HL Deb 07 July 1965 vol 267 cc1332-410

3.30 p.m.

Debate resumed.


My Lords the House will be grateful once again to the noble Lord, Lord Amulree, for drawing our attention to the question of community care. Indeed, the long list of speakers this afternoon is sufficient indication of the importance that the House attaches to this subject. The question of community care is, I think, sometimes overshadowed by more obvious matters connected with medicine: such matters as the future of our hospitals, questions surrounding general practitioners' conditions and remuneration, and problems connected with the drug industry. This is perhaps unfortunate. for, in my view community care is of increasing concern as the Ten-Year Plan gets under way, not only because it represents the requirements of so many of our fellow-countrymen but also because of the contribution that those great regional and voluntary services make to the welfare of this country, and which I am sure all of your Lordships agree are so much deserving of our encouragement and support.

In the last debate we had on this subject in April of last year, which was also introduced by the noble Lord, Lord Amulree, I had the honour to be performing the same function as the noble Lord, Lord Taylor, has to do this afternoon. I kept a record of what I thought had been some of the more valuable suggestions made in that debate, and I should like briefly to mention some of them again now, not only because I believe they are important but also to give the noble Lords who are to reply an opportunity of telling the House about progress which has been made in this field over the past months since the Government came into office.

I think the first point that was made in the previous debate was that a much greater degree of co-ordination between medical officers of health and county and local welfare officers should be achieved. The suggestion was made that the two branches might be combined, at any rate in a single headquarters, so as more easily to co-ordinate and centralise the help that is available to the community, and also the more quickly to allocate it where necessary. Another point was that if the pendulum is swinging back, as I think we all believe it is, towards more domiciliary care, then there is a pressing need for more voluntary auxiliaries who must be adequately trained. I have often wondered whether there is at this moment a case for an inquiry into the whole question of domiciliary training and enlisting more voluntary auxiliaries. I should be very glad to know what is the Government's view about this.

The third point—and I think this was made particularly by the noble Lord, Lord Stonham, on the previous occasion—was that a more imaginative appraisal of specialised needs should be encouraged. He gave the example that a Chair of Retardology should be set up and established at one of our universities. I myself thought that was a most interesting suggestion, for we must all know how desperately the parents of such children are in need of specialised research and advice on this matter.

Then other speakers urged a more positive and educational approach to what I might call the family nurse; in other words, those relatives who are prepared to shoulder some of the burdens of home nursing, either of old people or of children, or even of mothers who some people might think are discharged too early from hospital after childbirth. I feel that short-term training would be valuable and should be made available to such people, and they should be recognised and appreciated as important members of the Welfare Services. This type of training, I am certain, would be particularly valuable, for instance, to the parents of spastic children.

Another suggestion made during that debate was to consider the possible setting up of a committee to look into the means of enlisting and using more voluntary service; for example, that of women over the age of 40, people just retired, and giving them a part-time, short course of training. I say that because I am certain that there is in the country at the moment a considerable untapped source of energy, good will and useful service. It was also urged in that earlier debate that a more vigorous and effective advertising campaign should be mounted, with a twofold aim: first, of spreading infor mation about the existing services, what they consist of and how to make use of them; and, secondly, of recruiting for both the voluntary and the statutory services. In my view, this should be done at two levels—locally, by local authorities' welfare officers possibly adopting more the role of public relations officers; and, in the national field, by enlisting the radio, television and Press.

I sometimes think it would be helpful if we could somehow illustrate to the layman, whose interest and co-operation we hope to enlist, the aims of the Ten-Year Plan in, perhaps, a more striking way. One of the comparisons which sometimes comes to my mind is of the welfare system regarded as a solid building but with its four beams of suffering upheld, as it were, by the four pillars of the Welfare Service—the requirements of old age by old people's homes and by home nursing; those of the mentally subnormal, whom the noble Lord, Lord Amulree, has already mentioned, by increasing domiciliary care; those of the physically handicapped by occupational therapy in more training centres; and those of the ordinary sick, the convalescent and the maternity cases by the whole apparatus of general practitioner, district nurse, welfare and maternity clinics, et cetera. I feel that in this way the public might get a clearer view of all that has been achieved in the past and of all that we aim to achieve in the future. What is really most important of all is how, where and when the public itself fits into this structure, not only by receiving the benefits but, even more, by giving to it its own service.

But, whatever the means, the problem of recruitment cannot be left entirely to the local authorities and the voluntary services; the Government must provide much of the impetus. I should like to know, for instance, whether the noble Lord can give us any indication whether the staff shortage problem is being assessed on a national level before it is broken down regionally; or, again, whether it is considered that training centres should cover larger areas than just within the boundaries of local authorities, and, if so, how the Government can help in this matter. On another slightly different point, I should be glad if the noble Lord could give the House any information as to the establishment of clinic centres—a matter which I know is very near to his own heart.

My Lords, those were a few of the points raised in our previous debate, and there are a few others I should like to bring to the attention of the House to-day. I apologise to the noble Lord for not having warned him of what I was going to say, and I shall quite understand if he cannot give us all the answers to-day. The Ten-Year Plan was designed to set new targets for community care and to give fresh impetus to the Welfare Services, and I think it is true to say, fortunately, that a great deal of progress has been made since the Plan was launched in 1963. I think it is also true that this progress has been patchy and varies considerably from one local authority to another, which is why I myself feel that certain requirements are still needed, and why I should like, if I may, briefly, to suggest a few to your Lordships.

For instance, I am certain that it is important to appreciate that there is still much to be done to ensure better liaison and co-ordination between the various existing organisations, both voluntary and statutory. In the Report of the Carnegie Trust on handicapped children, which was published last year, there is a short passage which says: The impression presented by our case material was that a unified and integrated approach was rarely achieved. Often there was no one person directing the series of consultations and programme treatment recommended, and the personal contact between general practitioner and consultant, consultant and school medical officer, school medical officer and special school, tended to be superficial or non-existent. There were many fingers in the pie, but no cook. I feel that, to some extent, that holds good for the general pattern of community care still. Indeed, whenever one hears this problem discussed or reads about it, this problem of co-ordination always seems to be the one important topic under discussion.

Most of us—in fact all of us—know that the vast majority of the existing organisations do most excellent work, and I should like to pay my own tribute to this. But I feel that there is still possibly too much overlapping, duplication, or, conversely, sometimes a lack of contact between them, and all this naturally causes a waste of time and money. One appreciates, of course, that there are all the usual problems involved—difficulties over loss of independence and sovereignty, pride and the like; all very understandable. But I feel that community care will never work really 100 per cent. until the word "community" takes on its real meaning—that is, of unity of purpose—and a real, harmonious, working partnership among hospitals, general practitioners and local authority services is achieved. I think this is the only way by which results will come, but I would urge on the Government to increase their influence, too, in achieving this partnership. I am wondering whether it would be possible, for instance, to foster a more competitive spirit between local authorities, perhaps singling out for special praise and congratulation those that do better than others.

The noble Lord, Lord Amulree, has touched on the problem of mental health, and I myself believe that in this field more extensive co-operation between the hospitals and local authorities is needed. For example, it is the case, as the noble Lord pointed out, that there are at the present time in the mental homes and hospitals up and down the country many hundreds of people whose condition is not really serious enough to require full hospital treatment or, indeed, to justify the expense. I know that in my own area, in our own mental hospital on the borders of Scotland, there are at least twenty such people. Equally, they cannot live at home among their families, so they do require this sort of intermediate accommodation—a hostel, or whatever you like to call it—where they can live under supervision, looking after themselves as much as possible, and being visited either by trained staff from the local mental hospital or by district nurses who have had some training in mental health. I know that many counties adopt this procedure—the noble Lord said, I think, that there were forty; but I feel it needs yet more encouragement and support.

Of course, it takes money, but this would be money well spent, for it would ease the pressure on mental hospitals, it would ensure a more normal and happier life for the patients (not all of whom, one must remember, are necessarily elderly), and in some cases, I should hope, it would help the patients in the transitional period towards full rehabilitation in the community. I think that this is one of the priorities. As noble Lords opposite know, I have not myself always felt that the present Government have been 100 per cent. right in the order in which they have placed their priorities, and I must say that I should have thought that, in this case, the extra £25 million or £30 million which has been allocated as a result of the abolition of the prescription charge should first be allocated to more urgent needs such as these.

It has occurred to me also, thinking of accommodation and these hostels, that this might be a possible use for some of our redundant cottage hospitals. I know that I speak for a great many country doctors, at any rate, when I say that I am not in favour of closing any cottage hospital unless there are exceptional reasons for doing so, but I would think that this is a possible use for some of those which have to be closed. I accept, of course, as the noble Lord, Lord Amulree, pointed out, that any increase in this type of accommodation raises problems of staffing.

There will also be—indeed, there is now—an increasing need for district nurses and health visitors who have some measure of training in mental health. I know that some of the larger authorities are providing this training, but certainly more is required by the smaller authorities. The reason is of course quite obvious: it is essential for any district nurse who has to deal with a mental patient to be able to supervise his drugs and his treatment. Another advantage would be for the district nurse to get to meet and to know the patient while he is still in hospital awaiting discharge. I know that this is all perfectly obvious, but it illustrates the need for increased co-ordination and co-operation in this instance between the local authorities, the county medical officer, and the local mental hospitals.

I think it is true to say that, of the many various and essentially human personnel who co-operate in the field of community care, it is the general practitioner who is the linchpin. I am told that, in some parts of the country, doctors are still having difficulty over the matter of notification about diseases or disability, especially among very young children up to five years of age. I know that in my own part of the world this is true. Several doctors have told me that they do not always get to know, for instance, about spastic children until possibly a year or so after they have been born—and, of course, with this particular condition the longer it goes unnoticed and unnotified the more difficult the treatment becomes. I am aware that this problem is perfectly familiar to the Government, and I would hope that it would be possible for them to encourage local authorities to devise systems to make sure, not only that medical officers of health are notified as early as possible about such cases, but that the general practitioners are, as well.

My Lords, if community care cannot operate without the general practitioner, equally the general practitioner cannot operate without the district nurse, and I am not certain myself that the relationship between the two is always as satisfactory as it could be. I know that in some authorities it is tightly organised: the district nurse is officially or semiofficially attached to a doctor or group of doctors. I believe, for instance, that Hampshire is a case in point. In other areas the connection is much less clearly defined, and the district nurse is more dependent on the nursing superintendent of the county or the local authority for her instructions. I myself believe that the former is the more helpful arrangement for the doctor; I think it is also better for the patient; and I would think that it would be more satisfactory for the district nurse, in that she would feel more a part of the team and her knowledge of the particular ways of the individual doctor would be greater. I know that it is impossible to be dogmatic about this—so much depends upon individual personalities, and upon the type and size of practice, whether it is in the country or in the town—but I think the general principle of a close, working partnership is indisputable and should be pursued as vigorously as possible.

Another brief point concerns the occupational therapist, who is a very important person, as you know, in this field. There is a shortage of occupational therapists, particularly outside hospitals, and the chief reason is not hard to find. It is that hospitals can provide the conditions and apparatus they need, whereas, in contrast, these are not always available outside. This is something which local authorities should be urged by the Government to tackle—to provide the right sort of premises and equipment. It is surely not too difficult or too costly a task.

I have tried to put before your Lordships a few of the problems that are still being encountered in the field of community care—problems in which it is, in my view, the duty of the Government to take a lead with local authorities. The main need, I think, remains the same. It is the insistent, overriding requirement for authorities, hospitals, doctors, district nurses and all those who work in this field increasingly to coordinate their activities, and to work together and for each other. In conclusion, my Lords, may I say that I have always hoped that it was possible to give any medical and welfare developments a non-political complexion, for they are all inherently the achievement of the unknown and often unsung public servants up and down the country who make realities of them, rather than of the politicians, who may or may not give the initial momentum. But I think it is fair to say that a climate was created by the last Administration in which far-reaching improvements in the field of community care were carefully planned and could develop. The Ten-Year Plan is, I think all your Lordships would agree, beginning to get off the ground, even though it may not yet be fully airborne. If it is really to be a new frontier in community care, then first the battle for co-ordination must be won. I think it is the present Government's duty now to achieve this, and the House will look forward to learning from the noble Lord who is to reply to this debate how the Government propose to do so.

3.55 p.m.


My Lords, as the first speaker on behalf of Her Majesty's Government this afternoon, I wish to say how grateful I am to the noble Lord, Lord Amulree, for putting down this Motion for debate. It seems right to consider, first, just what we mean by community care. In the way in which it is likely to be used in this debate, it means services given outside hospitals: that means services given by the local authority health and welfare services, supported by voluntary services. It also means housing. It means the services of general practitioners, dentists, chemists and opticians, organised by the executive councils. The key figure is the general practitioner, who calls on the other services for the benefit of his patients and is, in fact, increasingly the leader of the domiciliary team.

It would, however, be wrong to think of the hospitals as outside the fold. They also serve the community, and the modern trend is more and more for them to join up with local authority services and to help to ensure that care for the patient is given, whenever possible, in his own home. As the expectation of life slowly rises and greater numbers survive into the seventies and eighties, and later, the elderly make up an increasing proportion of the population. The importance of community care, as well as care in hospital, for them is increasingly recognised, as was particularly emphasised by the noble Lord, Lord Amulree. The Government attach great importance to the development of these services, and in what I have to say I shall turn for illustration largely to the care of the elderly.

I do not wish to attempt to deal with all the points which the noble Lords, Lord Amulree and Lord Lothian, touched on in their excellent speeches. There is a long list of other speakers to follow me, and no doubt many of them will wish to discuss these matters further. My noble friend Lord Taylor will make a speech at the end of the debate, and no doubt he will wish to cover many of the points, so I shall confine myself to discussing the development of community care in London and the development of the nation's geriatric services.

