long for us to introduce it into your Lordships' House as a private measure.

Last February the Minister of Health declared: The local authority clement in the National Health Service is unduly overlooked and disregarded. That is not only too true, but is, I think, the reason for most of the deficiencies in our service to the elderly. There is much that we can be proud of, but, as the right reverend Prelate the Lord Bishop of London mentioned in what I regarded as a most welcome speech, the agencies by which they are administered are far too numerous and indeterminate. There is duplication and even competition between them. The aged are often passed from one person to another in their efforts to obtain assistance. Indeed, the cunning few may secure relief from several sources, but the majority remain in need, because they are too proud to ask for help or just do not know where to go. I think that the present set-up is enough to bewilder the most resolute.

Think of the list of statutory authorities who have to deal with the aged. The Ministry of Pensions looks after their pensions; the National Assistance Board gives supplementary pensions and allowances for food, fuel, rent, clothing and so on; the Regional Hospital Boards provide hospital care and specialist medical services. The local health authorities find accommodation, and county and county borough councils provide nursing, health visitor and domestic help services. They may make arrangements for the prevention, care and after-care of illness, and they may provide residential accommodation. Fifth, we get the district and borough councils who also have power to make special housing and hostel provision for old people; and they can, and do, contribute to voluntary organisations which provide recreation or meals, or provide, maintain and equip buildings, and contribute to the expenses of societies having social objects.

Those are five different kinds of statutory authority, the good ones often wastefully overlapping and the bad ones neglecting their opportunities. In addition, there are the splendid voluntary organisations, large and small. The services they render are so varied and so vast that it is impossible either to list them or to estimate their total of services. I submit that though the services of the voluntary organisations ace vast, their volume in many areas is not very great and certainly never sufficient to meet the need.

As my noble friend Lady Summerskill made clear—this is a point which I should like to develop—the great and glaring need is for one responsible authority or person in each area, known or respected by the old people, to whom they can turn for any kind of advice or help. I do not think any of us wants a regimented service—that would be alien to the nature of what is needed—but, in my opinion, the responsibilities of the statutory authorities should be reviewed so that overlapping is eliminated. I think that where county or district authorities have the same powers, the sole authority for such powers in connection with the aged ought to be the district authority, because they are so much smaller and so much closer, and in many cases they really know the people intimately—a matter really necessary in regard to old people.

If it is argued by the Minister that a particular service could not be provided by a single district, then two or more districts should have the power to get together to provide that service. But the second essential is to make one person responsible. However highly we regard the National Assistance Board, the Regional Hospital Board, the Ministry of Pensions or the county councils, not one of them could possibly take on overall responsibility. In my view, that must rest with the district, in the person of the medical officer of health. He is the only person, because already he administers many of the services and his department already has the confidence of the old people. He also, by his status, has the confidence of Government Departments, local authorities and voluntary organisations. Indeed, I think the voluntary organisations would be more likely to accept leadership from the medical officer of health of the district or borough than any other official. I think, then, that he would be in a position to knit the services together in a comprehensive whole, without any essential interference with existing organisations. We should get an integrated service for the aged, more efficient, relatively less costly, and, above all, one which neglects no old person in need of help.

It may be argued that progressive medical officers for good local authorities already, to some extent, fulfil this co-ordinating function. I know that they do. But their powers are insufficient, and, in any case, the present system creates grave variations in the quality of the services provided for the old people in different parts of the country. In my opinion it is necessary to place on the medical officer of health the statutory responsibility for the care of the old people in his district. As my noble friend Lady Summerskill suggested, his first duty should be to compile and maintain a register of all aged people likely, in his opinion, to require or desire assistance of any kind. After all, the first requisite for the planning of any service is information. How can you plan properly the services for old people if you do not know how many there are, how many want assistance or what kind of assistance they want?

Therefore a register is essential. Some authorities keep one. Shoreditch, one of the two boroughs in London which I represented until a few years ago, has an old people's register. It contains between 5,000 and 6,000 names out of a population of 46,000. Those are aged people actually in need of some form of help or care. That is maintained and kept up-to-date by the tactful devotion of the staff of the medical officer. But, as my noble friend suggested, their work would be much easier and much more comprehensive if the Ministry of National Insurance and other Government Departments were required to furnish to the medical officer of health details of elderly persons residing in his area. If this were done there would be no more sad stories of old people dying neglected or living friendless, uncared for, or alone.

With this new agency the medical officer would be able to set up the most valued service we could provide for the elderly, that of enabling them to live on in their own home. I know that there has been a tendency for one or two noble Lords to disagree with what my noble friend Lady Swanborough said about the vital need of helping people to live in their own homes as long as possible. The noble Earl, Lord Fortescue, I think suggested that they are much better in institutions. I should be quite prepared in some cases to think that they would be cleaner or better fed and warmer, but I would dispute with him to the last moment that they would be happier. It is the old people themselves who are really the best judges of that. As my noble friend said, if they like to sleep in the same room where they eat, and if they like to have their own warm "fug", if they are happy, that does not matter at all. It is they who decide whether they are happy and comfortable. They are the only ones who can.

Of course, as has been said, the first essential is adequate housing. The extraordinary thing is that, although the general housing shortage is so acute, with old people it is more a case of over-accommodation than under-accommodation, as the recent survey of 140,000 people over 80 years of age showed. Nearly 70 per cent. of those people over 80 years of age living alone had three or more rooms to themselves, and less than 10 per cent. had one room. The noble Earl, Lord Fortescue, made a suggestion on this point. He suggested building a little house or a bungalow in between two houses. I hope he also meant putting another flat on top, because that would otherwise add to the rather grave shortage of building land.

But I strongly support the view—and I hope that the noble Lord, Lord Newton, will mention this when he comes to reply—that in new estates at least 5, 6 or 7 per cent. of houses or flats should be devoted specifically to the needs of old people. They should not be in an old peoples' corner, but should be distributed throughout the estates, so that they are part of the community. Also, would the noble Lord deal with this question of the over-housing of old people and say whether the provision of special accommodation for the elderly would not help to release that surplus accommodation, which is so much more than they need, for young people with families? I think that that is a matter which really needs attention.

Would the noble Lord, in replying, also deal with the fact that no fewer than 300 local housing authorities have yet to build their first special dwelling for old people? They have not built a single one, and it is quite disgraceful. We need a determined drive from the right honourable gentleman, Dr. Hill, in this matter. We must also ensure that the subsidy arrangements are satisfactory and enable the local authorities to build and supply houses for rent which old people can afford.

My Lords, as quickly as possible I should like to mention, in support of this important matter of keeping old people in their homes as long as possible, the domiciliary services, which I think must be under the direct control of the medical officer of health of the district or borough. Home helps have been mentioned, but even now they are only one-tenth of the number of the total domestic staffs in our hospitals. Grateful as we are for them, there is only a microscopic number of home helps up and down the country. Some elderly people can have a home help every day of the week, but others can have one only once a fortnight—which is better than nothing, but not very much better.

I submit that there is a need for a specialised home help service for the elderly, based on frequent, though short, visits, and with a wider range of services; not only housework, but shopping, companionship, and help with washing and dressing the old people. I should also like to see the medical officer of health empowered to pay small sums to neighbours—even though the neighbours may be "poor old things" themselves—who can come in and make a cup of tea, help to get a meal, and occasionally clear up the rooms when no voluntary help is available. Of course, they should also be in a position to supply baths, either static or mobile, with the assistance of a nurse or an attendant where necessary. A personal laundry service is also necessary if some old people are going to be kept in their own homes in a state of decency.

Meals, of course, are very important. The other borough which I represented, Finsbury, has recently started the domiciliary supply of frozen meals, which can be obtained commercially in bulk. The experiment has been going on for a few months and it is expanding. A full meal is contained in three envelopes which keep for 36 hours; therefore, they only have to deliver three times a week. By the benevolent "wangle" of forming a welfare committee, they are able to make a grant, and supply for one shilling to the old people a meal that costs three shillings.

