§ 2.59 p.m.
§ LORD AMULREE rose to draw attention to the increasing use being made of community care in the health and welfare services; and to move for Papers. The noble Lord said: My Lords, I first came across the term "community care" when I saw it on the cover of a Blue Book published in 1963 on the health and welfare services which it was proposed should be provided by the local authorities as part of the Ten-Year Plan. When I came to read that book it seemed to me to have a great deal in common with what one had read about the teaching in mediæval times, when the people of the world were encouraged to take their standards from the Seven Works of Mercy. These appeared in a great deal 1322 of mediæval teaching. They appeared in pictures, in paintings, in churches, in stained glass windows; and, apart from the fact that the Motion does not propose to deal with the burial of the dead, I think it can well be covered by what was intended by the Seven Works of Mercy.
§ Not long ago, most community care meant that people should be put into institutions. They were offered "the house", as the rather uncomfortable saying was, and at the same time some were given a certain amount of rather scanty outdoor relief. And that is one of the points I want to raise about the community. They have always shown a tendency for the community—and it is one that I hope this debate may assist to dispel—to shut up people they do not like, who they feel are not quite people they can approve of, people about whom possibly they feel a somewhat bad conscience. That, I think, has certainly been the tendency in the past, and that is what we have to get away from now. There has been a great movement away from it, but a certain amount of that opinion still stands.
§ I do not want to take up a lot of time with a great deal of history, but I think that the Old Age Pensions Act, 1908, was the first Act under which the State took care of some of its members and made some provision for their care. In thinking of that, one now comes to put the question: What, in the year 1965, does community care really mean? To my way of thinking—and I do not say that I am completely right—surely community care means enabling those who are destitute—and by "destitute" I do not mean necessarily financially destitute—or disabled to live as full and as normal a life as they can among their friends in the community. In other words, how can the community enable those of its members who suffer from some disability, be it mental or physical, to lead a happy, independent life and to contribute, if they so wish, their share to the work of the world, within, of course, the limits of their disability?
The second proposal or suggestion is that, in order that this can be done, one of the most important things is that you must be able to get easily into contact with people who are in need of community care. Therefore, you have got to have good means of communication. At
the present time, the need of quite a lot of people is missed because the means of communication are not very good and the means of contact with them very difficult. The contacting can be done in a large number of ways. It can be done by medical social workers, health visitors, district nurses, voluntary workers of all sorts, and particularly, I think, people working for the various churches in this country. That seems to me the way in which contact can be made, and if we can use these means we shall find there are far more people in need of care from the community than would appear at the present time. The other day I read a paper by a Dr. A. R. May, and Dr. May made what seemed to me to be a profoundly important remark:
In our society employment carries with it a social status.
Supposing it is agreed that this is so, and that does seem to me to be a very fair proposition to make, what can be done to ensure this? One could talk at great length on this very big subject and one could pose all sorts of questions. That I do not propose to do. I should like just to give one or two examples of what has been done, possibly to ask one or two questions, and to trust that, supposing my proposition is agreed to, more and more will be done to encourage this state of affairs.
§ I should like to say, in passing, that I do not wish to confine my remarks to-day to any one particular class of person. I have talked to your Lordships frequently about the elderly in the country. I shall refer to them in passing, but I want my remarks to refer to all people in the community, young or old, and whether mentally disabled or physically disabled.
§ I would start with a few words about the mentally ill and the mentally subnormal. As your Lordships will known, once upon a time people who were suffering from mental illness were kept firmly locked up in large hospitals and very little treatment was given them. I know one or two places where that was not so, but that was the broad picture in the country. Gradually that has been shown to be wrong, which was one of the great things done by the Mental Health Act, 1959. It opened the doors of these great mental hospitals and took away the stigma of certification from the patients who had been in them. The patients or the ex 1324 patients of those hospitals were to become the responsibility of the local authority and were to be taken care of in hostels rather than in hospitals. This, of course, was a long process, but I think I am right in saying that about forty local authorities have gone so far as to construct hostels, and one of the difficulties has been who they are to be staffed by. I gather that a voluntary committee was set up some years ago which was going to go into the staffing question, and that will be reporting towards the end of the year. Perhaps the noble Lord will be able to confirm that and say what steps have been taken to implement its recommendations.
§ One has got to be careful with mental patients, as with all other patients. A certain amount of difficulty occurred when the Mental Health Act first came into force, because some of the mental hospitals discharged their patients rather too enthusiastically. There was one particular example which I came across concerning about sixty or seventy elderly women who were not suffering from real mental disease but had something wrong with their mentality; they had been taken care of in a big mental hospital for something like twenty-five or thirty years and they were suddenly told they had to go out into the world. They had no idea what to do outside. Their families did not wish them to be with them, and so there was a good deal of trouble. What finally happened was that one of the old workhouses built immediately after the Poor Law Amendment Act, 1834, which had been shut before the war as unfit for human habitation, was turned into a hostel—a not very satisfactory hostel—in which they could be taken care of. Therefore, one must not be too enthusiastic about keeping mentally sick patients away from hospitals, because a certain number should be admitted to hospital for their own sake and for the sake of others, for the sake of the public and their families; and because, looking at it from another and rather different way, it is important that they should not be in the community, since they tend to have far too many children; they breed too easily, and children who are the offspring of two mentally sick people are not very satisfactory children.