This is, of course, a crucial time so far as London is concerned, a time of radical change. The redistribution of functions brought about by the London Government Act has put the health and welfare services into the hands of London boroughs. Many of us on this side of your Lordships' House expressed our concern at the breaking up of the great organisations which were directly responsible for so much of the life of the Metropolitan area. However that may be, it was done, and out of the miscellany of local authorities 32 new London boroughs emerged. They have had executive authority in these spheres for only three months. Their preliminary planning is, by all reports, going as well as can reasonably be expected. We look forward to seeing the advantages which will, no doubt, flow from a health and welfare service that is that much closer to the people it serves.

"Communication" is an overworked word, but there is no real substitute for it, unless one says "continuously keeping in touch". Since many different agencies are concerned, communication between them is literally vital. It is required between the boroughs, between Regional Boards and their individual hospitals and the boroughs, and between the teaching hospitals and all the agencies in the areas they serve. I am glad to say that satisfactory progress is being made in all these directions. The London Boroughs Joint Committee has come into existence to provide links between the boroughs, and will play an important part in this, together with its specialist sub-committees—for example, on welfare services and on staff training.

There is also liaison machinery at Regional Board level and hospital board level to bring the hospital services and the boroughs together. Good liaison machinery existed before the present reorganisation in London and exists elsewhere in the country, but it is the foundation of well coordinated planning, and the Government look for even closer contact in the development of plans for the future of Greater London. I shall be returning to this point later.

It is, of course, not only in the local authority field that there are changes in the London area. The changing role of teaching hospitals is an interesting example, with many implications for the health and welfare community services. The Hospital Service has from the very beginning been based on the idea that every district shall be served by hospitals within it, providing all services, including geriatric, that the district ordinarily would need. The idea of the district general hospital has emerged from this. With the teaching hospitals in England and Wales things have been different. Especially in London, they have selected their patients according to their needs and abilities as specialist teaching institutions, and have not attempted to serve a particular district.


My Lords, the one teaching hospital to which I have the honour to belong has become a district hospital and does undertake full district responsibilities.


My Lords, I was just coming to that. The provincial teaching hospitals have always, of necessity, served mainly their own area and they are now becoming district hospitals as the surrounding hospitals develop. The same trend is developing in London. University College Hospital has accepted complete responsibility for two postal districts in the Borough of Camden. Charing Cross Hospital, preparing to move to Fulham, and St. George's, preparing to move to Tooting, have absorbed local hospitals as a basis for district services. King's College Hospital and St. Thomas's have similarly taken over local hospitals with the object of providing district services in their own areas. Guy's Medical School propose to set up a unit in the Woolwich Arsenal Housing Estate to study from the very outset the whole of the service needs of an area and the part that hospitals should play in it. With this trend, medical education may be expected to broaden and the area of contact between the teaching hospitals and the other services, already large, will become still greater.

I now turn to my other theme—the care of the elderly. This is one of the most important functions of the community health and welfare services. Much is already being done. In the hospital world, it is especially gratifying to note the increasing interest of the teaching hospitals in geriatrics, to which I alluded just now. This reflects the increasing importance that our society attaches to the care of a rapidly growing section of the population—namely the elderly. Our future doctors—hospital doctors and general practitioners—will be better equipped to treat, and, still more important, to try to prevent, the ills of old age. I am told that only 5 per cent. of elderly people are in hospitals or residential care of any kind at any one time. Some 95 per cent. are in their homes, looking directly to the community services for their welfare. The general practitioner is usually the first point of contact of the community with the health and welfare services. He therefore has an important part to play in co-ordinating and calling upon the other services which are available.

One means of making firm the link between general practice and the local authority services is the association of health visitors with general practice. The figures I am now giving are from statistics for England and Wales, but the Scottish statistics are comparable. Some 300 practices already have health visitors attached to them. The function of health visitors to advise and help mothers and young children is already well known, but they are extending their work to take in the whole family, including the elderly. In 1964, there were the equivalent of 5,100 health visitors, whose visits covered some 275,000 elderly people, besides all their other work. In some areas, health visitors are employed as specialist visitors to the elderly. Present plans are for an increase in health visitors to about 8,200 over ten years.

The noble Lord, Lord Amulree, referred to home nurses. There were the equivalent of 7,937 home nurses in 1964, working under the direction of general practitioners. They made visits to about 440,000 patients over the age of 65. Exact figures of the number of visits involved are not now collected, but it can be estimated safely that it amounted to well over 10 million visits. Present plans are to increase the numbers of home nurses to nearly 10,000 over the next ten years. Advice has recently been given on the use of auxiliary help to increase the range of work of these and other local authority nurses. Domestic assistance is given by home helps in homes where there are elderly people, covering normal household work, cleaning, cooking, shopping, washing, and also "good neighbour" visiting and sitting-in to help relatives—the scope varying widely from one area to another. Numbers of staff have nearly doubled since 1953. There are now some 27,000, and present plans are for an increase to about 40,000 in ten years. The elderly account for some 75 per cent. of the cases in which service is given—266,000 out of 355,000 in 1963.

As the noble Lord, Lord Amulree, has pointed out, we must do our best to see that old people who want to keep their independence can do so. That is where all these services are of such value. The name of the noble Baroness, Lady Swanborough (whom I am glad to see in her place) is, if I may say so, almost synonymous with that of the W.V.S., who play so important a part by providing Meals-on-Wheels for elderly people who cannot cater for themselves. Here, local authority welfare services make a great contribution. Residential care in old people's homes is provided for those who cannot live independently in the community but in an atmosphere and place as closely related to normal living as posible. Up to 85,000 places had been provided for the elderly by the end of 1964. Present plans are to increase this total to 135,000 places in the next eight to ten years. Modern small homes, of from 30 to 60 places, are now typical of local authority building. But a third or more of places are still in former Public Assistance institutions. Authorities plan to be rid of most of these in the next ten years.

Another community service is housing for the elderly. This is for people who are getting on in years but can still look after themselves, if the environment they live in is adapted to their needs. About 25 per cent. of public housing programmes has been devoted to single bedroom dwellings, which are particularly suitable for the elderly without families. The total stock of such dwellings is about 375,000, although not all are always occupied by the elderly. Still in its infancy is sheltered housing—grouped single-bedroom dwellings with communal services under the watchful eye of a warden, with the assistance of his wife, to whose work I would pay tribute. These wardens are usually paid for by the welfare authority. There were dwellings in such schemes for about 36,000 people in 1963. We now have plans to increase numbers to 125,000 by 1969.

Besides the various advisory and practical services I have mentioned—and in this connection I recall again the invaluable Meals-on-Wheels—local authorities can provide various recreational services, and also help voluntary bodies to do so. Social clubs and voluntary visiting services can help to keep elderly people socially active and to avoid the isolation that can lead to apathy and neglect. There were some 7,000 social clubs, with various functions, in England and Wales last year. Besides this, local authorities—not only counties and county boroughs but all local authorities—can, and do, help with recreational trips and holidays. Some of these arrangements are most ambitious. I heard of an old lady of 90 who wanted to go on a trip to Ostend—her last chance to go overseas. So far she has lived long enough to go twice more.

There are, of course, some who need this kind of social help but are not fit or active enough to take the initiative. For them, the local authorities are providing day centres, where a range of services may be provided. There were some 200 in 1963 and the number is expected to double by 1974. Here, too, though not in the local authority field, can be mentioned the day hospitals which are attached to many geriatric units in England and Wales and relieve pressure on hospital beds. Some of the day hospitals perform a strictly health function; others emphasise the day care rather than the treatment of the elderly.

I spoke earlier on of the need for co-ordination if the community care services are to play their full part. I should like to end by saying that while much has already been done to draw together the many aspects of care for the elderly, there is still much to do. My right honourable friend the Minister of Health has already asked hospital authorities in consultation with local authorities and Executive Councils, to review their building programmes, giving a due and early share of resources to geriatric and psychiatric services. Local authorities will shortly be asked likewise to review their plans for health and welfare and to carry them forward to 1976, jointly with the hospitals and Executive Councils. The Minister expects soon to send a memorandum to all of those about joint planning in the particular field of care of the elderly. I think it is a good story, and I feel honoured to have told it to your Lordships and the people.

4.13 p.m.


My Lords, I ask for your Lordships' indulgence in making this maiden speech. I ask for this with all due seriousness, and not merely as a formality, because on this occasion I am at the peculiar disadvantage of being a university professor of some thirty years' standing. I am sure you do not wish to have yet more professorial utterances ex cathedrâ in this House. I have been much assisted in my delibera tions on how to learn a new style of speaking at my age of life by the example set in my university for forthrightness of utterance and clarity of speech by our Chancellor, the noble Marquess, Lord Salisbury.

So far as community care is concerned, it seems to me that this debate has shown that we are all agreed. It is not yet quite a quarter-past four, and I suppose if we were to return home now we should be able to take part in family tea. Nevertheless, there are points latent in this debate which may raise matters on which some of us are at issue. The situation is this. We all agree that institutions should, so far as possible, be emptied, and that families should be asked to take over, where possible, the care of their members who are now in institutions. But it is often extremely difficult for them to do so, and some families suffer crushing burdens when their afflicted members are transferred to them from hospitals or, for instance, from mental deficiency institutions. Therefore, we have now got to the point at which we have to create a large number of supportive institutions, for the assistance of families who would otherwise be overburdened, and we are thus endeavouring to soften the sharpness of the transition to family from institutions.

A vast array of institutions—halfway houses, short-stay homes, psychiatric day hospitals (the varieties are legion)—is now being created, and it is highly desirable that they should be created, and we have thus arrived at the paradoxical position that, in order to empty the institutions, we are creating a large array of institutions of other sorts. And as to where the process will lead us in the end, one is very doubtful indeed.

This leads me to my first substantial point, which is that a muddle of truly British dimensions is being created. There will be more and more depth to the muddle if we cannot call a halt for a moment and take a look round to see where we are getting. The noble Earl, Lord Longford, has just been able to produce an interesting and important Report of a committee which has gone into the question of crime and has arrived at much the same sort of conclusion. Not being able to deal effectively with the health and welfare services which have so far been discussed, without somehow or other dragging in the family and the private lives of individuals in order to assist us, we have arrived eventually in this debate at the W.V.S., for instance; and I am glad to hear that.

So, also, the noble Earl and the other members of the Committee arrived at the same conclusion in their study of crime. They have come to the final conclusion that a general family welfare service needs to be created to make it possible to deal adequately with the needs of families one of whose members may have had criminal tendencies or have been convicted. The committee have asked for the consolidation of the services available for these persons and for these families at the centre. They have asked for the consolidation of these services in the Home Office and in a variety of other Ministries, as well. Furthermore, we need, for that purpose, to have the consolidation of services at the local level.

I am wholeheartedly in support of the noble Earl and his Committee in their suggestions. The only comment I have to make, which I feel is an important one, is that the report of the committee stops too short. We do not wish to have a new service limited to general family welfare; it seems to me that we need to go a little further and have a service which is directed more to the community than to the family. I give, as an example, the rapid development of the child care service that has taken place in the last ten or fifteen years in this country. We no longer seek to deal with the care of children in institutions. About half our children are out of institutions and in the families of foster parents—and foster parents who are not unaided. The foster parents are assisted and advised by child care officers, who give them the feeling that they are part of a wider scheme and that they are not alone. They can discuss their difficulties in that way with fully trained people. Thirty thousand children are now dealt with in this way. This seems to make good use of scarce resources, and, so far as the health services are concerned, it is something to which we must turn our attention in the immediate future.

Professional social workers are in very short supply—I speak now as a professor responsible for the education of social workers among other people—and we need to spread them as widely and profitably in the community as we can. We need to supplement their services by those of all people of good will, and we need to try to put them in the community at the point at which their services are of the greatest benefit to everyone. Community care seems to me to need a wider interpretation than has been given so far in this discussion. The noble Lord, Lord Amulree, seems to have dealt with community care solely in the interests of the medical services. Speaking of the aged, as the debate went on, it seemed to me that we were dealing with old people as people who were suffering from some sort of ill-health, as such; that old people are necessarily very sick people. I am sure that many noble Lords will not agree with that conclusion. There are many great statesmen in this country who were servants of another place and of this House at an advanced age. I am sure that that will continue more frequently in this House as more people become old.

I speak again as a former President of the National Federation of Community Associations. We have made good but slow progress with the development of the Association, and our services have been particularly beneficial to the members of our society in so far as they deal with youth and old people. It is obvious, to my mind, that the best place to deal with both these kinds of people is in the community as a whole. We do not want to extract young people from the community. If we do, we may well at times get further occurrences such as that at Brighton; and we do not want that to happen too often. Similarly, we do not want to extract old people from the community and deal with them as an odd sort of people on their own. It seems to me that that is about the most unpleasant kind of circumstances in which one can be placed. I hope it will never occur to me—at any rate in the immediate future—that somebody will put me into, or cajole me into joining, an old person's club, and do good to me while I am there. I do not want to have good done to me. I want to live as a member of the community.

It is exactly that situation that we have endeavoured to develop inside the National Federation of Community Associations, in which old people can play their part in community associations, and can be valued as persons with something particularly important to contribute to the associations: namely, the wisdom and experience they have accumulated during a long life. Furthermore, in the Association we have encouraged people in later middle age to prepare for retirement, so that there is no great jolt between active and wage or salary earning life and living in retirement in advancing age. We want to have in our community as few of those jolts as possible.

We also think it is a good idea, good social theory as well as good finance, for as many citizens as possible to be involved in the administration of the social services. That appeared to us in the past to be local government in its truest sense. The end product may be, and often has been on a small scale, the involvement of people in the administration of services, so that the services administered locally are their services and not the services of somebody ex machine, who appears from the Town Hall or from Whitehall, both places being possibly equally remote to the ordinary citizen.