Of course, there are many other invaluable services provided by those district councils which have a proper regard for their responsibilities. I will list a few of the services which are being provided by some authorities, and I should like to know how general these services are for old people. There is a domiciliary library service; a fortnight's holiday by the sea and numerous day outings; social visitors and nurse visitors—not merely health visitors—paid for by the borough councils. Old people get nutritional supplements at a cheap rate; domiciliary chiropody services; S.O.S. cards which old people can put in their windows in case of emergency, if they need help; there is a hairdresser and barber service and a mending service which is provided especially for the men, who are less nimble with a needle and cotton; and there is the redecoration of accommodation to cheer up old people when they cannot get the work done by their landlords.

My Lords, all these things are being done now by some local authorities which I could mention; but I could equally mention other local authorities who are doing almost none of these things. It cannot, therefore, be argued that they have not the power to do these things, but it can be argued that they have the power to avoid doing them. That is my case: that these permissive powers should be made mandatory. We should then get a better service for aged people and its quality would be improved all over the country. For example, there is, in the Borough of Finsbury, a most valuable, happy and flourishing old people's employment scheme for about 150 old people. They have several sessions a week. It is very happy, with an atmosphere like a club, and they get paid for what is done. As the noble Lord, Lord Luke, knows, that was done by the courage and determination of individuals, including the medical officer of health, and supported by voluntary organisations, and also, indeed, by the local authority. It is a complete and wonderful success. There is no reason whatever why it should not be copied successfully all over the country, which would be a great boon for old people.

Therefore I plead with the Government to give consideration to bringing in a measure which will end the uncertainty as to whether certain services can be provided or not, who is allowed to pay for them, and whether or not they will qualify for a grant. If these services are permissive, then let us have them all over the country and let us remove the uncertainty. I think that is the least that we should ask for. Then a wider range of powers and complete statutory overall responsibility should be given to the medical officer of health. By this means the back sliding authorities could be brought into line and there would be great improvements. This would cost more money and the Treasury would presumably have to make the main contribution, although not the whole of it by any means. I think that the local authorities should pay a substantial part. If the administration is to be local, then some of the financial responsibility should be local, too, which would make for better control and management.

I think that there will be savings through the elimination of overlapping, if this scheme is carried out. If, for example, the medical officer of health had a putative allocation of 30 to 50 beds in a geriatric hospital, I am sure that a better, truer use would be made of them and that there would be greater regard for proper priorities. If that were done there would be much better use of beds than there is under the present system.

But, my Lords, whether it costs more or not, the primary consideration is that we must fulfil our obligations to our older citizens who have borne their burdens and who are entitled, in their declining years, to the best we can provide. Unlike the noble Earl, Lord Fortescue, I am not able to quote an ancient Latin phrase, but I think it is true that the Constitution of ancient Athens, which was even earlier, placed an obligation on children to nurture and protect their parents. I should have thought that that obligation should apply to our society to-day. But even when any of us forget that obligation, it devolves on to the State. I think they should honour where we forget. My last word to the Minister is this: he cannot pretend, after this debate, that the means to an efficient and sufficient service are not known. The only question that is in doubt is whether the Government have the will to provide it.

5.51 p.m.

THE LORD BISHOP OF SHEFFIELD

My Lords, I find myself in very great sympathy with all that the last speaker has said, but at two points he left me feeling a little sceptical. I doubt very much whether you can get rid of the irresponsibility of any action by local authorities without trespassing on their responsibility to do their jobs. It depends on them a good deal nowadays whether one gets a good day-school or an indifferent day-school, or whether one gets good medical treatment or not very good medical treatment; and, while I think it is the duty of the Government and the nation to see that, so far as possible, the services are extended equally right through the country, I do not think you can push that too hard without removing from the local authority their responsibility for doing good—and sometimes for not doing good.

The other thing which I was not entirely convinced about in what the noble Lord, Lord Stonham, said, was whether the medical officer of health in a local authority is the best person to assume this over-arching responsibility. To-day, the medical officer of health, in his department of local government, has a great deal on his plate and has very exacting professional duties. He also, more and more, gets involved in questions of hygiene and sanitation, not to mention clean air; and I should question whether he could carry this additional burden very well or whether it might not be better to put it on to the social care department, which I believe is going to be an increasingly responsible department in local government.

LORD STONHAM

My Lords, will the right reverend Prelate allow me to interrupt? So far as concerns those local medical officers of health that I know, who are friends of mine, not only do they think that they are competent and able to do it without much of an increase in their departments but, as he has so rightly said, they are already doing many of these things. So why transfer those functions to yet another department when, by adding a little more to the existing ones, they can carry them out? Then, I am afraid I did not explain myself properly: I want to add to the responsibilities of the district authorities, not take away from them.

THE LORD BISHOP OF SHEFFIELD

To continue my argument about the medical officers of health a little further, I think a good deal has been said in the course of this debate which makes the point that it is important not to associate the care of the ageing population too much with ill-health as such. That is the basis for my asking: why put this matter under the medical officer of health rather than under the social care department? However, I think the subject wants very careful consideration.

May I come back to my own thesis? I think we are all grateful to the noble Lord, Lord Amulree, for making us exercise our minds once again on this very important part of our nation's life. I believe, for a variety of reasons, that it would not be an unfair judgment to make of a family or of a community to take the way in which it really cared for its old people. It almost seems to me that there are five parts of this business of caring for the old people. First, they must have the means of subsistence, and I confess that here I am a little bothered by the fact that over 1,300,000 pensioners have to apply for National Assistance. I think that is about the right figure. It is a large figure; and it is not quite right that such an extra anxiety should be placed on old age pensioners.

The second thing they need, as has been said again and again this afternoon, is adequate places in which to live. That raises a wide range of subjects, but I should like to take just two points. I believe that one of the valuable things in our community life, by and large, is the sense of responsibility of families for their old folk. Some of the most significant social statistics and studies recently have shown the quite outstanding care which a family will take—and by a family I do not mean just the parents and the children; I mean almost the clan—for their old people. That is one of the reasons why, for example, on the new housing estates which are being built in big cities like the one in which I live, during the first few years after the estate has been built there is a staggering amount of mobility. One substantial reason for this extraordinary mobility is the determined attempt by the members of a family, in which I include not just parents and children but grandparents and aunts and uncles, to get together again. As one moves one unit inside a larger family unit into a new house in a new area, the inevitable result is that parents and the next generation are separated by several miles, and the ingenuity exercised by family after family to get into proximity is remarkable. It bears witness, I think to a very valuable, stabilising element in our social life.

I only wish—although I can see the great difficulty in doing this—that local authorities, when building new housing estates, and so on, and when thinking who was going to have the priority to move into them, would not just consider the family, meaning the parents and their small children, but realise how important in the holding together of the community is the larger family unit, and how much, at any rate temporarily, is lost when it is broken up. But I realise that that is a difficult thing for a local authority to do.

The other point which has been made and which I am sure is very important is that when we build our new estates and our great big blocks of flats and all the rest of it there should be provision to an adequate degree of the kind to which the noble Baroness, Lady Summerskill, was referring—one single room, possibly, for old people. But, as the last speaker also said, it is very important they should not be down a cul-de-sac or by themselves, because as one gets older oneself one realises that how much youthful spirit and youthful mind one has left depends on contact with the younger generation. If you were to put all the old people on an estate down a cul-de-sac and leave them there they would all age with incredible rapidity, at great loss to themselves and also to the younger people. That has happened, because very frequently I have been taken to a housing estate, and it has been said to me. "Look what a nice little corner we have arranged for our elderly people", and the poor things, of course, are not as happy as they might be. There it all is.