§ I am sure that the trend of discharging, or not admitting, patients to mental hospitals is one that should be encouraged. 1325 There are two interesting experiments that I would mention which I have come across only recently. One is occurring at Bristol, about which I read an article in The Times newspaper of June 9. There, apparently, a great number of people who are mentally sick, schizophrenics and other people who really suffer grave mental illness, are working in factories, doing normal kind of work, outside the mental institution. The total number of people concerned in the Bristol area, so far as I can make out by doing some sums with the figures given, seems to be about 500, who are enjoying, certainly for the time being, a normal life, working on a production line and doing work which can compete with work done by normal people working in ordinary factories.
§ The same thing, I think, occurs in the Borough of Croydon. They have a big, comprehensive mental health service, and there about 300 or more people are working in some kind of industrial workshops where normal factory disciplines are kept. These are all people who suffer from the effects of severe psychotic illness, or they are all people who are said to be mentally abnormal. In some parts of the country such people are still kept under some control and care and they are people who, ten years ago, would certainly have been kept from any kind of work. It shows what can be done if you really try. I gather that the work done by these people is contract work with large firms upon a long-term basis, and the work they produce meets the employers' requirements as regards both delivery time and inspection.
This raises another important point—namely, that the staff working in these hospitals and giving patients what is called occupational therapy have got to learn that we must now proceed from doing handicraft to real industrial work, which I think has a bigger therapeutic quality than purely handicraft work. Here, I think one has to be careful in the appointment of the disablement resettlement officer, because, from what I read of Dr. May a few moments ago, it is essential to have a really
critical appraisal of a patient's chances of employment unhampered by sentimentality or wishful thinking"—
both of which have been strong factors in keeping people back in the past. Those
hospitals which have sheltered workshops (call them what you will) have to be skilfully managed so that there is a gradual changeover from what was the doctor-patient relation to the doctor-employee relation. If that can be done successfully, we shall have gone a long way to obtaining something of what we want.
§ There is another way in which the community can help. The women's institutes now have 14 branches in large mental hospitals. That is a way of bringing these women back into the world, and making them feel that they are in the world. The question one would like to ask is: Why cannot more be done in other hospitals for women patients? And what becomes of the unfortunate men in the purely male hospitals which do not get the benefit provided by the women's institutes? Surely something rather similar could be done there. That covers what I want to say about mental hospitals. I have given one or two examples of what can be done. I should like to know whether more is being done, and whether more of that kind of work cannot be encouraged on as big a scale as possible.
§ I should now like to say a word about the physically disabled. I think one has to look at this problem in a similar way. One thing I should like to see expanded is the work that I have seen done in a department of the hospital at Stoke Mandeville where a great man called Dr. Ludwig Guttmann treats a large number of patients, mainly young men, who have broken their backs or their necks in diving or other accidents. One thing Dr. Guttmann says is that he does not feel they have left his care until they are back paying their income tax. He can generally get these people who have broken their backs paying their income tax in a period of seven months, provided that he treats them from the start. That, I think, in passing, shows the value of a centralised, specialised department for difficult and specialised treatment. It also means that if one has a large place like that—I think he has about 170 or 180 beds—one can do much more to bring pressure on possible employers to employ these people.
§ If this can be done for people with broken backs and for paraplegics, cannot more be done for others suffering serious illness? I know quite well that a 1327 lot is being done by some firms now, particularly by Vauxhall Motors who, at Luton, have been running a rehabilitation department since about 1946 or 1947. They have had a large number of people pass through their hands, about 6,000 working all the time and recovering from their illnesses and their accidents, in the factory where they are working and continuing their work. I am pleased to see that this type of work is being copied by one or two firms, including British Railways. I think that it is an extremely important thing to encourage, so far as one can.
§ I should now like to say a word about some of the elderly people. There is a body called the Employment Fellowship which sets up workshops for the elderly. These have been quite successful in a general way. One or two have done really well and, because I think they have done well, I am going to quote one instance to your Lordships now. It concerns the former metropolitan borough of Finsbury. I cannot remember what that part of London is now called, but it is not Finsbury any more.