I discussed this with a former Minister in the Dutch Government; and Dutch Government policy has been for many years—certainly since the last war—to encourage the development of community associations with precisely these objectives in view. The Dutch Government have not shrunk from giving quite substantial financial encouragement to the growth of these associations. They have assisted them financially both in the way of capital grants and also in the current grant to make it possible to employ trained staff who can now take part in what is another kind of social worker profession within which they can seek promotion. This seems to be ignored by the nationally-organised services in this country at the moment, except for some of the work done by the Ministry of Education. Grants have been given to foster community associations, but these grants have been small and have not added up to much. Furthermore, the Ministry of Health Circular 7/62, which sought to encourage local authorities to consult with the voluntary associations before they made their Ten-Year Plans devoted to health, seems never, somehow, to have got to the community associa tions. I enquired about this recently but I could find no indication that any discussions had taken place with the community associations as a result of that circular.

This seems to me to provide us with evidence that the Ministry of Health is insufficiently community-minded. We can carry the medical profession with us, we hope; we can carry the auxiliary medical professions; but can we carry the people, the ordinary citizens? That seems to me to be still a matter of doubt. We are too apt to consider that people need assistance by way of treating what I may term "ill-fare" medically, rather than to approach welfare socially. In sum, I am asking for the redeployment of scarce social work staff, to redeploy them so as to stimulate community activity. I am asking also for the giving of less attention by the social worker, such as the case worker, to services which cater for a few individuals, who are assisted personally by the social worker concerned. I am also asking for the involvement of our neighbours as citizens in meeting their own needs and those of other people. I am satisfied that very much more could be done in this way if we had a wider conception of community care.

4.28 p.m.


My Lords, the last speaker began by asking the indulgence of the House for his maiden speech. I feel that I also need to ask the indulgence of the House, speaking, as I do, immediately after a maiden speech of that calibre. I am sure that all noble Lords will wish to congratulate the noble Lord warmly on his magnificent speech. We shall look forward very much to further opportunities of benefiting from his wise counsel and advice in the future. I should like to add my word of thanks to the noble Lord, Lord Amulree, for putting down this Motion for debate to-day, because I think it is well that we should take a careful look at the community services; and when I tried to do some homework on the subject, in preparation for this debate, I was amazed at, as the Motion puts it, the increasing use being made of community care in the health and welfare services to-day.

I should like to speak this afternoon mainly from the aspect of the problem as seen through the eyes of a Regional Hospital Board; because I have for some time had the privilege of serving as Vice-Chairman of the Birmingham Regional Board. As that Board serves five counties, and most of the West Midlands, it has the opportunity of seeing these problems and opportunities for service on a fairly wide scale. In his speech earlier in the debate the noble Marquess, Lord Lothian, mentioned the fact that what was needed was an increase in the co-operation between the hospitals, the general practitioners and the local authority. So far as our region is concerned it is that kind of team spirit which we are most anxious to foster. It should be noted that in our area 33 per cent. of all general practitioners have hospital appointments, and that, from the other point of view, between 30,000 and 40,000 visits of a domiciliary kind were paid by consultants during 1964.

The reason why this community care in the home is of such value and importance is that without it we should be in a very serious position in regard to the provision of beds. The provision of hospital beds is a very expensive and difficult matter. Since 1949 the number of beds available in our region has gone up by 6.7 per cent., and that has cost a great deal. But the actual case-load borne by these beds in a similar period has gone up by 70.6 per cent. That obviously means that, on average, there is a shorter stay in hospital for each patient. In our region again, with the considerable increase in population that has come through large immigration, the matter is becoming particularly pressing in regard to maternity hospitals and maternity cases. We have therefore evolved a planned early discharge of these cases, so that from 1953 to 1964 the average stay in hospital of a maternity case has come down from 11.2 days to 7.7 days. Some may regret this: they may feel that the mothers are leaving the hospital too soon after their confinement. But in view of the enormous demand on our maternity beds I do not know what would have happened if this reduction in stay had not taken place.

The point I wish to make this afternoon is that, because of this team spirit that we are trying our best to foster, we would maintain that these patients are not receiving any worse treatment as a result of the fact that they are staying a shorter time in hospital, but that through community care, which they can and do receive in their homes, they are being looked after as well as they would in any other way.

I should also like to draw attention to another development, again in our region, with which our Medical Officer of Health in the County of Stafford has been closely associated. An experiment was made in the Stafford General Hospital, whereby a County Council social worker visited all the patients, discussed with them their position at home, their needs, and so on, and thus was able to see that those who could go out from the hospital at an early date were able to go out, and also that these people received at home the facilities which the County Council and other appropriate authorities were able to offer. These facilities are not always known. It is true, of course, that the general practitioner, in his care of the patient, will endeavour to put the patient in touch with the various forms of assistance which that patient may need. But if this could be done on a really organised scale, with the hospital co-operating in the way I am quite sure it would, then it would be greatly for the good. I mention this as an illustration of the increasing use of these services to which the noble Lord has been drawing attention to-day.

The point I wish to make in regard to our hospitals is that we are seeking to use the beds there to the best of our ability, by ensuring that they are not occupied by in-patients who could be dealt with in some other way, and equally well cared for. Last week Her Royal Highness Princess Margaret visited the City of Stoke-on-Trent in order that she might officially open our great new out-patients' department which is now associated with the North Staffordshire Royal Infirmary. That is but one of these out-patient departments which our Board has been opening, but I think it is probably the largest in the country. It is not really an out-patient department—it is an outpatient hospital; and we believe that when it is in full use patients will be so well cared for that there will be no need, in many cases, for them to enter the hospital at all as in-patients. This will mean a great deal of new organisation, a new technique and a new approach to the problem, but I am quite sure that an immense amount of good will result, the whole object of the exercise being to see to it, so far as possible, that the sick person who is in need of care is kept in the community and not segregated out of the community.

A short time ago I had the great privilege of being asked to open a hostel set up by the local authority in the town of Newcastle-under-Lyme. The object is to bring to this hostel patients who have been discharged from the mental hospital. There they will come and live, for some months, it may be, while they adjust themselves to life again; and from this hostel they will go out, day by day, to suitable work and so earn their living again. As I saw that hostel, I thought that it was a splendid development. Thus we are trying to see to it that these people, who have been suffering in one way or another—and sometimes suffering acutely in their minds—are helped to find again a purpose and a real meaning in life and to have the satisfaction of knowing that they are once more able to do a really useful job for the community.

Mention has already been made in this debate of the contribution that can be made in this and many other ways by the voluntary organisations. Having, naturally, been associated at one time or another with many of these organisations, I should like to say that I think the voluntary organisations, taking it by and large, receive the same helpful encouragement from the statutory bodies. Next Sunday afternoon it is my duty to preach at a special service for the deaf and dumb. The work that is done by the voluntary organisations for those people has impressed me greatly as I have watched them over the years. They are people who have suffered, and do suffer, from a great physical disability. But, because of the loving care with which they are surrounded, they are able to go out and live a surprisingly useful life. I have the privilege, also, of being the president of our local association which cares for the blind. And I have been amazed at the way in which those blind people go out and live useful lives.

It is only when you come into contact with this kind of thing that you realise the amount of loving community care that is going on. Your Lordships will understand that in the course of my duty I often meet mayors and civic heads. Over the years I have been struck with the way in which those men, as they draw near to the end of their year of office, have said, "I thought that I knew my town pretty well; but it is only now that I have been mayor, and appreciate the work that is being done in a quiet and unassuming way on behalf of the community, that I realise the amount of that good will and good work that is going on." It is to this good will and good work that I wish to pay my tribute to-day. I am not asking for anything special: I am trying merely to underline what the noble Lord, Lord Amulree, has said, that increasing use is being made of all this community care, so that we may help all our friends who are in need of help to stay in the community and, so far as possible, subject to any limitations they may have, to live normal and useful lives.

As I draw towards my conclusion, I would say that in the Church, through the teaching of Christian stewardship, which I believe is something that is playing a great part in the life of the Church to-day, emphasis is being laid on the need to look out to see what practical help you can give to your neighbour. In the course of my duty, it is my privilege to take a number of Confirmation services, and as I have taken those services I have often been moved by the Blessing it is my duty to give to the candidates: Strengthen the faint-hearted, support the weak, help the afflicted. We in the Church in this country sometimes get depressed by what appears to be a good deal of indifference; and that may well be the case. However, I think we can also say that in our country to-day we have a vast amount of practical Christianity and a real desire to help one's fellow men. Therefore I am thankful that to-day we have this opportunity of surveying the community care which goes on, in so many aspects and on so wide a scale. I am glad to have this chance of thanking most warmly all those ladies and gentlemen who play their part in that work, and to pray that God's blessing may rest upon their efforts on behalf of their fellow men.

4.42 p.m.


My Lords, this is my maiden speech and I crave the indulgence of this House for any faults, an indulgence which I know your Lordships always readily give. It is now nearly two years since I took my seat here, and during that time I have been filled with admiration for the wonderful speeches and debates that I have heard, which have interested me more than words can say. So I feel extremely pleased that to-day I have the chance to support the noble Lord, Lord Amulree, in his Motion, because it gives me the opportunity to talk about the Health and Welfare Services in the rural areas.

There is a great difference in the conditions to be found in the towns and in the countryside, and also in the amenities that can be given. The services which are available in towns often cannot reach the wild places which I have in mind—the hills and the valleys and the scattered farmsteads. The amenities which have been mentioned to-day have filled me with great admiration and I have thought how wonderful it would be if they could be taken to the wild places of our country. Particularly do I feel this in the case of the elderly. In the remote hills and valleys people are good neighbours, but more and more the old people are becoming dependent upon voluntary organisations. This becomes increasingly evident as the years go by. The voluntary organisations have the chance to bring, and do bring, the necessities of life to the old people. In particular they bring medicines, the necessities for chiropody, bandages, bedrests, special foods and things of that nature which the elderly could not possibly get in any other way. This helps to make life better for the old people. No one can help but admire the work of the voluntary organisations, but it is becoming increasingly difficult for them. The price of petrol is increasing and so is the cost of car repairs. Also, of course, people have less time than they used to have.

In Wales, where I live, the Community Council and the National Old People's Welfare Council and the Committee for the Welfare of the Elderly have started many schemes and are anxious to expand them. They have also started some extremely good homes for the elderly, but many old people in the country do not want to go into the populated districts. The scent of the heather and the tang of the marshes is in their blood and they do not want to go into homes and institutions in towns, where they will not be so happy.

The financing of all the activities about which we have been talking to-day varies greatly: some undertakings do not make use of all the money which the local authorities have allowed them; and, on the other hand, some local authorities have only limited powers of giving assistance. An inquiry would fill these gaps, and from what I have heard this afternoon I am sure there are many noble Lords who agree with this. Everybody at some time has loved an old person and everybody is in sympathy with this subject. As we have heard, a great deal has been done but there is a great deal more still to be done, and I feel that the speeches made this afternoon on all sides of your Lordships' House will greatly help to improve the position.

4.46 p.m.


My Lords, before the noble Lady sits down, I feel the House would wish me to rise to my feet and congratulate her. I understand that I have to refer to her conventionally in the House, even on this most unconventional occasion, as "my noble relative", although it has never before in the history of the House occurred that a son was able to get up to congratulate his mother. However, I should like most warmly to congratulate my noble relative, not only on her courage in rising to address this Assembly but also on the content of her speech, which I think your Lordships will agree was well worthy of the speeches which have been made in this debate so far. I hope indeed that I shall sit and hear my noble relative make another speech on some occasion in the not too distant future.


Hear, hear!

4.47 p.m.


My Lords, may I join with the son of the noble Baroness in saying what a remarkable speech we have just heard and how fortunate we are to share in this little bit of history? I am sure she feels supremely happy, as I would under similar circumstances, to have her son follow her and congratulate her. Incidentally, her son has given me permission to tell the House that we have just heard the maiden speech of a lady over 80 years of age.


Hear, hear!


Some of us who have joined in these debates before are familiar with the subjects, and I am sorry that the noble Lord, Lord Amulree, has gone out of the Chamber at this moment because I was going to congratulate him on once more initiating a debate on this subject. On this occasion he has called it "community care" and I have noticed that every speaker so far has defined "community care" in a different way. I warn my noble friend Lord Taylor that when he comes to answer he can be forgiven for not being ready with the answers because I am indeed going to range widely; I have been given permission. We have heard the noble Lord, Lord Simey, say he believes that the position of the aged and those in the field of crime should have our consideration; and he dealt with employment, with which I am going to deal also.

I have taken part in many of these debates and after receiving this week the Annual Report of the Ministry of Health—the Annual Report, I should point out, for 1964, which exonerates the present Minister of Health—I am of the opinion that if some of the advice which has been given over and over again in these debates had been followed we should have less cause for concern. We now learn in the latest Report that general practice is no longer attracting young doctors. Perhaps noble Lords here think this was already known. This was not known until this Report was issued this week. But not only has there been trouble with the general practitioners, but the young doctors of the country now are apparently experiencing a distaste for general practice and are no longer entering that field. If the comprehensive domiciliary service which my noble friend Lord Bowles has expounded to the House this afternoon—and some of us have been asking for that with monotonous regularity for the last twenty-five years in this place and the other place—had been established years ago, it would have been of inestimable service to the aged and to the chronic sick, and the burden which the exasperated doctors are complaining of would have been taken from their backs long ago.

I quite understand that my noble friend has come to this whole question to-day for the first time. When he tells the House, for instance, that 700 health visitors are attending doctors, has he forgotten that there are nearly 25,000 medical general practitioners in the country. We have been asking for the domiciliary services and the health nurses to attend the thousands of doctors in the country for years and years, and far from sitting back and purring with delight I was absolutely shocked when he said there were only 700 health nurses. The domiciliary service, of course, which could help the doctor in such a manner that his life would be completely changed, simply seems not to move at all.