This ties in with the next point I want to raise, which again is so important and has been so well emphasised, that in the care of old people companionship and friendship are of tremendous importance, as the right reverend Prelate said so well earlier on. Here, I think, is great scope for co-ordination between the skilled social worker, be he statutory or voluntary, and the unskilled person of good will. Some of the help which elderly people in the community need requires, I think, a good deal of psychological understanding, and all the rest of it, for which one has to look to a trained social worker. But I think that if a trained social worker in any given area has a group of semi-skilled or unskilled people co-operating with him, together they can do an immense amount of good. Because this problem of loneliness is a very difficult one to solve, and while sometimes the lonely old person needs that skill, often he also needs the friendship of someone who is kind and sensible, who can just gossip with him, and things of that kind.

I do not think we have gone nearly far enough in this business of co-operation between the skilled craftsmanship of the social worker and harnessed inexpert good will which is latent in the community. Personally, I think that the churches themselves might get busy on this. We have a kind of organisation concerned with this question in the country, and other Christian communities are operating with us also. There are many organisations for various age groups attached to most churches, and some of them do not get very much further than drinking cups of tea and listening to teachers' speeches. I think they might be much better employed if they were persuaded to look outwards, to see where the lonely people of the community are with whom they can try to be "matey". I think there is very great scope in our local life for more of this kind of thing. Also, I think it is rather regrettable that these organisations, and so on, are not in sufficiently close touch with the trained social worker, who is, of course, doing quite a splendid pastoral job up and down the country to-day, and will continue to go on doing so.

I think that what is very important for old people is that they should be occupied. So often I think they suffer at the hands of younger people of good will who assume that occupations are not what they want, whereas they are. I think that what keeps many old people young is that they are tremendously occupied by the younger generation, their families, and so on. I see no reason why an old person who in his or her younger days had taken a vital part in the life of the community could not at least continue to take an interest in the life of the community after that person's working days are done. But all this business of care for the old and keeping them happily occupied is very important, because I am sure that when one ceases to be occupied, one will tend to brood about one's health.

Then we come on to the immediate point of the noble Lord's Motion, the care of the sick and the infirm. I wish that he could have developed a little more fully for my amateur mind his distinction between departments and units for the sick and infirm in the community. One is very uneasy about the real state of many of the homes and hospitals where old people are being treated under crowded conditions, with inadequate nursing service, and all the rest of it. It is good that he should pinpoint certain places where these difficulties have been overcome. But if you were to go up and down the length of the land and go inside some of the ex-workhouses which are still used to-day to house sick or infirm old people, I think you would be rather horrified. I know a good many of them, and while one admires the way in which the vocational staff try to overcome the inadequacies of the building, I do not think that we as a nation should be satisfied with these buildings.

Three weeks ago I had the privilege of being present when Her Royal Highness Princess Royal opened a new geriatric hospital—I am not sure whether it was a "department" or a "unit"—on the outskirts of Barnsley. It was a quite lovely place, admirably done, nicely furnished, full of light and colour—everything one could want. I compared it with other places designed to do the same work which were not so very far from it, and the contrast really was staggering. While one realises what has been done since the Health Act was passed to improve our hospitals and hospital services, and that in this improvement of our hospitals our old folk who are being cared for have benefited to some extent, I think we ought, in fairness to the older generation, to make a very big effort radically to improve a lot of hospitals and homes where old people are sometimes living under very crowded and not very beautiful conditions.

So that, in the last resort, undoubtedly this question depends more than anything else on personal and social relationships. We are all very susceptible to our physical environment, and I think that some of the terribly gloomy buildings we have, which must be very difficult to work in, are of quite a low standard for a community which sets out to care for its old folk. So while we welcome, and wish to pray about, all that has been done to improve conditions over the last seventeen years, I think that this end of our medical service—I am not talking so much about the service of people as about the buildings in which the service is rendered—is still much behind any kind of satisfactory standard. Therefore, I am glad that a member of the medical profession, who has this so much at heart, should have brought this subject up for our consideration.

6.10 p.m.

LORD ARCHIBALD

My Lords, unlike the noble Lord, Lord Amulree, to whom we are indebted for putting down this Motion, and most of the other speakers in the debate this afternoon, I can claim no special knowledge or experience in this field. But I do not think that many Members of your Lordships' House have reached my age—perhaps, from what has been said earlier, I should declare an interest in the debate—without having some personal experience of the problems which have been covered in the range of the debate.

One thing that has struck me particularly is the number of speakers who have emphasised the problem of accommodation for the elderly. That is well put in this year's Annual Report of the National Old People's Welfare Council, which says: The difficulty of finding a suitable place in which to live is one of the greatest problems confronting the older person to-day. For various reasons, many are forced to live at the top of houses, which necessitates carrying coal and sometimes water up long flights of stairs. Often toilet facilities are on another floor. It has come out in the course of the debate that for people so circumstanced one of the most important contributions that can be made to their welfare is the provision of residential homes of one type or another.

I know that these can be provided both by local authorities and by voluntary associations. My noble friend Lord Stonham referred to the fact that 300 local authorities have not yet built a single house for old people. Some few authorities have provided a certain amount of accommodation by conversion. The point that I want to put before your Lordships this afternoon is the backwardness of local authorities in the support which they may give to voluntary associations in this field. I think I can illustrate it best by telling your Lordships of the experience of a housing association, with which I am connected, which was set up for the purpose of finding a large house and converting it into flatlets for old people, either for one or two persons, with kitchen accommodation and adequate provision of bathrooms, and with a housekeeper who would be available to give help in time of sickness but who would not be a matron or nurse in the hospital sense.

The noble Lord, Lord Beveridge, referred to the high cost of suitable houses for such a purpose in Oxford. I tell him that the cost is even higher for a suitable house in the London area, and it is much more difficult to find one. Having spent a long time in finding a suitable house, the association then applied to the local authority for the 90 per cent. mortgage which they may give. But this is permissive. My noble friend Lord Stonham has said that many of the permissive powers of local authorities should be reconsidered and perhaps made mandatory. In this case, the local authority refused the 90 per cent. mortgage. The amount which could have been raised by an ordinary building society mortgage left such a big gap that the resources of the housing association could not meet it.

After another long search another suitable house was found, but again the local authority refused the 90 per cent. mortgage. This time, however, this rather small housing association made the necessary effort, got loans at a low rate of interest, and was able to meet the gap between the building society mortgage and the cost of buying the house. There was still the question of conversion. Again it is optional whether the local authority will give a 40 per cent. conversion grant. Then, when the place is open, it is again optional for the local authority to give any grant aid.

In this respect, I suggest that local authorities are being very short-sighted, because for them this is a very inexpensive method of dealing with a problem which properly lies on their shoulders. I would ask the noble Lord who is to reply if he would bring to the attention of his right honourable friend the possibility of putting a little pressure on local authorities or at any rate of drawing their attention again to the fact that they have these powers and that, if they use them wisely, they will not only be helping the elderly but will also be making that help available in the most inexpensive manner possible for the community.

LORD NEWTON

My Lords, I should be delighted to pass that on. I would also say that a great deal of encouragement has been given already, but there may well be a case from giving more.