§ There, an employment centre was started ten or fifteen years ago with a small number of people. Gradually it grew, and to-day it employs 60 or 70 people; and the doctor in charge finds it of great value in preventing these people from becoming ill. In fact, so successful has it been that one or two of the patients have even got back to full employment following a period of work in the centre. I think the reason that it succeeded was that there are a great many little shops and firms in Finsbury, and the people in charge of the centre went round and found out what they could make to sell to these shops. They said "What things do you want to sell that we can make for you?" I think that is the way to start all employment schemes to find out what market is available, and not to try to fill the market with things that nobody particularly wants.
§ The same thing can occur, on a much smaller scale, in another institution with which I am connected, the Royal Hospital and Home for Incurables, at Putney. There, there was for a long time a big occupational therapy department which made things for the annual 1328 bazaar and the annual fete. They made nice baskets and rugs, and that sort of thing. But about five years ago we again got on to the production line in a proper way, and now a limited number of people, about 20 or 30, are working on full contract work for a factory, and they are doing their job just as well as if they were on the staff. That again seems to me to be something which it is important to encourage. There are difficulties: there is the question of the people being able to keep to their contract. There is the question of the raw materials being transported, and of the finished goods being transported. But I do not think that these difficulties are insuperable. There is one more point on this aspect. I am pleased to see that the fixed age for retirement is gradually falling off. More and more firms are employing more people who wish to work, and who are fit to work, for as long as they can do so. I think that is to be greatly encouraged.
§ I come back once more to the elderly people. I do not want to go in great detail into the domiciliary services, because other noble Lords will be speaking about those. In the Guardian on July 1 there appeared a sad little report from Bournemouth (and it came from a reputable, well-informed church-worker) about a lot of old ladies who were dying from malnutrition and starvation—not because they were poor but because they were lonely; because they felt isolated from the world. Nobody spoke to them, nobody saw them. And one must not forget that the taking of a meal is quite a social act. All of us might sometimes, perhaps, eat by ourselves, but if people have to take all their meals alone, without ever speaking to anybody, they do not eat as much as if they had some company, somebody to talk to.
§ In the case of the elderly, although the domiciliary services are very good indeed, there is the feeling of being cut off, a feeling of isolation rather than of loneliness. Old people do not so much mind being lonely, but they do like to feel that in some kind of way they are part of the community. I should like to refer to one of the difficulties of the domiciliary services run by the local authorities. A large number are still permissive, and this is one of the most evil forms of legislation that can be enacted. The good local authority will provide a proper 1329 service, but the bad local authority will not bother to do anything. I know that the Government do not like to tell the local authorities what to do—and on the general principle I agree with them—but they should take a stronger line from time to time.
§ The provision of successful community care will make a further demand on cooperation between statutory and voluntary organisations. That co-operation, I am pleased to say, is developing more and more. I am also pleased to see that a certain number of local authorities are employing medico-social workers to do work for them, instead of these workers working from a hospital. That is an encouraging sign. There is at the same time a great desire among people who are disabled, either physically or mentally, to lead an independent life and to be able to enjoy amenities in the same way as other more fortunate people can do.
§ There are all sorts of minor ways in which one can help. For example, a great many people have to go about in wheelchairs, and this will become more prevalent as the idea grows that many people do not need to be kept in bed but can be moved about in a wheelchair. The provision of a simple ramp leading up to one of the doors of a church or a cinema, if adopted widely throughout the country, would be a great step forward for people who are confined to wheelchairs and who cannot get about by the normal means of locomotion.
§ For those suffering from grave disabilities, such as the people from the hospital at Stoke Mandeville, there are these days electronic typewriters which can be operated almost effortlessly with one finger. In this way these unfortunate people can become competent typists and earn good money. The machines cost a good deal, but I know that the Ministry of Health are quite kind about supplying them. Their use will mean that a person is able to do a job of work and can himself contribute something. One sometimes has difficulty in finding people to take into their employment the people who use these electronic typewriters. They may not do so because they feel that they will not be as efficient as others might be, but I would assure them that they are as efficient. In this way the community could take a great step forward.1330
§ I have said little so far about the work of the voluntary bodies—I was going to leave that matter to other speakers who know so much more about them than I do; the Red Cross, the Women's Voluntary Services, the Councils of Social Service, the Citizens' Advice Bureaux, Day Centres, and many other admirable bodies. In all community work, where disabled persons, whether they be mentally or physically disabled—and I think that mental disability is the more difficult—are being encouraged to live at home with their families and to become part of the community, it is important that the family should be taken into full trust and confidence from the start. If one does not do the job with the full and complete agreement of the person's family, one will run into disaster. However, if one takes the family into one's confidence, then they will put up with the conditions involved in taking care of people. They will know that if things really break down the patient can be taken into hospital. In this way the family will do as much as they can for the person concerned. I have spoken for longer than I intended, I have covered a long, and rather rambling, field but I trust that my good friend Lord Taylor will be able to make something of what I have said. My Lords, I beg to move for Papers.