I listened to every speech very carefully. The noble Marquess, Lord Lothian, kept calling for voluntary help in this field. He accepted the principle; he knew it was important. But we have got full employment. Where are all these women of forty sitting back in their homes, languishing, longing for a little job? I am sure that all the ladies here know what I am talking about. The suggestion is so ridiculous. Where are they? They are all doing a job, not sitting back in some Victorian drawing room saying, "Let me go into the homes of the sick and cool somebody's fevered brow". That was what the noble Marquess, Lord Lothian, was calling for, the women of forty, as though at forty women are sitting back with plenty of time because they are in such a decrepit condition that only a visit to the sick room now and then would be suited to their physical condition. These people are not there. They are in full employment. If you are going to have a comprehensive domiciliary service—physiotherapists, health nurses, chiropodists, the whole team—you have got to pay them. Women are no longer there to wait on men, without payment, particularly women of forty.

I listened to the noble Lord, Lord Simey, I am sorry he has gone to have that cup of tea which he said he could have with the family at a quarter past four but which he has missed. He said to the House, is ageing physiological or pathological? The aged person is suffering from a physiological condition, but nevertheless the pathological condition is quickly superimposed upon it. He or she develops arteriosclerosis, and arteriosclerosis of the brain can produce pre-senile dimentia and it comes very slowly. He had the most extraordinary theory that what was wrong with the country was that nobody was going up into the tall Peabody blocks in London and finding the old women and saying "What is wrong with you is that you want to come into the community and enjoy yourself". Habit determines our approach to so many things. If you have lived to 60, 65 or 75 you cannot develop new habits. You cannot say "Yes, I am a gregarious person. Take me quickly to some room where I can hear a stimulating lecture, take part in Morris dances", and so on.

Lord Simey's conception of old age is the conception of the senior common room, where elderly men delight in sitting with each other exchanging conversation on matters of the past, what they did at their public school or their university when they were young and what sports they indulged in. He has no conception of the mind of a woman who has produced seven children, let us say, brought them up well, devoted her life to cooking, scrubbing and washing. In some cases her husband has predeceased her and she finds herself alone in a miserable little room at the top of a building in this great wen of ours, with ten million people in London and Greater London. That is the problem we are discussing to-day, not the abstract problem that occurs to a professor (and I should say all this if the noble Lord were here, as your Lordships know) who has been out of touch with this particular aspect.

I say that the affluent society has passed by old people. Once more I would suggest to the Government that they should compile a register of the aged in their areas. The present method is absolutely haphazard. The doctor may tell the welfare officer that there is an aged person down the street. But these people I am talking about become stubborn. If they are ill they do not go to the doctor. There are plenty of noble Lords here who have now and then said to me, "Can I have a tablet?" and I have said, "I am not your doctor"; and they have said, "I do not like to go to him". These isolated people do not like going to doctors. It is no good the noble Marquess, Lord Lothian, saying the doctor should notify the welfare officer that there is an old person there. What we should do—and why the local authorities do not do it I cannot conceive—is to have a register of the aged in their areas, and it should be the duty of some official to visit the old people regularly. I believe that contact with these isolated and helpless people in our sprawling urban areas can only be maintained when a comprehensive register is compiled.

I listened to the right reverend Prelate the Bishop of Lichfield speaking on maternity just now. Listening to a man on maternity is always interesting, because, as we all know, we have never lost a father yet. But listening to the right reverend Prelate on maternity I thought was most enlightening. I have said again and again in these debates: Why do we not recognise that the midwife is the key figure in the maternity service and treat her like a queen, give her better conditions, higher pay, instead of letting her, in the crowded streets of London, use a bicycle to go to her job? What has happened? The midwife has been in silent revolt. Now we find, of course, that the conditions in our maternity hospitals have deteriorated instead of improving in the 20th century, and this has resulted in mothers being discharged from hospital in some areas 48 hours after the birth of their child. I raised all this last year and the year before, and I see from the Ministry of Health Report that all the warnings and pleas from this House and another place have had little effect.

In 1964, the latest year for which we have figures, 9 per cent. of mothers were discharged less than three days after delivery, which indicated that there has been no improvement on the previous year; it was 9 per cent. in the previous year. And the right reverend Prelate says, "Well, it is quite clear that this is normal. The team is working. Why should we worry that these women are being discharged?" It seems to be rather illogical. For instance, if it is desirable to discharge a women three days after the confinement, why have we for years always kept her in hospital for at least ten days? No doubt the right reverend Prelate has done a lot of visiting in his life, but he has not called on many women who have just had their babies. Probably they have not wanted to see him because they have not felt like it. The fact is that a woman who is sent home, as she is in this country, and as she is in any country (as again I said last year) where mediæval conditions exist, sits in bed with her purse under her pillow and conducts her housekeeping from bed, and she is denied all the rest which is her due. That is the reason why she must stay in bed.

I am beginning to think that in some Government Departments there are officials who feel that any criticism in this House or in another place reflects on themselves, and that accounts for the negative results. We can have these debates year after year, and we read the Ministry of Health Reports. In some respects there has been no change—in fact, conditions have deteriorated.

My noble friend Lord Taylor need not answer this point to-night, although I invite him to do so. We have been told that we can arrange our community care. I believe that the care of the pregnant woman is a matter for the community, and I should like to know whether there is any likelihood of reform of the Abortion Law now that we have a Minister who is sympathetic. I am thinking of pregnant women who are not fit to bear their children; I am thinking of young girls who have been subjected to some sexual offence; and I am thinking of thalidomide mothers—those women who may have taken drugs which may result in congenital malformation of the child. In my opinion the time has come when a doctor should be allowed to perform an operation on these women without the risk of being struck off the Register.

I come back to what the noble Lord who generally sits opposite and who is identified with the pharmaceutical industry says is my ritual dance. The only medical service where there seems to be no shortage of money or supplies is in the pharmaceutical field. The prescribing of expensive proprietary drugs continues to increase. Does my noble friend know that they accounted for 71 per cent. of all prescriptions last year, although there is a cheaper alternative in the National Formulary? Although we are told that committee after committee is formed to watch these things, the cost rose last year from £65 million to £72 million.

The National Formulary is a list of mixtures, pills, tablets and so on, which can be prescribed as an adequate alternative to expensive proprietary drugs, and it is distributed to every doctor. A doctor who prescribes in the National Formulary and has a social conscience sent to me last week a copy of the prescribing costs of his area. It is dated June 30. The cost per head of his prescriptions was 5s. 8d.; the average cost for the area was 9s. 11d., and the average for the country is just under 10s. My deduction from this is that the cost of drugs is twice as high as it need be—I know that my noble friend and I are spiritually attuned—if the Ministry took strong action and insisted that the National Formulary should be observed.

I do not want to be guilty of tedious repetition. I have dealt with drugs before, and everybody knows how strongly I feel about the subject. I want to come to another aspect of community care. This debate synchronises with the presentation of the Report of the National Assistance Board, which surely is concerned with the community care of the poorest in the community. In the course of the year I introduced a Bill into this House designed to help the unmarried mother and the separated and divorced woman and their children. I was opposed by both Front Benches. Nevertheless, your Lordships gave me an attentive hearing and the Second Reading received a majority vote, for which I thank the House. Subsequently, the Government opposed that Bill in another place simply by requesting a new Member, on hearing the name of the Bill called, to shout "Object!". He had neither heard the Bill expounded nor had he read the Bill. The Title of the Bill was called, and a voice shouted like a ventriloquist's dummy, "Object!". In fact, the procedure is that an individual may not necessarily identify himself at all. His mouth need not move. He can mumble "Object". The Bill fell.

I want to bring to the notice of your Lordships that the Report of the National Assistance Board justifies completely the provisions set out in my Bill. It will be recalled that I asked that the affiliation and maintenance orders should be underwritten by the Board, at the Board's scale—no more than the Board's scale immediately the court had made the order. This was to avoid the misery entailed where the man disappeared and some weeks elapsed before the woman applied for assistance. I would remind your Lordships that in the case of an unmarried mother it is she herself who has to find the man, wherever he may be, and report him to the police. This, of course, the girls are completely unable to do. I emphasised that by taking immediate action, not only would the mother and her child benefit, but it was in the interests also of the Assistance Board, because they have the machinery to summon the man and make him pay to the Assistance Board the amount which the Assistance Board pay to the mother. All my Bill asked for was that this machinery should be set in motion immediately the order was made at the court.

This Report was presented only last week and, to my amazement, it completely justifies my action. The Report says: When a woman applies for National Assistance because she is not being maintained by her husband, the Board's first duty is to meet need, but inquiries must from the outset be made about the husband. A quick approach may result in his providing maintenance so that no assistance has to be paid at all. That is precisely what my Bill asked for. The Report goes on: When a man has disappeared without trace, much more effort and time have to be spent trying to find him and, if he is found, in persuading him to accept his responsibility. Later on it says: The preceding paragraphs in general apply also to the maintenance of illegitimate children. I see that there are Members on the Government Front Bench who I believe have a social conscience, and I am asking them to see that this Bill survives. The Bill still has a chance of survival in another place if the Whips call off the individual prepared to shout "Object" to a Bill which he has not even seen. I am asking if the Government will relent and will help these unfortunate women.

The noble Lord, Lord Amulree, spoke of employment. My final words are going to be about employment, but on another aspect of it. I have said that these women certainly deserve community care, for they are doubly handicapped. Not only have they the responsibility of motherhood—a lonely motherhood with no man to support them—but in the labour market they are denied the rate for the job. We cannot talk about community care in a vacuum; we must relate it to the economic conditions of the most needy with whom we are concerned.

One in every three workers in our manufacturing industries is a woman, and in consequence our economy is based on cut-price labour. We read in our newspapers to-day that the general workers in the Transport and General Workers Union realise this. It is not surprising, therefore, that they rejected the prices and incomes policy as a totally unacceptable concept, if the rate for the job is not basic to its implementation. The Minister of State for Economic Affairs has perhaps not realised that very important problem, and that it is the Transport and General Workers' Union which covers all the women who are not getting the rate for the job. Other unions with high rates of pay may understandably think otherwise. It should be axiomatic that the rate for the job is paid in an industry before even one half of 1 per cent. increase is proposed. One cannot build a sound edifice on rotten foundations.

I would remind the House that the International Labour Organisation adopted a Convention advocating equal pay for women. Forty-four countries have ratified it, but not the Labour Government of Britain. Women's labour is used to subsidise an employer by the difference in the amount which she receives and the rate for the job. As a third of the labour force are women, the employer enjoys a very heavy subsidy at their expense. We should not congratulate ourselves on our social ambulance service which we have been discussing to-day, a service of community care, while we countenance the exploitation of labour at the lowest level.

5.12 p.m.


My Lords, like others I am delighted to have the opportunity of listening to this debate on community and domiciliary care. Those of us who are working in this field feel that in recent times it has been possible to take a tremendous step forward because of the support which has been given to the voluntary helpers, both by Central Government and by local authorities. I do not know whether many people realise the value which is put on the opportunities by those who are backing the professionals and by the realisation that they are being given the opportunity of the privilege of service. I am very thankful to say that to-day young women are coming forward on a short-term basis to back the work which is being done. They are being more and more drawn into the service of the community.

I am going to discipline myself to-day not to speak about the voluntary services and the advance made in domiciliary care in recent years. Therefore, I am going to devote myself, in a short speech, to one point which I am constantly meeting as I travel the country, a matter which greatly preoccupies local authorities. I feel that special attention should be given to the solution of a very serious problem. In any group of patients the hospitals should surely be responsible for those who need continuous medical nursing care, and those of the rest who cannot go home should quite obviously be the responsibility of the local authority. This is not a question for discussion; it is a point on which everybody would agree.

If one takes almost any mental hospital in the country to-day, it is true to say that more than half the patients are over 65 years of age. I am convinced that this is a pattern which is quite general throughout the whole of the country. Again and again one finds that a large proportion of those who do not require continuous medical or nursing care have no home to go to, and a number of those who cannot be discharged require only a little extra care, as we term it—by which I mean help with dressing and bathing, and that sort of thing. This balance of patients who do not need the skill and attention of highly trained doctors and nurses is clearly the responsibility of the local authority, since they do not require hospital accommodation and are taking up space in a specialised hospital, but the local authorities are in great difficulty, in regard to both accommodation and finance, in establishing extra-care homes. There is no direct grant for this service. It is hidden somewhere in the general grant. While I know that Her Majesty's Govern ment have promised a percentage grant, which I believe will be a great encouragement and help, I would plead that the whole question be looked into as soon as possible.

I am not a doctor, but I am advised by my doctor friends that many old people become confused because of some underlying physical illness. Their minds become as delicately poised as those of babies, who become delirious in fever and recover with the fall in temperature. The general feeling is that if the underlying physical cause can be found and treated, the patient can go home, fit and well again, in two or three weeks, instead of spending two or three years in hospital. I believe that all confused old people should go, in the first instance, to an assessment and short-stay treatment centre for thorough investigation by a geriatrician, with the help, where necessary, of other specialists. Those whose confusion is part of a serious condition will obviously become the responsibility of the hospital. It is generally felt by those who work in this field that a very large number will go back home fit and well, with the result that not only will they not be a burden on the hospital and local authority accommodation but they will be all the better and happier for it themselves.

I realise how hard-pressed the Government Department must be, and I realise also the great burdens they bear, but I believe that if this matter could be investigated and coped with at an early stage, beds could be freed, waiting lists shortened, and the problem—which at present is cruelly affecting both local authorities and individuals—solved.

5.19 p.m.


My Lords, those of your Lordships who have looked at the list of speakers in this debate may have come to the conclusion that this is "maidens' day". As your Lordships will see, I am the last "maiden" on the list. I am fully aware that custom requires a maiden speech to have the merit of being brief, and the additional merit of being without contention; but at this point perhaps I ought to confess to your Lordships that in the normal way in future I may find that rather difficult, because I have not been reared in either school.