LORD ARCHIBALD

I thank the noble Lord. If he wishes it, I shall be happy to give him particulars of the two cases I have quoted. There is only one further point to which I wish to refer. I do not think that the need for provision for those who may generally, and I hope not unkindly, be referred to as the old and mentally frail has been stressed in the course of the debate. They could very well be cared for in the type of residential accommodation I have been describing. But it is not really the kind of work which should be undertaken by voluntary organisations. The National Old People's Welfare Council says specifically: Residential accommodation for the mentally frail is a need which has hardly yet begun to be tackled. A few local authorities have plans for homes reserved for this type of resident, though none has yet been opened. Certain voluntary organisations are considering special homes for the mentally frail in addition to the three now open. Voluntary societies generally are not, however, recommended to start new homes for the mentally or physically frail. If it is not a suitable operation for voluntary organisatons—and I think that the Council are right—it certainly is a suitable operation for statutory organisations. The burden of looking after the mentally frail is often much too great for even the best of families to be able to carry. It is the sort of burden which can produce such family strains and stresses that it may even go to the length of producing what we hear of in regard to delinquency—namely, the broken home. That is something that should be avoided at all costs. If local authorities would set up with sufficient, but not lavish, staff the type of residential accommodation that is needed for the mentally frail, I would again suggest that this would be a very economical use of money, because it would not only mean in many cases, as I have said on the one side, the removal of stress and strain from the family, but also, on the other side, make it possible to look after the mentally frail without requiring them to be hospitalised. Instead of being in hospital at a cost of £35 to £40 a week, they could be accommodated in that type of residential home at a mere fraction of that cost. I would again ask the noble Lord who is to reply if he will particularly draw the attention of his right honourable friend to the need for this type of residential accommodation for the mentally frail, and even for the physically frail, who are not so seriously ill that they require hospitalisation.

6.22 p.m.

THE EARL OF LONGFORD

My Lords. I should like to support the special plea made by the noble Lord, Lord Archibald, for the old who are mentally frail, and also to join him and others of your Lordships in a tribute to the noble Lord who initiated this grim-sounding debate with so much charm. He made reference to the famous social reformer, Chadwick. I think that what most of us remember about Chadwick is the famous statement that: England wants to be clean, but not to be cleaned by Chadwick". I suppose one could adapt that by saying: "England wants to be well, but if she must be ill she would like to be treated by the noble Lord, Lord Amulree, assisted by the noble Lord, Lord Taylor, the noble Baroness, Lady Summerskill, and any other doctors who form this ever-growing medical lobby in this Upper Chamber to-day".

The noble Lord, Lord Taylor, called my attention to the presence earlier today of large numbers of young people in the Gallery, and that, I think, is interesting and encouraging. There is no doubt that the young people are anxious to do more for the old providing they can find a method of doing it. Some of your Lordships may have seen an article by Sir Harold Nicholson (not the last one, in which he said that he hated a certain political Party; that does not arise) in the Observer, in which he was referring to the young and their awkardness in some ways, when he said that they were very kind and attentive to old people like himself. Of course, Sir Harold Nicholson has special charms which may not be possessed by all the elderly sick and infirm, and they may not all receive this same attention. But I think the right reverend Prelate who has just addressed us so powerfully, and the other right reverend Prelate whose maiden speech was such a great success, would both say this—and it was touched on by the right reverend Prelate the Lord Bishop of London—that the young of today in youth clubs are showing a distinct interest in service to the old. That ought to be very much encouraged.

I am bound to say, however, that noble Lords and Ladies who have taken part in the debate to-day would not claim extreme youth as their main qualification for speaking. Some of them have been doctors and others bishops, and some have frankly spoken as old people. I think the noble Lord, Lord Beveridge, described himself as old; and I do not think anyone would be insulting him if they agreed with him that he is quite old, as I think he must be around the 80 mark; and even by the standards of your Lordships' House he must be regarded as a thoroughly mature person. I am only sorry that the noble Lord is not with us now, because I owe him so much in so many ways.

But I cannot agree with the noble Baroness, Lady Swanborough, when she describes herself as old. A person is really as old as he is thought to be by those who meet him. I met a man the other day when one of those rather embarrassing discussions was going on in which people were guessing one another's ages; and this particular man, who lacked tact it seemed to me, looked at me and said: "I do not know your age, but you must be much younger than you appear to be". That, I thought, was not the kind of conciliatory remark that should be made. If the noble Baroness, Lady Swanborough, really claims to be old, all I can say is that she must be much older than she appears to be. I do not accept her as old in any sense at all. She made a poignant speech, and I side with her tremendously (particularly as some of the scientists, though not all, have left) if she says that science has a great contribution to make to the social services. But sheer humanity has a contribution to make which nothing else can equal.

The question of who are the old has been running through our minds, and this may make it all the harder for the noble Lord who is to reply—and I apologise to him if I have to leave before the end of his remarks. The school led by the noble Lord, Lord Taylor, seem to hold that a man is old at 50, because he began by saying that we were entering a gerentocracy as we were now being led by men of 50 and over. The noble Lord, I am sure, is under 50, but I suppose that 50 is within his sight. Those of us who are in their fifties do not necessarily accept that account of old age. It is, as I suggested earlier, a somewhat relevant matter. I remember attending a dinner given here to that wonderful public servant the late Tom Jones, on his eightieth birthdray. The Lady Astor made a speech in which she said she had visited Bernard Shaw that afternoon—he at that time, I think, was not far short of 90—and he had asked why a dinner was being given to Tom Jones on that particular day. Lady Astor said: "Because he is celebrating his eightieth birthday"; and Bernard Shaw snorted with contempt, and said: "Eighty! Why, he's a mere boy". That is one view of old age.

I think we are primarily concerned today with the sick and infirm among the elderly. I say that because, although various speakers, including the noble Lord, Lord Beveridge, have pointed out that you cannot single out one group in the old and separate them from the others, yet if we were discussing the old as a whole we should surely have been much more concerned with the active contribution that old people can make. We have, on the whole, attended to-day to the categories mentioned in the Motion—namely, the people who are, generally speaking, incapable of rendering much physical service, though they may contribute much of moral and spiritual value. If we were discussing old people as a whole, we should surely wish to discuss the far greater opportunities that might be provided for people when they retire to add to their existing achievements. But that, perhaps, does not arise so much to-day.

I should like to say one or two words (I hope not to be long, because all those who have spoken so far have much more knowledge of this subject than I) from the point of view of the National Old People's Welfare Council, because that is the kind of body which is doing work of exceptional value. They are a coordinating body linking together the six Government Departments concerned with the care of old people and some 50 national voluntary organisations which are wholly or partly concerned with helping the old. The Council is a national focal point for information and advice and acts as headquarters for all the 1,650 local old people's welfare committees, plus county and regional committees. I think that in considering the work done for the old, whether by the Government or by particular bodies, we should not pass over the unique contribution that is being made by this body. I hope that the Minister will, at least, pay his own tribute to them, because I know how highly valued by the Government this work is.

If we think of these 1,650 local old people's welfare committees, we must, I think, realise that they are not only effecting co-ordination, but have been instrumental in initiating or providing on a co-operative basis a variety of voluntary services: for example, organised voluntary visiting, social clubs, day centres for the infirm and lunch clubs. Of course, there are the "meals on wheels" (mainly carried out by the W.V.S., but sometimes, I understand, on a cooperative basis through this Committee; the noble Baroness, Lady Swanborough, confirms that), workshops, laundry services, flatlet schemes, residential homes, boarding out schemes and a variety of other personal services. Some of them have been touched upon in various ways during to-day's debate.

I should like to make one point which is certainly very much in their minds, and which seems to me of great importance. It was implicit, I think, in something said by the noble Lord, Lord Stonham. There are certainly all sorts of ways in which the local authorities can grant aid voluntary organisations. It is the considered view of the National Old People's Welfare Council that far too few local authorities are using their powers in this way. I am not talking of the services provided by the local authorities of which we have heard a good deal, some of it good, and some not so good, but of the powers which they have to grant-aid voluntary bodies.

I am quite sure that the National Old People's Welfare Council are quite right in saying that a much more imaginative use of these powers by the local authorities could make a tremendous difference to the development of the service, and particularly the domiciliary service, provided by the voluntary organisations. These would supplement the work being done by the local authorities. I will not pursue that point now, but I hope the Minister, even if he cannot add anything today, will draw the attention of his colleagues to this important question (not, of course, raised for the first time by me now, but raised throughout the day in various forms) of the increased assistance that might be given by local authorities to the voluntary bodies.

I suppose the theme that has been pressed most strongly—not to the exclusion of others, but most strongly of all to-day—has been the shortage of accommodation and, in particular, of housing. We have been given a strong lead from various quarters, from the noble Baroness, the noble Lords, Lord Beveridge and Lord Taylor, and others, but this stress on the need for better housing is something with which I have no doubt the Minister will deal at length when he replies. I do not want to run over that ground again, although the point could not be repeated too often.

I would rather say just one word on a point that has not come up so much to-day but which must not be altogether overlooked, and that is the question of financial security of the old, including the old who are sick and infirm. It was touched upon by the right reverend Prelate, the Lord Bishop of Sheffield, in distinguishing the five categories. I remember that when I was more active on behalf of the old than I am now (I am afraid, to my shame, that I have become mixed up in so many other things), as a city councillor in Oxford before the war, I was engaged in pressing for the increase of the old age pension, which was then extremely low, by 10s. I was discussing this question with, as he seemed to me then, an elderly cabman. I do not know how old he was, but he was an old age pensioner and he drove a cab. He told me that in his earlier days he had been a close friend of Lord Nuffield, as he had become—Billy Morris, as he had been—who had tried to persuade him to go into the motor business with him. This cabman had replied, "No, thank you. You will never beat the horses." Of course, he was proved wrong. Lord Nuffield made a great fortune and is one of the greatest business men in the world, and this elderly cabman was still driving a cab. I asked him whether he regretted that Lord Nuffield had got so far ahead. He said, "No. I am told he does not enjoy very good health. I have three excellent meals a day and sometimes more, and I can drink several pints of beer. I am afraid my poor old friend is not able to do that, but I must say I should like an extra 10s." I think it is that minimum of finance which makes the difference to everybody, however simple their tastes.

I am sorry the noble Lord, Lord Beveridge, is not here, because I wanted to say something that was intended to be complimentary to him but might be regarded as heretical in his absence—I am not quite sure. Perhaps the noble Lady, Baroness Wootton of Abinger (since she has assumed a position on the Liberal Benches) might undertake the task of speaking from that point of view. As I see it, the Beveridge principle of 1942 was threefold. I am thinking of the principle of the pension to be eventually achieved by the old. As I see it, it was a threefold aim or principle. The subsistence benefit was first then there was to be an element of insurance involved, and then there was to be the absence of a means test. Its benefit was to be given as of right, without your having to prove that you were more or less destitute. I do not want to strike too much of a Party note, but we remain a political House, and I would submit that the first principle, that the pensions should eventually reach subsistence, has been rejected by the Conservatives. I do not think they claim to be trying to achieve subsistence through pensions now. The Minister will be able to correct me if I am doing him an injustice, but that seems to be so.

As I understand it, for the last seven years or so our present Government have claimed that the State pension should provide only a kind of basic minimum, and that individuals should be expected to obtain additional income to the pension in order to arrive at subsistence. That is how we understand the change, and it seems to me a departure from the general principle. The general principle is not sacred, and the Government may have ideas which are better. I think they are worse, but it seems that a change has clearly occurred.

On a point mentioned by the right reverend Prelate, those without additional incomes have had to turn to National Assistance, which was originally intended to be a sort of emergency measure to cope with a few thousand. But people have had to turn to National Assistance in very large numbers. My figures are that at the end of last year there were 1,265,000 who were receiving National Assistance—that is, one in four retirement pensioners. The right reverend Prelate said 1,300,000, so there is not much between us. His figures may be up to date, while mine refer to the end of last year. Let us say that 14 million of the retirement pensioners, that is one in four, are now receiving National Assistance. So the attempt to provide subsistence pensions seems to have been abandoned, and if so it is something we heartily deplore. The Labour Party have advanced beyond the general principle in respect of the subsistence idea. I hope that no one will say that we have retreated from it in the way noble Lords opposite have. We have advanced beyond it. The noble Lord laughs. I suppose he is laughing at something, but at the moment it is very hard to know what.

LORD NEWTON

I merely observed, "Well!"

THE EARL OF LONGFORD

If the noble Lord will restrain himself, he will place himself in a position perhaps to appreciate the gravity of the failure. But as his knowledge of this whole subject is new to him, he must allow me to put him right on this point. I gather that the point I made just now was something that had not occurred to him. It seemed to need immediate consultation. I must be allowed to inform him of what has really occurred.

The Labour Party wish to go beyond this plan. They do not want to fall below it, which is what the Conservatives appear to be doing. Now where we have gone beyond the Beveridge Plan in our own scheme is that we feel you cannot accept only a purely physical minimum. On the point of inflation, which was stressed by the noble Lord, Lord Beveridge, himself, I think that everyone, including noble Lords opposite, is anxious in his own way to defeat it. But, quite apart from inflation, we would not say that as society got richer there should be no rise in the minimum of real pensions. We therefore say that subsistence itself should be increased at the same rate as the general prosperity of the country, and in that sense we have gone beyond it.

I am sorry if I was a little testy just now towards the noble Lord, but really there is nothing at all comic in these things when a lot of old people who, if we were returned to power, would greatly benefit, are being seriously damaged under his Government. That is our view of it and I hope the noble Lord will forgive me for being testy when so many elderly people in some distress are concerned.

I will now close with a few words which I came across in the editorial of a religious paper last week. It happens to be a paper of my own denomination, but I think these words will appeal to anybody of Christian or humanist faith, anyone with any ethical feelings, and I am sure they will appeal to the noble Lord opposite. An elderly priest, in his 82nd year, was telling the other day of the experiences of old age. He was saying that, as we reached old age—I now quote the editorial: … we 'listen for that Voice which could not make itself heard so well in the clamour of the busier years'. Now that Voice begins to converse with us in the cool of the evening and the courage of old age is the courage of an exalted vision, a glimpse of reality and the foundations of things. The young are to profit by the interpretation, yielded by the faith of the aged, of the meaning of the universe". That and other words which we have been offered this afternoon by those that are greatly in contact with the old will remain in the minds of many.

I remember spending a day or two in a religious house some years ago. We used to proceed from the refectory after lunch in a kind of queue and I found myself always walking beside a young priest who was about to set off for San Francisco, where he was going to dedicate himself to religious work. We were always behind a very old, doddery priest, and it became a great nuisance because this old priest moved so slowly that we were always left a long way behind, and by the time we got to the coffee it was cold. We became irritable and I indicated as much to the young priest as we were walking behind this doddery old man; but he turned to me in absolute sincerity and said, A wonderful old man grown old in the service of God". That is how we ought to think of the old. Sometimes they have been great people like Sir Winston Churchill, sometimes they have been people who have made some notable contribution to the world, though of course they may well have been people who were rather futile and would always have been rather futile; but all share this same common humanity given by God and we owe all of them this same reverence. I do feel that this debate has been one of the most valuable we have had in this House, and I only hope it will bring about great benefits to the old in future.

6.45 p.m.

LORD NEWTON

My Lords, I think it was the noble Lord, Lord Beveridge, who drew attention to the fact that we regularly have in your Lordships' House debates about various aspects of what are generally called the social services. We do, my Lords, and often as not it is my task to reply to them, and I regard myself as being fortunate in having to do so this afternoon, not only because of the importance of the subject introduced by the noble Lord, Lord Amulree, but also because of my own personal interest in it, as well as because of the fascinating nature of the speeches we have listened to and their variety and the spirit in which they have been made. There was really very little that I listened to this afternoon with which I disagreed, until that part of the speech of the noble Earl, Lord Longford, when he indulged in a little skirmish into Party politics on the subject of old-age pensions.

THE EARL OF LONGFORD

My Lords, is that going to be the noble Lord's sole reference to that or is he going to deal with the topic?

LORD NEWTON

I think the noble Earl will discover the answer to that as my speech develops.