Having been a lecturer for many years, when brevity is seldom possible and provocation is often essential, I have to guard against telling my audience what I am proposing to say, then proceeding to tell them, and finally telling them what I have told them. It is an occupational disease with lecturers, as some of your Lordships will know, but I am informed that it is often the hallmark of a good politician. However, over the years I have had to gear myself to a 45-minute period and have developed a built-in automatic device which pulls me down at the 45th minute. I am hoping that to-day it will operate at about the 15th minute, as I do not want to incur the displeasure of your Lordships, who are renowned for your charity on the occasion of a maiden speech; nor would I want to upset the noble Lord, Lord Egremont, if he were here, for I am sure he would have a concealed stop watch.

To-day, because of the shortage of time, there is only time for me to comment in a general way on community care. The phrase "community care" seems to be very much on the lips of all who are concerned with any form of social work, and I think there is a very real danger of its becoming meaningless and of being thought of as a solution to all our problems. Many people see community care as a State responsibility. Year by year we spend more and more on hospital and welfare services, and I think we have all to face the fact that there is a limit to the amount we can spend in these fields. We have to face the fact that in the future we shall not be able to afford to spend what the health and welfare services in this country need. Yet, in spite of what we spend, and it is a considerable sum, we appear to be a long way from meeting the wants and needs of the many people in the community.

The noble Lord, Lord Bowles, has given us this afternoon a definition of "community care". I suggest that it is the current definition of community care; a definition with which I should not disagree. But I think that in the very near future we must have a very different definition for community care. I am tempted to ask, when we talk of community care: does the community care? Is the community taking a full share of its responsibility? Is the community being given a real chance to participate? We have to think in terms of giving the community the opportunity of doing far more than it is doing, or is encouraged to do, at the present time. I believe that if the community were encouraged to show a greater sense of social responsibility toward's one's neighbour, we could get far more done at very little cost.

There is a growing tendency to talk in terms of "they" and "them", meaning the State or the local authority, and there is too little reference to "we" and "us"; and it is the "we" and "us" who are often far better placed to undertake some aspects of community care and service than many of the people in the community who are supposed to do it. Let me make it quite clear. I am not suggesting that a heightened sense of social and personal responsibility will solve all our social problems, nor am I suggesting that certain of our grave social problems can be met just by kindness or a desire to help, but I am saying that there are few instances where the needs of the individual cannot ultimately be met by adequate community care in the real sense, as distinct from some form of hospitalisation or institutionalism.

Residential care in one form or another will always be needed in the community for certain groups, particularly the mentally and physically handicapped and the aged, but by no means all of them. I recognise that the cost of providing residential accommodation will always be high, be it in hospitals or in institutions, and I feel sure that greatly improved domiciliary services with the ordinary people participating, and a greater awareness by ordinary people of the problem and a willingness on their part to help, to care for the handicapped and those in need, would be not only cheaper but more beneficial in the long run to those who are in need of help.

I am not unaware of the problem which faces us at the present moment. As a former probation officer and a sociologist—though, may I hasten to add, not in the same distinguished class as my noble friend Lord Simey or my noble friend Lady Wootton of Abinger for I have learned and continue to learn much from both of them—I feel that we are concentrating too much on providing residential care which caters for only a comparatively small number of people and forgets the wants and needs of the many. In my view, it is too great a concentration of time and energy, as well as money. In the field of old people's welfare, only a small percentage are in care. The remainder, generally speaking, fend for themselves if they have no family to help them.

Without the assistance of ordinary people—and I want to emphasise "ordinary people"—in the community, it is doubtful whether the Children Act, 1948, would ever have worked, or be working as well as it is to-day. To-day, as my noble friend Lord Simey said, as a result of a vast army of foster parents, thousands of children are given the benefits of a normal home life and all that that means in terms of happiness, natural development, and the feeling of being wanted and loved, not to mention the substantial saving to the community. I believe it would be possible to do something similar for more of our mentally and physically handicapped, and perhaps the lonely aged, by recruiting suitable people—I come back to it, "ordinary people"—for this aspect of community service.

In East Anglia where I live—and we are supposed to be a kind of backward people—something along this line has already been started. Severalls Hospital, which is a mental hospital in Colchester, has in a modest way already shown something of what can be done for the mentally handicapped, apart from what may be done by the local authority. The hospital social workers have already been successful in boarding out approximately 30 elderly patients, some of whom have been in the hospital continuously for many, many years—one, I believe, for 30 years. Large-hearted people and families have come forward and taken these patients into their homes. Can anyone, can your Lordships, can any of us, really imagine what it must mean to them to be back in the community, to feel that somebody cares, that somebody wants them to be a person, an individual again?

The National Assistance Board has made an allowance or supplemented a pension, as the case may be, to a total of £5 a week, so that the people who have taken them in are not doing it for nothing. It is worth while noting that the present cost of keeping a patient in that hospital is something in the region of £12 a week, but they can be kept out of the hospital and given the comforts of a home and the feeling of security, and the feeling that somebody needs them, for £5 a week.

This kind of development is all the more important in view of the serious shortage of professional social workers: and there is a very serious shortage. To me it is not surprising that there is a shortage, in view of the treatment meted out to professional social workers in this country. For far too long have they been treated as the Cinderellas of our Welfare State. Because they have developed social consciences and a deep-seated feeling for and understanding of people, they have been expected to work long hours for very little material return. If you are a professional social worker, you are not supposed to want a reasonable standard of living.

It is all very well for people in the community to pay lip-service, as has been paid this afternoon, to the professional social workers in the community. What is really needed is to pay them more money, not more lip-service. I speak with some feeling on this, having been one in years past. Because the shortage is going to get worse—and let us understand that the situation is not going to get better; it is going to get worse—we need to encourage ordinary people of the right kind of temperament to work within their own locality under the guidance of a trained worker. As the noble Lord, Lord Simey, said, we have got to deploy our trained people better in the future than we have in the past. I believe that in the community there is a tremendous amount of good will and sympathy for those in need, and I hope that we shall do something in the immediate future to harness that good will and put it to practical use.

Most of your Lordships will be familiar with the Younghusband Report of 1959, which made this point—and I want to quote: The good neighbour is a voluntary worker, though she may never have thought of herself in that way. Let us face the fact: the good neighbour has a place in our social and welfare services, and we should be making plans now to use her to the full in the future. She will eventually be wanted, and will eventually become the centre of community care, with the professional social worker having oversight of her work and the work of a large number of similarly placed people in the locality.

Far too much of the professional worker's time is spent making systematic visits, in some cases quite pointless, and in others where persons of less skill could do just as much—and here again I speak with some experience of this, as a former professional social worker. Many of the people who are visited need only assurance, the opportunity to talk and the companionship which the visit gives; and, in my view, such visits could be undertaken quite effectively by the less skilled person. Every community is full of voluntary organizations—we all know that—many of them doing first-class work, and I am the first to recognise that; but far too many of our voluntary organisations are content to be inward-looking instead of being outward-acting. I would suggest that they use their membership, not so much for themselves but for the benefit of the community and for the welfare of the community.

In the Suffolk village of Combs, where I live, the rector has a system of wardens—a group of people each one of whom is responsible for visiting regularly six or eight homes. In this way the wants, needs and problems of those visited are quickly known; and, what is perhaps more important, the sick, the aged and the infirm feel in touch with what is going on. It should not be beyond the wit of man to arrange something like this in the towns, instead of waiting until the milk has been on the doorstep for several days before anyone bothers to investigate, only to find that it is t/o late to do anything. We could organise ourselves in wartime, when every street had its air-raid warden responsible for a group of houses. Why not a similar system, community care wardens, in peace-time?

5.35 p.m.


My Lords, I am happy to follow my noble friend Lord Wells-Pestell, and to congratulate him on the success of his maiden speech and of his built-in device. It acted as he predicted. The noble Lord has done pioneer work in the marriage guidance field, and many of us are grateful to him for his work there. He has had a long and difficult illness to face, and he has faced it with faith and courage. We are delighted to see him with us again, and I hope that we shall have the advantage of listening to him and of learning from his wisdom on many future occasions.

I share the gratitude which many of your Lordships have expressed to the noble Lord, Lord Amulree, for this debate. My approach is the approach of the noble Lord, Lord Wells-Pestell, because I am thinking first of the responsibilities of the community and the weight laid on its members by the increasing claims they have to meet—on communities where there are full employment, rising costs, competitive standards and decreasing free time. I seldom meet people with leisure. Let me give your Lordships just two instances of increasing claims. First, I would mention fatherless families. I was reading the Report put out by the Salvation Army, called Tragedies of Affluence, on the occasion of its Centenary. In this Report, the Salvation Army draws our attention to the 400,000 children who are suffering some form of deprivation because their parents are separated—and the position is worsening. Perhaps these figures were in the minds of the members of the Labour Party's study group, under the chairmanship of the noble Earl, Lord Longford, when they pleaded for an urgent review and radical improvement of current allowances. The noble Lord, Lord Simey, has previously referred to this Report, which pointed out that many of the most intractable problems facing social workers arise from inadequate allowances and benefits.

The second area of increasing claims that I would mention is that where unmarried mothers are concerned. The Longford Report has argued for a family service and family centres to help re-habilitate homeless families, and to ensure that children suffering from any kind of handicap receive the care they need. Reference has already been made to this family service, and the noble Lord, Lord Simey, I think, questioned how far such a service could be adequately staffed, because we have to consider our limited resources and the shortage of trained social workers. Nevertheless, I am sure that the claims of unmarried mothers call for special consideration for many reasons, quite apart from the command that we should love our neighbour as ourselves. If we do not do more for these unmarried mothers, we shall increase delinquency and mental illness.

How can we help the community to meet these new demands? As I think of the communities I know, I see that their strength lies in their close-knit family life—family life of a cellular kind. It is limited to the family, limited to the home and limited to the garden; and their strength lies in the improved amenities of the new areas. But then, as I think of the risks and the dangers they face, the ever-increasing mobility of these communities comes home to me. A vicar who was working in such a community was saying that, of 66 couples he had married in the last three years, I think, only one was still living in that parish. And, my Lords, the speed of movement increases with the years.

The problem of mental illness is another thing that threatens these new communities. I would mention only one particular project, which commends itself very much to me. It is the Richmond Fellowship, one of these "half-way houses" which takes in people who need to be treated in smaller communities before they are ready for the rigours or delights of home life and who have been voluntary patients at mental hospitals. I feel that if the Government were able to encourage this particular Fellowship, or others that work on similar lines, it would be of real value to them. Because one of the difficulties these organisations meet is, first, that of acquiring a house; and, second, when they acquire a house, of persuading the neighbours that it is reasonable for them to support such an adventure. It is criticism from local residents that often prejudices these developments.

When I ask how we can help the community to meet the new demands on them, I break that question into two parts: First, what can be done to stimulate a community to develop its sense of responsibility? Second, how can communities grow in depth? I believe, in answer to the first question, that if we can encourage small groups to get together we can make progress. In my experience people to-day are more ready to meet in groups for informal discussions and group action. The other day I heard of a development in Bedfordshire where, in response to an invitation from one of the health officers, a group of Scouts took a hand in putting in good order an empty house so that it could become a community centre for Pakistanis. A small group talked it over and took action. They provided the necessary stimulation and the Pakistanis were able to take part.

On my second point, what can be done to help a community grow in depth? In new areas these communities grow their roots slowly: and the rate at which their roots grow is related to the amount of paper that enters the house. It seems to me that we are over-communicating. Memoranda of various kinds go out and stifle those who receive them: they are cluttered up with papers, and make no response. if we are to have communication—as the noble Lord, Lord Bowles, said: it is an overworked word—we need to communicate by word of mouth. If we can get people in the district to take a hand in visiting their neighbours, listening, befriending them, waiting on them; and then, when the opportunity comes, speaking to them about ways of serving the community, I believe that we shall get greater response from the community and that the community will grow in depth. If we have some of these points in mind when we appeal to the community, I well believe that it will give increasing support to the health and welfare services, and I am therefore delighted to support this Motion.

5.45 p.m.


My Lords, we are indebted to the noble Lord, Lord Amulree, for initiating this debate to-day. Like the noble Baroness, Lady Summerskill, I think I have taken part in a good many debates on this or similar subjects; but to-day's debate is particularly interesting and particularly original, since we have had this delightful, charming, historical moment when a noble Lord on the opposite side was able to congratulate his mother on her maiden speech from this side. Secondly we have had, in addition to that of the noble Baroness, two other maiden speeches. I was thinking, when I was listening to these, of how very varied are their experiences; how varied their speeches have been.

The last maiden speech was from the noble Lord, Lord Wells-Pestell, who comes from a community in East Anglia, a very rural part of England. He has, as we all know, great experience in social work. We have had from the noble Baroness, Lady Strange of Knokin, her account of rural ways. It rang a bell, so far as I was concerned, because the county I serve as a county councillor is an exceedingly rural area. I well understand the difficulty one has in persuading the widow of, let us say, a shepherd, who has lived all her life not nearer than 10 or 15 miles to a town and finally cannot be left by herself, to come into a home or perhaps to a house belonging to a relative nearer the town. I appreciate the agony she feels at leaving the country in order to come into what she believes to be the iniquities of a great metropolis—though it may be only a small village or a country town. Nevertheless, to her that does not matter. I appreciate very much the great problems of rural areas. We have had the speech of the noble Lord, Lord Simey, whom we all know and admire and have listened to many times on other occasions, talking about social service in Liverpool. We have had three important contributions to this debate by speakers from three different areas.

I should like to pick up one or two points which relate to my experience as a local government person, because I have found some of these things to be very frustrating and difficult to know how to handle. The first matter I should like to talk about is the responsibility of local authorities under the Mental Health Act. This is really a tremendous responsibility and I do not believe we are really facing it, nor do I believe it is being undertaken as well as it should, partly because it is so difficult to get the people to do the job and partly because it is a very formidable charge on any local authority. There is a sentence in the Report, Health and Welfare: The Development of Community Care, which was published in 1963, and is thus somewhat out of date, which I should like to quote: The purpose of the services in the community for the mentally disordered is to help them live as nearly normal lives as the nature and extent of their disability will allow. That, I am sure, is the kind of text one should give in trying to organise local authority services; but the problem is enormous.