THE EARL OF LONGFORD

Will the noble Lord give way? I want to say that I was not skirmishing in the sense he implies, with any Party object; I was really concerned sincerely with the aged.

LORD NEWTON

My Lords, what I was going to say later on, but I may as well say it now, is that I did not think that at the end of a long debate on a wide variety of subjects, in which pensions had hardly occurred at all until the end, it would be appropriate for me to start on a Party political debate with the noble Earl on the subject. On another occasion it would be very agreeable because I do not think it would be very difficult to establish that the record of my Party on pensions is better than the record of the noble Earl's own Party. That was really all I was going to say about that.

We have had this afternoon a notable addition to the ranks of those noble Lords and Ladies who speak in debates of the kind we have been having to-day. I am of course referring to the right reverend Prelate, the Lord Bishop of London, and I am sure all of us who heard him were impressed by his call to us to support the appeal of the Lord Mayor of London, not only to make this an old people's Christmas, but to carry further the spirit of the appeal. The noble Earl, Lord Longford, delighted us at the beginning of his speech with a disquisition on the philosophy of old age, and I will not attempt to follow him on that. But I would say that all of us who are at any rate middle-aged—perhaps I can safely say that about myself—and have watched our parents and other relatives grow old and die, understand the importance of combating loneliness and conferring companionship on old people in abundant measure. I hope that the right reverend Prelate will be a regular participant in debates of this kind.

In 1955 there were just over 5 million people aged 65 or more; that is to say, one in nine of the population. In 1960 the number had risen to nearly 5½ million, or one in eight of the population, and of these, as the noble Baroness, Lady Summerskill, said, nearly 2 million were at least 75. It is estimated that in the year 1975 the number of people aged 65 or more will be about 7 million, or one in seven of the population. These figures show, I think, the size of what is sometimes called the problem of old age. But it would be a mistake to conclude that every person who becomes old poses a problem for the social services. As the noble Lord, Lord Amulree, pointed out in his speech, many old people continue to live in their own homes and require no special help apart from the services provided for the whole community. Old age in itself is not necessarily a problem. That has been argued, I think, by many of your Lordships.

I am constantly struck by the ease with which, when one is considering the proper function of the State in caring for the old, one can think and talk as though elderly people do not have children to whom they can look for affection and interest and assistance. But surely it is a serious error to make any such unconscious assumption, if it is unconscious. One sometimes hears it said—indeed, my noble friend Lord Fortescue said that he had heard it said, I think by a doctor friend—that it is a characteristic of our Welfare State that when children are grown up they neglect their obligations to their parents. I do not believe that those who make such statements have any evidence to go on. I am not aware that there really is any real evidence one way or the other on that, although possibly we may get some from the Lewisham experiment, about which I will say something later on. I was fortified in this connection to hear the views of the right reverend Prelate, the Lord Bishop of Sheffield. The point which I am making, that elderly people are not by definition childless, has a bearing on the problem of what may be called ascertainment of the needs of the old, about which I want to speak later.

The State comes into the picture because there are elderly people, particularly the more infirm ones, who need something extra in the way of support—a great deal of care at home; a special house or residential accommodation; or a hospital bed. I do not claim this afternoon—indeed it would be absurd to claim—that all the difficulties attendant upon providing these things have been resolved, or that all the defects in the supporting services have been remedied. Staffing difficulties are obviously a problem in a time of full employment. There are shortages too, varying from area to area, in buildings and in hospital beds for chronic cases. What can fairly be claimed is that the services for the elderly, which are wide in range and scope, are growing and developing all the time. It is the Government's intention not only to keep pace with the increasing numbers of elderly people who need help but also to fill the gaps and the deficiencies as quickly as resources will permit. This, then, will he the theme of my speech, and I could quite easily make a speech of inordinate and intolerable length, as your Lordships will no doubt believe. Indeed my difficulty is not what to say but what not to say.

So I do not propose—and I hope the noble Lord, Lord Taylor, will forgive me—to say anything about private homes and private nursing homes; nor will I say anything about the ancillary staffs. The noble Baroness, Lady Summerskill, who referred to that question, is riot in her place, and in any event she is going to give us the opportunity of a debate on that subject as soon as we get back after Christmas. The noble Lord, Lord Stonham, made an interesting suggestion. Perhaps I could deal with it now. It was that there ought to be some form of central register compiled, I think he suggested, by the Ministry of Pensions and National Insurance and supplied to the local authorities so that they knew where the old people were with whom they ought to concern themselves.

LORD STONHAM

My Lords, will the noble Lord allow me? My suggestion was that the statutory responsibility for the compilation of the register should be placed on the medical officer of health for the district or borough, but I asked that Government Departments should be directed to supply the medical officer of health with details of elderly people on their books.

LORD NEWTON

On that latter point, I want to say that it is an interesting suggestion which I think should be looked at. But I believe it would be a difficult one to carry out, because the information possessed by the Ministry of Pensions and National Insurance is confidential, and I think a great many old people would strongly object to particulars about them being given to local authorities.

I want now to summarise the ways in which the Government consider that services for the elderly should be developed, and I believe that there will be general agreement among your Lordships that the Government's ideas on this matter are right. The aims are: first, to encourage and help the elderly to live in their own homes as long as they can. This is what most of them want to do, a point emphasised time and time again this afternoon, particularly by the noble Baroness, Lady Swanborough; secondly, to provide special housing (with or without a resident warden) for those who need it; thirdly, to provide residential accommodation suitable to their needs for those who require care beyond that which can be made available in their own homes; fourthly, to provide hospital beds for those requiring treatment or prolonged nursing care. Those are the aims, and I feel satisfied, after listening to this debate, that your Lordships would agree with them.

I was glad that the noble Baroness, Lady Swanborough, laid so much stress on the domiciliary services. In the domiciliary services the lynchpin is the family doctor. It is not always realised how much of the doctor's time is on average spent in the care of his more elderly patients. The most recent survey on this showed that among a representative sample doctors saw their patients who were 65 and over about twice as often as they saw those between 15 and 45. The family doctor has the further responsibility of bringing into action wherever necessary the other services available for elderly patients living at home, and I think that is partly the answer to the right reverend Prelate, the Lord Bishop of London, and to the noble Lord, Lord Beveridge, on the points which they raised about ascertainment of the needs of old people for individual services.

A booklet entitled, Services available to the Aged and Chronic Sick, prepared by the Standing Medical Advisory Committee for the Central Health Service Council and my right honourable friend, has recently been published. It describes the problem of an ageing population and sets out the kind of services which are available to a doctor's older patients from the local health and welfare authorities. Copies of this have been sent to all general practitioners in the National Health Service, to local health and welfare authorities and to housing authorities.

Your Lordships have praised the work of the home nurses. I am glad to say that you all, I think, referred to them as district nurses, which is what I like to do, but I am told that I ought not to. At any rate, I am very glad your Lordships praised them. There is no doubt that they meet an increasing need of the elderly sick who might otherwise have to go into hospital. The number of nurses employed whole and part time has risen from 7,000 in 1948 to 10,000 in 1960. In 1960 over 23 million visits were paid, of which more than half were to patients who were aged 65 or over at the time of the first visit during the year. The increasing proportion of the time of the home nursing services devoted to the elderly is shown by the fact that in 1953 the proportion of cases aged 65 and over was only a third of the total number attended.

Many of your Lordships have suggested that the home help service is the mainstay of old people living in their own homes, and I am sure that is so. All local authorities have made provision for it and it is increasingly used for old people. The noble Baroness, Lady Summerskill, talked about a universal shortage of home helps, but the fact is that the number of home helps employed has risen from 11,000 in 1948 to 49,000 in 1960. The number of households helped has now gone up from 139,000 in 1949 to 312,000 in 1960. That seems to me to be quite an appreciable increase.

Both the numbers of elderly helped and the share of home helping devoted to them has risen steadily. During 1960 the elderly and chronic sick represented about 75 per cent. of all those in receipt of help. In 1953 the figure was about 58 per cent. Many old people need only a few hours of help a week to enable them to continue living in their own homes. Nevertheless, the home help is often a friend as well as a helper, and sometimes even, as the right reverend Prelate pointed out, the main regular contact with the outside world. Additional special services provided by some authorities include night attendance, to relieve relations who look after the very infirm or confused old people; male helps for old men living alone; early morning or late evening visits to lay fires and help the elderly to dress or undress, and central laundry arrangements to do the washing, especially the bedclothes and personal linen of old people who are suffering from incontinence.

The noble Lord, Lord Taylor, reminded your Lordships of the importance of chiropody in keeping old people active. Since 1959 most local authorities have, in response to the Government's suggestion, introduced chiropody services which give priority to the elderly, among other special categories; and where an elderly person has difficulty in attending for treatment, transport can he provided, or even a visit to the home can be arranged. I am afraid I have no figures which I can give your Lordships as to the extent of this service.

The right reverend Prelate, the Lord Bishop of London, and the noble Earl, Lord Longford, spoke about the voluntary services. They have been expanding, helped by the power of local authorities to contribute to the funds of appropriate organisations. They make a substantial contribution to the care of the elderly by providing personal services, visiting, clubs, recreation, "mealson-wheels", holidays and many other things like that. The number of old people's welfare committees continues to rise. As the noble Earl said, there are over 1,600 of them in England and Wales. They provide a magnificent service in co-ordinating the work of organisations and of individuals, and my right honourable friend hopes that the voluntary services will go on from strength to strength. I am glad to respond to the invitation of the noble Earl, Lord Longford, to pay my tribute to the National Old People's Welfare Council which is, as he explained to us, the central organisation. They do invaluable work and give a great deal of assistance to Government Departments by their co-operation and advice.

May I add a word on "meals-on-wheels"? As your Lordships will know, a Private Member's Bill, promoted by Mr. Geoffrey Johnson Smith, was read a second time without debate in another place on Friday. That Bill empowers local authorities to provide meals and recreation for old people, either directly or through the agency of voluntary organisations. It also preserves the power of local authorities already contained in Section 31 of the National Assistance Act, 1948, to contribute to the funds of voluntary organisations which provide these things. The underlying aims of the Bill have the Government's general support. It would, I think, be improper for me to say more about the Bill at the moment; but if and when it reaches your Lordships' House I shall look forward to doing so.

I should like to turn now to housing schemes especially designed for old people. Most elderly people want, as I and as your Lordships have already said, to lead independent lives in their own homes. There is no doubt that to do so gives them the best chance of an active and happy old age. There is therefore a widespread need for small, labour-saving homes in which the elderly can live and look after themselves. The suggestions and advice given in this debate this evening about what these small homes should be like will, I think, be useful to those who have to provide them.

Housing authorities have been given every encouragement to provide homes of this type and they are making great efforts to meet the demand. To help them, a special subsidy of £10 a year for 60 years for one-bedroom dwellings was retained when the general needs subsidy was abolished in 1956. The measure of their effort is shown by the fact that the number of one-bedroom dwellings completed actually rose from 11,000 in 1951 to 27,000 in 1960, a rise from 7 per cent. to 26 per cent. of their total building.

The priority which the Government attach to satisfying this big and expanding demand was re-emphasised in the White Paper Housing in England and Wales, in February of this year, and in a circular issued in March of this year. Under the new subsidy arrangements now in force, local authorities which satisfy the test of financial need in the Housing Act, 1961, will get a much bigger subsidy—£24 for any kind of house, flat or flatlet which they build for old people. Those authorities which do not satisfy the test—which means that they do not lack untapped resources—will still get a subsidy of £8.

A valuable and growing, contribution is also coming from the voluntary organisations. Housing associations can do a great deal to vary the provision made for old people and can bring to the dwellings which they build and manage the personal touch which old people value so highly. Under the 1961 Act the housing associations will get the £24 subsidy for their building for old people.

LORD STONHAM

My Lords, might I ask the noble Lord a question on the point of the proof of need? Does it mean that if a local authority can show that there is an acute shortage of special housing for old people in their area, they will get the larger rate of subsidy?

LORD NEWTON

I should not like to answer that "off the cuff". As the noble Lord knows, this business is extremely complicated. I will look into it and will let him have an answer as soon as I can. Undoubtedly, housing authorities must provide in adequate numbers a range of different types of dwellings (flats, bungalows, and flatlets): some fully self-contained in which active elderly people, particularly married couples, can be wholly independent; others in which, by grouping the dwellings together, friendly help is obtainable from a nearby warden; others in which, especially for the frail, provision can be made for communal services in addition to a warden.

In recent years more and more emphasis has been placed on careful planning of all dwellings intended for the elderly. I am now about to say what I think the noble Lord, Lord Stonham, wanted me to say, namely, that they should not be in isolated colonies, but interspersed among other houses, or sited in groups of a manageable size within easy reach of shops and buses. Many local authorities build their small dwellings for old people in the middle of family housing. This enables the elderly people both to be near their families and to be living in a house of their own. That was a point made by one noble Lord. But dwellings for the elderly should also be designed with an eye to safety and convenience. Stairs must be easy to manage; windows and cupboards must be at a convenient height; regular warmth and an even temperature are most important, and central heating, in one form or another, is especially recommended. The Ministry of Housing are preparing for publication a comprehensive booklet on designing for old people.

My Lords, as part of their campaign for encouraging schemes of the kind that I have mentioned, the Ministry of Housing, in co-operation with local authorities, is giving wide publicity to demon-station blocks of flatlets. One such block at Brighton was opened by Mr. Henry Brooke a year ago, and another one at Swansea was opened more recently by Dr. Charles Hill. A scheme of 24 flatlets at Stevenage should be finished next spring; a model of it, and an exhibit showing the special system of construction used were on show at the Building Exhibition in November. I have here, and perhaps some of your Lordships saw it, a page from the Daily Telegraph on December 2, which contains some extremely good photographs and descriptions of some of these modern housing schemes for the old. I have the page here if any noble Lord would like to see it.

My Lords, I should now like to consider progress in providing residential accommodation under Part III of the National Assistance Act, or Part III accommodation, a term which some of your Lordships have described as so unfortunate. The number of people accommodated increased from 46,468 in January, 1949, to 84,556 in December, 1960. This includes accommodation in former public assistance institutions, as well as in new homes opened by local authorities since July, 1948, and also accommodation provided on behalf of local authorities in homes run by voluntary organisations. From the end of the war to December 31 last year no fewer than 1,184 modern small homes were opened, of which 207 were in new buildings specially designed for the purpose. Places were provided in these homes for 39,000 residents in need of care, mainly because of old age. Where former institutions have had to be retained, local authorities have done a great deal to improve them by dividing up large dormitories, improving decorations and furniture, and similar means.

Nevertheless, what local authorities have been able to achieve has failed to overtake the demand. Pressure on accommodation is one reason why it has been impossible for all large institutions to be vacated. In some places demand has been so heavy that it has led to overcrowding. A need has been revealed for much more accommodation on the ground floor or on floors served by lifts. And so almost all the new buildings which have been built latterly have been designed for very infirm residents. Lifts have been installed in many existing houses. The ratio of staff to residents has tended to increase because of the greater degree of care needed by the type of resident now in the homes.

In spite of all that has been done there is still a shortage of accommodation for the very infirm. But I must emphasise, my Lords, that the amount of capital investment authorised has been stepped up strikingly. In England and Wales the annual level of loan sanctions recommended in the years 1956–57 to 1958–59 for the provision of old people's homes was about £2½ million. By 1960–61 it was £8¼ million—a very large increase indeed. In the current year, it is expected to be even higher, which illustrates the importance attached by the Government to the development of this service, notwithstanding present restrictions on public expenditure. In a circular issued to all local welfare authorities last August, my right honourable friend urged them to proceed with all health and welfare capital projects which could be regarded as essential for providing care in the community. Already he has told them about 200 schemes for which he will be prepared to recommend loan sanctions in the current year, as soon as plans have been cleared.