I do not have the figures for Scotland but I have those for England and Wales. They are for 1961–62 and are nearly three years out of date. About twice as many mentally disabled people live in the community as live in the mental hospitals. Twice as many—that is a very formidable number. About 400,000 mental patients every year are looked after by their family doctors, half of them looked after by general practitioners alone. Local authority expenditure on mental health service in the community rose from £4 million in 1959–60 to £9¼ million in 1963–64. As I think one speaker said, this is very unlikely to get less; and the responsibility on the local authority is really enormous.

As the noble Lord, Lord Wells-Pestell, said, there is a great shortage of trained workers for the care of mental health patients. The psychiatric social workers, who are in some senses the key people in this work, are very rare. In the area where I live, I pressed the Regional Hospital Board hard for three years to get them to appoint an additional psychiatric social worker for the area outside the hospital, particularly for patients who are now living in the community but who have been discharged from mental hospitals and care. Children in similar circumstances also needed care. Three years of hard hitting to get the Regional Hospital Board to appoint merely one extra person for this vital work! We have got the person now; but it has been a long haul to get her.

I should like to say a word in praise of one of the great voluntary organisations which has done a tremendous lot to help with the care of mental patients and also to help people to understand what it is to have to look after these people. I refer to the National Association of Mental Health. Here is an organisation which, I think, has done more from day to day, and with ordinary people, to care for the mentally sick than any other organisation which I know. It started from practically nothing and now has 53 branches. It has created an atmosphere of friendly understanding, so that a person suffering from mental illness is no longer looked upon as a sort of strange creature and someone to be avoided rather than helped.

The National Association of Mental Health has shown that mental health is part of the better undertanding between one human being and another. That is a great revolution in thinking and in action. In many places it has started clubs to which people can belong and where, as it were, they may be reintroduced to society and mix with people before they are completely fit and well, ready to take their place in the community. I hope that when the Government are considering, as they do from time to time, giving assistance to voluntary organisations, the Government will give particular attention to the National Association of Mental Health, because it is a key organisation for helping all who are concerned with this work, and particularly local authorities.

I wish to say a word about the community care of handicapped children. The noble Marquess, Lord Lothian, referred to a Report made on this matter by the Carnegie Trust. It so happens that I was the Chairman of the inquiry. I am also Chairman of the Carnegie Trust. The inquiry took place a long time ago, longer than I should have wished, in the sense that the Report took so long to publish. It is a very interesting Report. One of the things it revealed was the need for earlier diagnosis and for continuing care in cases where care is difficult.

Out of the Report came experimental centres. One is in the rural area near Shrewsbury. Here the day care of children is undertaken. They live with their families and are brought to the centre where assistance is provided for both mothers and children. The children concerned are extremely handicapped. The centre is a great success and is supplementary to the local authority services, although it is run by the local authority. It was expensive to provide, and the Carnegie Trust and other trusts assisted to finance it. This centre is doing a remarkable job in helping with a very difficult type of child.

We opened another centre which was financed partly by the Carnegie Trust and partly by Glasgow Corporation. It is a very big centre where there are facilities for helping mothers and babies. For the first time this form of help and diagnosis is available in one building. Previously, certainly in Glasgow, and I think also in other cities, mothers had to take their children to different places to obtain diagnosis and treatment. I strongly re- commend to the Government that experiments of this kind, which are proving very successful, should be regarded by the Ministry of Health as a pattern for the future when the provision of accommodation for this purpose is being considered. I recommend one other group to the attention of the Ministry of Health and to local authorities: I refer to the autistic children. The diagnosis of the mental state of these children is so new that a great many people do not know what an autistic child is. I am aware that the noble Lord, Lord Taylor, knows full well, so I will not burden the House with an explanation, but will simply say that this is a problem requiring special treatment and special schools. It is a problem with which local authorities are concerned, since many authorities find that there are autistic children in their communities. A certain amount has been done in London, a big city where large sums of money are available, but there are other areas in which this work could be developed but has not yet been started.

Other speakers have referred to old people and their care. I was particularly interested in the speech of the noble Baroness, Lady Summerskill. I thought that she was in rattling good form—as she always is, and I so often agree with her. We have occupied opposite Benches, or opposed each other in politics, for almost the whole of our lives, but I find it very difficult to disagree with her on subjects of this kind, in which her experience and knowledge is so vast and about which she adopts such a practical and sensible approach. The domiciliary care of old people has reached a much better standard to-day than that which obtained in past years. There are, of course, many old buildings that we should like to see destroyed: they are a hangover from the past, the old Poor Law hospitals and so on, which one longs to see blown up so that they may never reappear again. It is a fact that when the local authorities of which I have knowledge start domiciliary homes for old people, they are usually established in delightful country houses, in delightful circumstances and conditions. On the whole, this is very satisfactory, although I entirely agree with the noble Lord, Lord Simey, that in one sense these are the last places to which we should like to see old people go. There are services available which enable many old people to remain in their own homes or stay with their families, but there are cases where this is not possible, and for the people concerned I think that the modern type of homes which local authorities are starting to provide is very much better than anything we have ever known before.

The noble Lord, Lord Simey, stressed the need to define community care. Is it simply care in the community, or is it—as I think it should be; and Lord Simey feels strongly about this, too—care by the community? If it is care by the community, not only the local authorities are responsible, but also voluntary services of all kinds. As we heard from the right reverend Prelate the Bishop of St. Albans it is the concern of the churches and youth organisations. This is a commitment which affects us all, because we all live in the community; and that is a fact that we cannot stress too much. We need a great many trained people for social work. I support what was said about the Younghusband Report and the tremendous job which is being done, as a result of what was contained in that Report, in training welfare officers and workers throughout the country. This is a developing service in which the quality of the workers is improving. We cannot have too many well-trained people. Courses are being run in conformity with the recommendations in the Young-husband Report and these are of the greatest importance in relation to the improvement of community care by local authorities.

The great hobby-horse of the noble Baroness, Lady Summerskill, is the domiciliary care of people. My own is family case-work service. I have been working now for so long in the different sections of community care—welfare, child care and probation—and all the time I have been conscious that I was working in three separate departments, often dealing with three separate Ministries, in connection with the same people in the same community and often in the same family. This has been brought out recently in the interesting Report on the care of children and delinquency by the Committee sitting under the chairmanship of Lord Kilbrandon.

There is only one real solution. We should have a family case-work service. Otherwise we shall continue to our dying day to have people "passing the buck", saying that this is not their job but the work of somebody else. What is required is a service which can deal with the problems of a whole family. The only question that has to be settled is what Department should control that service. I know that in talking to the noble Lord, Lord Taylor, I am talking to someone who understands this problem. This is the last and most important revolution we have to face both in local and central Government, the co-ordination of these community services into a family casework service, which would deal with community care in toto and not keep it broken up in different sections. At present, much of this work does waste money and also wastes manpower and womanpower. I hope that the noble Lord, Lord Taylor, will take into consideration the large variety of views which have been expressed. But all of us hope that community care will be improved, will go from strength to strength, and will become more effective for the sake of the whole community.

6.3 p.m.


My Lords, I cannot remember a day on which we have had so many noble Ladies and noble "Maidens" in the field together making so many valuable contributions to our debate. I do not suppose that the noble Lord, Lord Amulree, would claim that it was as … some watcher in the skies, When a new planet swims into his ken that he calls our attention to community care, because community care is a fundamental without which none of our more advanced Hospital and Welfare Services could operate. If it were not for ordinary people caring for ordinary people, as the noble Lord, Lord Wells-Pestell, reminded us, no amount of policy and planning by the Government and local authorities, no amount of good work by voluntary agencies and no amount of training of professional social workers, could possibly avail.

I should like to turn first to look at the community and develop a little more the point made by the noble Lord, Lord Wells-Pestell, that we are concerned not only with care in the community, but also with care by the community. In many respects, the conditions of the community are not what they were a generation ago. In housing they are very much the better, but in other respects, particularly those relevant to this debate, a number of good things have been left behind in the old city slums which it would have been better to transfer into our new housing estates and New Towns. A year ago, in a debate similar to this, the noble Lord, Lord Taylor, told us of a survey he had caused to be undertaken in Harlow, from which it transpired that a high percentage (I forget the actual figure) of the people who had moved to Harlow were satisfied with their environment. He then instituted a similar survey in Bethnal Green and found a still higher percentage of people who were satisfied to remain there.


My Lords, it was 86 per cent. in Harlow and 92 per cent. in Tottenham.


My Lords, I am sorry that I have not got the places right, but this illustrates the point that there is something in those older communities which we have not succeeded in transferring to the new ones. If we had succeeded, that story from Bournemouth would not have emerged. A welfare officer from Bournemouth, being interviewed by the B.B.C., ended the interview by saying, "If the old people will not come forward, what can we do?" Our system will not work if the community is not properly geared for it to work. A few days ago I heard another comment, from a member of the Council of Social Service in Letchworth, who said that it was not so much a problem of caring for old people as of finding the old people. They get lost. In the New Towns there is not the built-in structure, which we find in the old market towns, for bringing to light, and keeping before the people concerned, the need of so many of the people for whom the Health and Welfare Services are designed. I think that there is much that can be done to create such a built-in structure in these new communities.

The noble Lord, Lord Wells-Pestell, mentioned the scheme which his rector had instituted in his village, and this gives me an opportunity of assuring him and, at the same time, of reporting to the right reverend Prelate the Bishop of St. Albans something which I ought to have reported to him before, because I am his executive chaplain, but I can do it now across the Floor of the House: on Friday week I am having a meeting at home with representatives from Bishop's Stortford, Hitchin, King's Langley, Royston and St. Albans, with a view to setting up the sort of scheme he has mentioned and, incidentally, deploying the resources not just of one denomination but of all the Churches in those areas. This is something which I am sure the Churches are in a unique position to do. What is involved is quite simple. It is to establish in every road or street, for every group of thirty or forty houses, one person who can assume the ordinary social responsibility for that group.

These people will not appear on the doorstep with a religious tract and set about trying to convert somebody; they are not people who drop in parish magazines; and they are not people who go bustling about trying to do a lot of good works. They are people whose chief contribution is their presence in the road, watching, waiting, and ready to take whatever action is necessary, or to see that somebody else takes such action. It involves quite simple things like welcoming newcomers and introducing them to their neighbours; it involves lending them a screwdriver, if that is what they want, and not giving them a parish magazine instead; it involves doing a little baby-sitting, if that is what they want, and not preaching them a long homily on repentance. It involves sensitivity to the social needs of the particular street or road for which they are responsible; and this service can be greatly developed.

Neither of the right reverend Prelates who have spoken so far has said much about this, but I very much hope to tempt the noble Lord, Lord Soper (and, incidentally, it is nice to see that in his feeling for the movement of Christian Unity he has moved along the Benches into a waiting position behind his Anglican colleagues), to tell us a little about the work in Notting Hill done by the churches under Methodist leadership, which have a great deal to contribute to the development of community care in that rather troubled area.

To turn from the communities to the care which is given in them, and away from the ordinary people whose help is so necessary, to the experts, the professionals who must guide and work with them, there is no doubt in my mind that we need large numbers of these people if all the developments and all the new insights into care and so on are to be followed up. But I think it is important to bear in mind that the number of people involved over the whole field of professional social work is really quite tiny. We are not now dealing with the 300.000 or 400.000 people who are required in the field of education in schools, or the 200,000 people who are required to man the work of the hospitals. We are dealing with a total, taking in the whole field—probation officers, child-care officers, psychiatric social workers, health visitors and everybody—of not more than 20,000. Surely it should be possible, with that quite small number, to reach higher standards of training, qualification and deployment than we have managed to reach so far.

The other day I was looking at a survey, carried out, I believe, by the child-care officers in 1963, which reveals that only 30 per cent. of that force is fully qualified, and 35 per cent. of them have no social work qualifications at all. That was in 1963, and perhaps the noble Lord can assure us that there has been some improvement since. Another instance is on the probation officer side. I believe that the male probation officer's case-load is not meant to exceed 60—and, in all conscience, that sounds high enough—but that since about 1956 the average case-load has exceeded that figure. Maybe this position is improving, too, in which case it would be nice to hear words of comfort to that effect. But I believe that if this elite, quite small force, on which the whole development and effectiveness of the Health and Welfare Services depend, is not fully trained and up to numbers, the rest of the service is bound to fail, and fail rather badly.

I do not know enough about this question to know exactly where the fault lies, but I suspect that much improvement would come if the arrangements for re cruiting and training over the social work field could be better co-ordinated. To the best of my belief—and I shall be corrected if I am wrong about this—there is one department in the Home Office which takes care of child-care officers: another department which takes care of recruiting and training of probation officers; another part of a department in the Ministry of Health which, in conjunction with the local authorities, deals with recruiting and training in the rest of the social work field: and lots of other separate bodies besides. It seems to me that we cannot get the best out of this service, and the limited number of people who have this sort of vocation, if the recruiting and training in the field of this range of workers is not properly co-ordinated. Perhaps the noble Lord can say something about this.

Another point about training which I think is important, and perhaps is not dealt with quite as thoroughly as it might be, is the question of refresher courses for the considerable number of senior men who are given some sort of social work title at the setting up of a service and find themselves in quite senior posts but have not had any full training for the posts which they hold. All this arises from the fact that since the war we have created new services far faster than we have been able to man them, and there is a serious short-fall which must be made good.

Finally, I turn from the community and the care of the community to the field which has been mentioned by so many other noble Lords—namely, that of partnership between all those concerned. By that I mean not only partnership between the statutory bodies and the voluntary bodies, but also between them and the private individuals, who have so much to contribute. I do not believe it is possible to establish any set pattern for this partnership. The blend will vary from place to place and from problem to problem. I think we must establish, though, that in any sort of social work all three—the voluntary bodies, the private individuals and the statutory bodies—will have something quite unique to offer; and all three must have respect for each other. They cannot make their full contribution in isolation from each other.