I will now come to the hospital services. In his circular of October, 1957, the then Minister asked hospital authorities to give high priority to establishing in every hospital centre geriatric departments, under the control of specialist physicians with special interest in the geriatric field. This policy is being pursued. The number of staffed geriatric and chronic sick beds rose from 57,713 in 1957 to 59,183 in 1960. More than 100 geriatric departments under specialist physicians are now provided by hospital authorities in England and Wales. The number of out-patients' clinics for the elderly rose froth 3,900 in 1957 to 6,600 in 1960, and the number of attendances during the same period from 39,200 to 65,900. Quite apart from these attendances, there is a high proportion of old people among the millions who attend eeneral clinics in medicine, surgery and other specialties.

With the coming growth in the proportion of elderly people, it will be necessary to continue making adequate provision to meet the demand for long-stay accommodation. At the same time, with active treatment and with active rehabilitation, more and more patients are being discharged from hospital to their own homes or to welfare accommodation, where they can, if need be, make use of geriatric out-patient facilities. There are certainly places where there is a shortage of geriatric beds, though generally speaking the need at present is not for more beds but rather for better facilities and better supporting services. It cannot be denied, too, that some geriatric departments are housed in old and unsuitable buildings. This was explained to us by the right reverend Prelate, the Lord Bishop of Sheffield. On the other hand, I was delighted to hear the noble Lord, Lord Taylor, say how much has been done to improve buildings of this type, and how worth while it has been to do it.

The first and, perhaps, the most important step in improving geriatric services in any area is the appointment of a specialist physician who is interested and experienced in the care of old people and is able to devote the necessary time to it. Indeed, it is often not possible for the Regional Hospital Board to decide whether additional hospital beds or staff are needed until a specialist physician has been appointed and has determined the local position in detail. It is hoped that the increasingly close relationship between geriatrics and general medicine will attract more staff into the specialties.

My Lords, the noble Lord, Lord Amulree, suggested that it would be a good idea to change the nomenclature from "geriatric units" to "geriatric departments". I would say to him that the relationships between what is now called the geriatric unit and the general hospital are now being considered, and very careful attention will be given to the noble Lord's views. He also asked me about the number of bedfast and house-bound old people. From a survey of the "meals on wheels" service in 1959, it was estimated that there were in England and Wales 1,154,000 people of pensionable age house-bound in their own homes for all or most of the year, in addition to 98,000 also in their own homes who were bedfast. This is 18 per cent. of those of pensionable age.

The noble Lord also talked about the difficulty of discharging patients who, in the opinion of the geriatric specialist, no longer need hospital treatment. I am sure that the noble Lord is well aware of the position, and the obligations on hospitals as set out in paragraph 12 of the circular of 1957. But, my Lords, this is recognised to be a very difficult question and it is being considered. What I think it boils down to really is the question of how much nursing these patients need.

LORD AMULREE

My Lords, may I just interrupt the noble Lord for one moment? The patients to whom I was referring particularly do not need nursing at all. I quite agree that if they need nursing they must be retained in some kind of hospital, but the ones I was referring to do not need nursing, although they need a certain amount of care and attention.

LORD NEWTON

We may possibly have been disagreeing about the use of words, but, as I understand it, there is no general agreement in the medical profession as to the extent of nursing care which ought to be provided in welfare accommodation by local authorities as opposed to some form of hospital department.

I had intended to say something about the ascertainment of the needs of old people, principally for the benefit of the noble Lord, Lord Beveridge; but, as time is getting on, I will not do that, although it will mean that I shall not he able to say anything about the Lewisham experiment, which I wanted to do. Perhaps the House will think that I am making the right decision.

LORD TAYLOR

My Lords, may we ask the noble Lord whether, if we put down a Written Question about the Lewisham experiment, he will perhaps give us a nice long answer in Hansard?

LORD NEWTON

I think that is a very happy suggestion, and I cordially invite the noble Lord to put down such a Question. I hope that I have marshalled sufficient evidence to prove my earlier claim that services for the elderly have been developing steadily and sometimes impressively. It is always easier to point to deficiencies than to achievements, but one of the satisfying things I have found about the debate this afternoon has been the number of your Lordships who were prepared to point to the achievements. It is trite but true that the rate of development of any service must depend on the available resources of investment, manpower and woman-power, and on the competing demands of other needs. As the Guillebaud Committee said: It would be unrealistic to suppose that the deficiencies in the services for the treatment and care of the aged can be made good overnight. My Lords, the noble Baroness, Lady Swanborough, spoke very wisely and knowledgeably about the subject of cooperation between voluntary organisations and statutory organisations, on the one hand, and hospital authorities and local authorities, on the other. if the various services do not everywhere work together as well as they ought, this is largely for ordinary, human reasons; it is certainly not for lack of advice. Some people will always find it harder to cooperate than will others, even in political Parties. But the necessity for coordination and co-operation between all those who operate statutory and voluntary services for the old has been the theme of reports and circulars from 1951 up to the present time, and there is evidence that the right attitude is growing.

For the future, we must look, and can look, to hospital and local authorities to work even more closely together so that we may have a more accurate assessment of need—that is one of the things that both the noble Lord, Lord Amulree, and the noble Lord, Lord Taylor, asked for—and may make our dispositions accordingly. My Lords, I do not think that there can be any firm national figure of the number of places needed in old people's homes, because this is not a static situation and it turns on so many variable factors—for instance, the proportion of old people in the population; the extent of special housing; the extent of the domiciliary services; the quality of the accommodation provided (because the better it is the greater the demand for it); the extent to which families are able to look after their old relatives, and things like that.

LORD TAYLOR

My Lords, may I interrupt for just one moment? This brings one back to the point that the noble Lord, Lord Stonham, was making about letting the medical officer of health have a list of all the old people, which the noble Lord was doubtful about because of invasion of privacy. I have been thinking about that while he has been speaking. I wonder if he would look at it again, because, after all, the medical officer of health gets a list of everybody who has a baby, in order to arrange health visiting for them; and if a health visitor calls and is not required, it is perfectly all right. I do not think old people would feel that it was an intrusion that their names should be known as people who were old; and in that way many cases, I feel, would be picked up where perhaps they were not necessarily bad enough to see a doctor and yet were in need of help.

LORD NEWTON

My Lords, my advice is that there are large numbers of them who would object to any intrusion into their privacy, but I promised the noble Lord, Lord Stonham, that his suggestion would be looked at, and I gladly repeat that promise to the noble Lord, Lord Taylor.

My Lords, may I say finally that I have not sought to deny that there are deficiences to be remedied, and it is for that reason that I am grateful for the points to which your Lordships have drawn attention this afternoon. They will all be carefully considered. We all want to do our best for the old, and I am confident that we shall do so as the ten-year plans of both hospitals and local authorities come to fruition.

7.26 p.m.

LORD AMULREE

My Lords, I should like to thank the noble Lord, Lord Newton, for the very long and careful reply that he has made to the debate. Certainly the catalogue of what has been done sounds quite impressive, but I can merely repeat what I said when I began: that things are taking far too long. There is really nothing which he told me this afternoon which I did not know before. In fact, much of what he told me was what I had already said in my speech when I opened this debate. I think one cannot possibly hope for more than that at the present time, but I trust that progress will be pushed along on these points, which are very important and which are causing a lot of discomfort to many old people.

Before I withdraw my Motion, I should like to thank all those noble Lords and noble Ladies who have spoken in this debate, and I should like to record my tribute to the right reverend Prelate, the Lord Bishop of London, on his maiden speech. I beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.