In saying this, I am quite aware that I am not saying anything at all new it is all fully accepted in theory. But we are quite a long way from seeing it work out in practice. This, I believe, is because we are content to enunciate the theory and the expectation in the hope that this is what will be done, without pressing further to take the practical steps that are required. One of the things required in many cases is that there should be a single person appointed, professional or non-professional, to do the co-ordinating. There is one example, of which I have some personal experience, that of a big mental hospital in Cambridge. This is where I did a certain amount of work during my training as a clergyman, and recently I heard of the developments there. They have appointed one person, Mrs. King—not a professional social worker—to do the necessary co-ordinating. I saw one of her recent reports. She is now co-ordinating (this has nothing to do with the professionals working in the hospital, but is quite separate) no fewer than 22 sets of separate groups of people, coming from twelve groups of varying kinds in Cambridge, visiting the hospital regularly; and on top of that, a hundred or so other particular visits from people outside making contributions of one kind or another. That sort of thing cannot happen unless somebody is appointed to do it. It is all very well to talk about partnership, but there must be a minimum amount of organisation to bring it into effect.

Another thing which is required—and this point has been mentioned already this afternoon—is some sort of directory available to people who need to know, setting out what work is being done, and by whom. The Council of Social Service for London produced an admirable booklet the other day, setting out all the voluntary work that was being done in London: the sort of work there was, what would be involved, in terms of the number of hours required, if one joined, the amount of training needed, and so forth.

One other step which has come to my notice recently (and I do not think anybody has so far mentioned it), is the initiative being taken by the B.B.C., which is wholly admirable. The B.B.C., on B.B.C. 2, starting in October, are producing weekly, with a short pause for Christmas, right into the New Year, a series of, I think, 15 or 20 short half- hour programmes, each one dealing with some particular aspect of social work. That in itself is a worthwhile operation, but it is made much more worth while by the fact that they are preparing a certain amount of literature in advance and encouraging people to commit themselves to watch this programme, week by week, in small groups and then, after the programme, to discuss the matter presented and take appropriate action in their own communities to follow it up. It is in this sort of way—these are just small examples from my own experience—that we shall enable these services to flourish. It is this sort of partnership on which the health and welfare services and, through them, the health and welfare of this nation, will grow from its present rather early forms into full maturity.

6.22 p.m.


My Lords, we have enjoyed three maiden speeches this afternoon. Perhaps it will be understood if I pick out one for special mention, for as a fellow countrywoman I should like to pay my warm tribute to the noble Baroness, Lady Strange of Knokin, who has to-day made her maiden speech. She was speaking from her heart, and that was recognised by your Lordships by the attention with which you listened to her. I am sure that those of your Lordships who heard her will join me in looking forward to hearing her next speech in very much less than the two years we have waited for this one.

We have ranged over a wide series of subjects in this debate to-day, and I have been fascinated to listen to the expertise with which so many of your Lordships have spoken on one subject or another. We are indebted—and I make no apology for adding my in-debtedness—to the noble Lord, Lord Amulree, for seeking to draw attention .to the increasing use being made of community care in the health and welfare services. I say this because he is an acknowledged expert in the whole range of subjects we are discussing to-day, and we are very fortunate to have had the benefit of his considerable knowledge and experience.

It seems to me that there is a very real need to build a series of bridges, underpasses, flyovers—what you will—between the hospital service and the local authority services. I am going to touch on only two of these possible bridges, because the hour is late, and most of us have been listening now for three and a half hours to a succession of speakers giving their own opinions on this great subject. Everyone wishes to live as long as possible, but no one wishes to be old—old and lonely. While science does much to prolong human life and ease its sufferings, it is doubtful whether the community as a whole does an equal amount to make prolonged life happy.

The first bridge of which I should like to speak is that provided by the "half-way homes." These are temporary bridges between the geriatric wards of the hospital and the more ordinary normal homes for the elderly. One of these, "Whittington," in Highgate, is run by the Association known as Hill Homes, after its remarkable founder, or foundress, Mrs. Hill, for patients coming from the Archway Group of hospitals that form part of the North London Group, of which I have the honour of being chairman. Patients who in the old days would have gone into hospital with no prospect of recovery may now look forward to at least a partial recovery, and in due course they may return to an almost normal life, commensurate with their age and temperament.

In hospital, quite rightly, every effort is made by doctors and nurses to help put bed-bound patients on their feet again. But what does the future hold for them then? Their old homes have often gone; relatives, owing to financial or housing difficulties, are not able to have them; and in many cases, although the people are partially recovered, they are certainly not well enough to live alone. Although transfer to local authority or voluntary homes for the elderly would seem to be the obvious answer, the patients often need more care and attention than this type of home is able to provide. The borderline between sickness and health has become a frontier over which it is difficult to pass, for the homes for the elderly and the geriatric wards of hospitals are under different authorities, both of whom are short of accommodation.

In 1949, the King Edward's Hospital Fund for London saw an opportunity to help both the hospital service and the patient. Homes with gardens, in pleasant surroundings, linked with the hospitals in which the patient was recovering, could give the patient a real incentive to get well, and the hospitals would not find beds occupied by patients for whom they could do no more, yet who were not capable of fending entirely for themselves. The King's Fund allocated £250,000 towards the setting up of such homes to be attached to specially selected hospitals in London where interest in geriatrics was well proved. The Ministry of Health expressed great appreciation of the scheme. Seven such "halfway homes" were opened most successfully, and three other organisations, which also received substantial grants from the Fund, opened homes running on similar lines. In the "Whittington" Home, we were fortunate in securing the advice and help of that well-known and gifted geriatric consultant, Dr. Exton Smith, who continued to work in the hospitals and also in the home, thereby providing a superb link and liaison. The patients passed on to the homes from hospital continue to gain confidence and mobility, and after some little stay are able to move into a normal home for elderly people. Think of the contrast between that and being bed-bound for the rest of their lives!

At this same Whittington Hospital in 1959 the National Corporation for the Care of Old People sponsored an investigation into geriatric nursing problems, and although much of what is included in the final report of the investigation refers specifically to the hospital care of the older patient, there are some matters which could be related to a much wider field. I would mention particularly the section on clothing suitable for older patients. I do not know how much notice manufacturers have been able to take of the suggestion that clothing should be specially designed in respect of fastenings, so that the older person could be independent, so far as possible, in this vital matter of dressing. I am sure that some of your Lordships know how helpless your wives feel when they need someone to "zip up the back". If one is helpless with even the simplest clothing operation, this must be very discouraging to one's self-respect. This problem is not confined to older people only, but applies also to many disabled people. Much is being done to redesign kitchen implements to deal with the special problems of disability. I feel sure that a lot more could be done in the design of clothing as well.

The second bridge to which I would refer is that provided by the establishment of the Industrial Therapy Organisation which has grown up in connection with St. Bernard's Hospital, one of the large mental hospitals in the North-West Regional Hospital Board's area. Industrial therapy is now being used widely in mental hospitals as a means of preparing long-term psychiatric patients for permanent rehabilitation; and we have heard this subject dealt with by one or two speakers this afternoon in connection with the Bristol scheme, and the scheme which the right reverend Prelate mentioned in his Diocese of Lichfield.

When these patients have been given a substantial period of industrial re-employment training in hospital, the Industrial Therapy Organisation factories, where available, are designed to bridge the wide gap between the hospital training units and open industry. They are trained, not for sheltered workshops but for open competition in the industrial field. In these industrial therapy organisations, which are non-profit-making limited companies run by a small team of industrialists, trade union representatives and doctors drawn from the neighbourhood, patients become trainees for a final course of instruction under realistic working conditions in factory surroundings outside the confines of the hospital. Where possible, these trainees are also accommodated in hostels outside the hospital while undergoing this course, so that they may adjust themselves socially as well as industrially before taking their full place permanently in the community again.

This Industrial Therapy Organisation realised that, although mental illness had become one of the greatest social problems of our day, there had not existed, in this country certainly, an adequate national scheme for the re-habilitation of long-term mental patients. The Ministry of Labour has done its utmost, through its industrial rehabilitation units, to assist an all too small proportion of mental patients—mostly short-term—but these units are really designed to deal with the physically handi capped. This particular branch approached the Ministries of Labour, Health, Pensions and National Insurance, the National Assistance Board and the relevant county councils involved. In every case they met with encouragement and a spirit of understanding and co-operation.

In August, 1964, the first section of a new factory was opened in Hanwell. This was set up in valuable industrial premises ideally suited for the purpose, about one and a half miles from St. Bernard's Hospital, which can be conveniently reached by the trainees from their homes, their hostel or from the hospital, by the use of public transport. These premises could only be acquired as a result, again, of the generosity of the King's Fund which, through St. Bernard's Hospital, made a grant of £25,000 to buy the premises.

Under the negotiations and arrangements made with the various Ministries, the company receives the necessary recognition as a rehabilitation agency specialising in psychiatrics. Its trainees may receive training grants, lodging and dependants' allowances, insurance training credits and other assistance of graduated scales comparable with the facilities given in Ministry of Labour industrial rehabilitation units. The industrial rehabilitation manager of St. Bernard's Hospital was made the honorary works director of the company. A scheme of social rehabilitation is considered an important aspect of the company's work. It is done in an imaginative atmosphere and is linked where possible with the existing welfare and social services of the local authorities and other bodies.

My Lords, I have tried to describe two of the promising new bridges being built between hospitals and the more normal, everyday life in which we live. Both are admirable and their engineers deserve our gratitude and our encouragement. I have read through the stimulating report of the Ministry of Health for the year 1964, which is just available to us, and I cannot find any mention of either of these bridging operations. Could the Minister in his reply tell us whether it is going to be Government policy to encourage such developments? I am sure that if he can do so it will be a source of great stimulation to those already experimenting in these fields, as well as to those who might be thinking of making similar efforts in their own areas.

6.35 p.m.


My Lords, many who have spoken in this most interesting debate have proffered their thanks to the noble Lord, Lord Amulree, for initiating it, and not least for the subject matter of his Motion, the amplitude of which has encouraged so many speakers to range over a wide variety of related matters. I am much tempted to follow the advice of the noble Lord, Lord Sandford, but I must resist that temptation, in order to talk about a number of matters which have exercised a great influence upon my own thinking and of which I have some practical knowledge. For instance, the care of pregnant girls at the moment at which they become aware of their pregnancy is almost a peremptory need in any civilised community. In the hostel for which I am responsible many of these girls are under sixteen. Then there is the need to care for youngsters who come out of approved schools and hostel accommodation. Suffice it to say, if I may, in reply to the courteous question of the noble Lord, Lord Sandford, that one of the things we have discovered in the group ministry in Notting Hill for which I am responsible is that community care must cover the whole area of human life, and it will appeal to those who find that at the particular point at which they feel the need for that care, that care is offered.

Therefore, I want to take another subject which hitherto has not been touched upon, and I do it because I believe that "community care" is not a bad description of the characteristic quality of the Kingdom of Heaven. Quite the most Christian thing that has happened in my lifetime is the Welfare State. In that overall concept of care I remember, and my right reverend friends on the Prelatorial Bench will remember, that a well-known Anglican clergyman of the eighteenth century, among his various pieces of advice to those who helped in the community in which they lived, said this: Go to those who need you, and especially to those who need you most. There are two sorts of care: there is the care which is auxiliary to the already existing capacity to help himself of the one who is to be cared for; and there is the care which has to be given spontaneously and continuously, in the absence of any capacity of the one to be helped at that stage to help himself. It is in that latter connotation that I would venture upon a subject which has not yet been touched upon and very briefly say something about the whole realm of alcoholism. I reflect, my Lords, that you will want a guarantee that because I am a minister of religion I shall not exaggerate, as we are so often inclined to do in descrying in our congregations numbers which to the naked eye are not apparent, maximising the areas of original sin, and certainly emphasising and exaggerating our effects upon it. Therefore I have taken some considerable care to arrive at data which, although they are not precise, are, I think, viable and are certainly not extravagant.

Alcoholism is a stress disease. It first of all shows itself in the habits of drinking, and then expresses itself in quite physical effects. According to the national organisation on alcoholism, and indeed the International Health Office, it is clinically to be described as a disease. The important fact is that the alcoholic is not a drunk who can, if he has sufficient will-power, get rid of his habit and become sober. He has become a compulsive drinker and therefore does not possess in himself the capacity to right the wrong which he is doing to himself and the community in which he lives. It seems to me that this is a prime case for community care.

As to the numbers of alcoholics in the community, the present Minister of Health in another place said, not so long ago, that in his judgment the number was 500,000. Ten years ago the Carter Foundation, after careful assessment, thought it would be about 300,000, but were quite satisfied that the number was rising. Whether or not one agrees with either of those figures, there is an increasing and strong conviction that this is a manifest and major evil in the community, and those who, like myself, have had some little experience of trying to deal with it have been appalled by its incidence and its prevalence.

The problem of alcoholism is, of course, a spiritual problem for the addict. It is not about that that I am going to speak, and I am certainly not intending to give a lecture on total abstinence, or the devil in solution. This is a clinically distinct episode in the kind of society in which we live. It would, I think, be not untrue to say that alcoholism is proper to the modern society in the same way that drunkenness was proper to societies that have gone before it. If you try to calculate, as it obviously is desirable to do, what are the deleterious effects of addiction to alcohol, as attempts have been made in the United States, where they claim, probably extravagantly, that there are 5½ million alcoholics, you find that the loss of productivity, the impairment of the total national product in almost every sphere that is worth calculating, must be immense. And if you reflect that there are perhaps 350,000 alcoholics in the community at the moment, and they are each set within a framework of at least four other human beings, it does not need any words of mine to persuade you of the terrible impacts of this scourge and the very great responsibility that rests on a civilised community to help those who, at the moment, are incapable of helping themselves.

I will refrain from any comment on the moral basis or the ultimate spiritual exercise in endeavouring to rehabilitate the alcoholic. I would say, in passing, that, in my judgment, cure is probably out of the question, and the only thing to be hoped for is permanent convalescence. But if that permanent convalescence is to be arrived at there are certain peremptory needs that have to be fulfilled, and I would presume to mention some of them in a very short speech. I should be unfair to myself if I did not in the first place say that I am quite sure that until we get rid of the particular aspects of the economic system in which we live, we shall increasingly impose stresses which will be almost intolerable on all except the strongest and most robust of our citizens; and, quite apart from the Christian ethic in this respect, it is surely the business of any civilised community to make it relatively easy for those who desire to do what is right to have an opportunity of so doing. Therefore, in general terms, since alcoholism is a conjoint quality of or disqualifica tion within the capitalist system, I, for one, as a professing Socialist, want to get rid of the capitalist system; and all the other methods that would be applied until that has been achieved would only be ancillary to that main task.

I believe that within the present system there is a widespread and reprehensible use of advertisement. I said, in another place (and by that I mean other than the other place to which your Lordships familiarly make reference here; it was in fact in the Methodist Conference a few days ago) that the prevalence of the public house as the cultural centre of English life in many of the films and other items shown on the television screen seems to me at least questionable, and I sometimes wonder what some of our television actors would do if they could not hold a cigarette in one hand and a pint pot in the other. And the almost continuous encouragement to drinking, I am quite satisfied is in itself dubious; indeed, I should go further and say it is wrong. The calculable results of drinking are no less in their final bad effects than those of smoking.

However, it is rather to specific issues I feel I can more properly direct your Lordships' attention, if I may, in these final comments. There are 196 active groups of Alcoholics Anonymous in this country; there are a number of institutions, most of them in London; there are a great many voluntary organisations at the moment calling meetings and taking minutes. But there is a great need for a national project in this country, comparable with the national projects already to be found in the United States of America, Holland and other places, and I hope that there may be something in the Governmental pipe-line to encourage us to believe that this problem will be treated nationally, because only under such a national attack do I think there is any real prospect even of modified victory.

The second and probably the most important immediate concern is to domesticate the alcoholic in order that he may be amenable to the treatment now offered to him, the anti-boost, the apomorphine, the drying-out process, the increase of vitamin, the various ways in which he can be encouraged to look more brightly on life and helped psychologically and spiritually to see that he needs and is prepared to accept the help that would be given. But unless you can put him into such an environment as would encourage the gradual emergence of new will-power—and this can only be done voluntarily at the moment—he will be unlikely to take that treatment. Therefore, in a simple sentence, what is needed is a hostel which combines the benefits of medical treatment and the domestic capacity to hold him there, by love, affection or kindliness, in order that he may be amenable to that treatment. Unless that happens it is almost a waste of time with 9 out of 10 alcoholics.

This kind of hostel treatment will have to be directed not only towards men but towards women. I am responsible for a small hostel for alcoholic women. I have no knowledge of the numbers there may be in the community, but the secrecy of wine-drinking middle-aged women who are alcoholics is to me an ever increasing concern, and I should not be surprised to find that the number, if it were known, would be frightening. I believe that this marriage of the voluntary society to the statutory body is the immediate way in which this particular enterprise can be carried through for both men and women.

Therefore, I would conclude by giving one practical illustration from the place where I worked for some little while. In the London County Council, just before its demise, a committee was set up to inquire into the poor relations of the alcoholics, the crude spirit drinkers, who pollute some of the open spaces in London—the crude spirit drinkers, who must, of all men, be the most melancholy and most unfortunate. I will not presume to tell your Lordships about them, but perhaps you do not know that they are so physically offensive that it is almost intolerable to be within three or four feet of them. Perhaps you do know that the processes of crude spirit drinking, the last processes of alcoholism, have the most ghastly physical effects. If a community believes itself to be civilised and if it really accepts the principle of community care, it will seek to care for such.

The London County Council went very carefully into this matter through an approved committee and came to the conclusion that only by the provision of some kind of hostel, some kind of home, would it be possible to do anything at all for the crude spirit drinker, and they felt it would be possible so to effect this remedial process only by the co-operation between the statutory bodies and an institution such as the one for which I work. The interim ethic of community care, I am sure, is to be found in the marriage of the voluntary association and the statutory body.

I would end with a plea. Most people find it much more convenient to ignore the alcoholic unless he happens to be a member of their own household, to pretend he is not there, and to minimise the whole idea in their minds when it is presented to them. Every other industrial country in the Western world is taking this problem with increased seriousness. We as a civilised and an officially Christian community should not lag behind. There is a great deal of good will towards the alcoholic. He is potentialy a most valuable member of society, for when he is not alcoholic he has no difficulty in finding a job. He is, while he remains an alcoholic, a curse to himself and a sorrow to those who love him. Community care for the alcoholic would be one of the marks of a truly civilised community.

6.50 p.m.


My Lords, I think we are all indebted to my noble friend Lord Amulree for initiating this debate, which has covered a great many different subjects. I should like in a few words to confine myself to just one aspect of community care—namely, the question of old people and their treatment in mental homes. If I follow my noble friend Lord Soper and strike a less happy note, I will at least try to speak with the moderation which is the custom in your Lordships' House. A great many old people are going into mental homes mainly for two reasons: first, there is a great shortage of old people's homes; and, secondly, many of these old people's homes are not able to take old people who are incontinent and enfeebled. The result is that many of them have to go into mental hospitals, although they are not psychiatric cases at all.

Many of these mental hospitals are good, but some are really a disgrace to a civilised country. An example of the kind of hospital I have in mind is the one which was described by a psychiatric worker in this particular hospital in the issue of the Guardian of March 19 of this year. In hospitals of this kind, of which I believe there are six or seven in the country, old people, it would be no exaggeration to say, are treated worse than in the old-fashioned type of Victorian workhouses. They are treated worse because they are regarded as mentally deficient as well as merely poor. There is, for example, the practice of what is known as "stripping". This means that on entry all personal belongings are removed, including spectacles, deaf aids and dentures. There are no personal lockers. The food is appalling. In some cases the last meal is served at half past three in the afternoon. Electro-convulsive treatment is given, I believe, to almost every old person, irrespective of whether it is needed or not. In certain cases it appears that this makes them worse.

But the worst thing of all, I think, is the fact that they are given nothing to do. No effort is made to interest them. Without their spectacles they cannot read or sew. There is rapid deterioration through boredom. In some hospitals visitors are discouraged; no information is given about hours; it is difficult to find your way to the ward you want, and there is a great lack of voluntary workers.

We have heard with great advantage to-day the excellent speech of the noble Marchioness, Lady Reading, and one knows of the wonderful work that her organisation, the W.V.S., does. I wish, though, that as well they would direct their attention to some of the mental hospitals, and particularly to the wards for the old people, they being in them because they have no other roof over their heads, for no other reason. There is now a tremendous interest and sympathy of young people throughout the country. If they only knew of the conditions, I feel sure that many of them would go in and work voluntarily and give company to these old people. Hardly any ministers of religion visit. I do not at all blame the Churches of any denomination. I think the fault lies with the hospitals, who do not notify the churches of the various denominations of the patients as they enter. There is a shortage of medical and nursing staff.


My Lords, on a point of order, I must point out that every hospital has an accredited chaplain—Church of England, Free Church and Roman Catholic—and great care is seen that regular hospital visiting by the churches is carried out.


My Lords, in reply to the right reverend Prelate I can speak only of what I know, and in the particular hospital that I know there are very few visits indeed. I do not blame the Churches. I think I made that clear earlier. I think the fault lies with the hospital, who do not notify the church when a patient of a particular denomination enters. There is a shortage of medical and nursing staff. Patients hardly see the doctor from one year's end to the other. The nursing staff do their best but are over worked, which leads, I think, to lack of attention and even, in some cases, although it is not the fault of the staff, indirectly to cruelty.

The result of all this is an atmosphere of humiliation and neglect. The patients are—this is a term which is used by some friends of mine in one of the universities who are making a study of this problem—"pulped". They lose all sense of self-respect. Worst than this, many are cowed and frightened. All just vegetate and seem lost to the world. And they are lost to the world. There is nothing more relentless than the State machine when it gets the helpless into its maw. I know one old lady of over 75 who spent two years in this place that I have described on the outskirts of London. The physical deterioration was rapid. Recently we managed to get her rescued and transferred to a good Catholic old people's home where she is making rapid improvement. I went to see her last Sunday and her progress was amazing. Of course, the reason is that she is being treated with love and kindness by the nuns. She has her own locker. She wept for joy when she saw that she was going to have one.

Therefore, I would urge the Government that there must be an early priority given to a programme of building more homes for old people, and in small units, so that those whose families cannot look after them do not have to be diverted into mental hospitals, which are not places for people who are not mentally incapacitated but merely incontinent and enfeebled. In the olden days, primitive tribes used to turn their old people into the cold to die. We are more civilised—we merely allow them to rot in mental hospitals. So far as a great many people are concerned, especially old people, the Welfare State is little more than a sham and a mockery.

7.0 p.m.


My Lords, I think that it would be advantageous if, straight away, I say a few words to my noble friend Lord Strabolgi while his speech is fresh in our minds. I remember visiting "Hillside," which the noble Baroness, Lady Brooke of Ystradfellte, will know very well. It is an old L.C.C. Public Assistance institution at the bottom of Highgate Hill, not far from her hospital. There they have an excellent ward for senile geriatric patients such as the noble Lord has been describing. I remember one old lady there who was 102. When I got home I remember my children saying, "Did you ask the question?" I said, "Yes, I did ask the question." The question was, "Do you get a telegram from the Queen on your 101st and 102nd birthdays, as well as on your 100th?" The answer, I now know, is that you do not.


My Lords you do not get a telegram from the Queen. You get a telegram from the Queen Mother on the subsequent birthdays.


My Lords, I stand supplemented, rather than corrected.

Now in "Hillside" a large number of these old people are incontinent, but there is no smell in the ward. They are nursed by one trained nurse and some assistant nurses, who come mainly from the Commonwealth. There is no reason at all why the conditions which he has been describing should obtain in any geriatric ward, whether it be in a mental hospital, in an old people's home or in a general hospital. If the noble Lord will let me have the particulars, that is to say the name of the hospital concerned, I will certainly see that his statements are dealt with and that we fully investigate the conditions which he has described. I can remember going, as a young lad, to my first job in a mental hospital. I was supposed to be looking after 450 people and there were some pretty bad things then. But the work I was trying to do then is now done by four or five doctors. I do not know of any hospital as bad as the one described by the noble Lord.


I can take the noble Lord one afternoon to the one that I have described.


We will certainly see that it is thoroughly looked at.

The noble Lord, Lord Amulree, cannot complain that his Motion has not succeeded. Its wording is To draw attention to the increasing use being made of community care in the health and welfare services. It is not critical, but descriptive. He succeeded in drawing from all parts of this House a long series of descriptions of what is being done and what needs to be done, and I shall have the greatest difficulty in trying to give your Lordships a full reply. May I say what a pleasure it was to have five noble Baronesses taking part in the debate, particularly the noble Baroness, Lady Strange of Knokin, and to hear the noble Viscount, Lord St. Davids, congratulate her on her maiden speech. Her contribution was, to me, a breath of the countryside. I am so glad she made it because, in thinking about the needs of the community or of individual human beings, one often forgets people isolated in the countryside where there can be just as much sorrow and misery in the backroom of the poor farmhouse as there is in the upstairs room of the tenement.

Dean Swift wrote in 1725 to Alexander Pope: I have ever hated all nations, professions and communities, and all my love is towards individuals; but principally I hate and detest an animal called man, although I heartily love John, Peter, Paul and so forth. I must say that I find the words "community care" very mysterious. The phrase means no more than caring for people. I do not quite see what special significance the word "community" has. The other phrase I do not like is being "in care". I hope to goodness that I am never "in care", although—who knows?—one may be one day. But I think that it is an unfortunate expression. The best definition of community care came from my noble friend Lord Soper, who said that community care is the equivalent to the Kingdom of Heaven. I began to think that there was something in what he said. At the same time, one had a feeling that community care can sometimes go wrong. One can be too busy, if one is not careful, minding other people's business.

Community care is something which, fortunately, most of us usually do not need. But that does not make it any less important when we do need it. Some of us will need it after a severe illness or in old age, some of us after suffering the loss of a faculty, such as sight, or undergoing a neurological illness, or a severe injury. We had a very good description from my noble friend Lord Amulree of the remarkable work of Dr. Guttmann at Stoke Mandeville. Caring for, and continuing to care for, severe injury is likely to be one of the growing forms of community care which we have to face. It is a major task, and the noble Lord described it so well that I do not need to go over it again.

I should like to say a word about industrial rehabilitation. My noble friend Lord Amulree said that Vauxhall Motors had an industrial rehabilitation unit. I remember visiting Austin's, at Long-bridge, where they employ about 14,000 people. They have a small industrial rehabilitation unit, but they have the greatest difficulty in supplying enough patients to keep that unit going. The Slough Industrial Health Service, which covers about 25,000 people, has an industrial rehabilitation unit, but only a quarter of the people in the unit come from Slough. To run such a unit efficiently it is necessary to draw on a large area of the community for people in need of industrial rehabilitation. The right thing to do is to relate rehabilitation to Regional Hospital Board areas because the Boards cover a large enough area for this purpose. This is not in any way to belittle the work of the industrial therapy organisations which were mentioned by the noble Baroness, Lady Brooke of Ystradfellte.


My Lords, the noble Lord might like to know that the Austin Company have in South Wales a factory employing 400 miners who suffer from pneumoconiosis where, in fact, they make many of the cars for Longbridge. It has been a very successful unit of rehabilitation for those suffering from this disease.


That is a most important and valuable contribution. This is a different kind of rehabilitation, but even more valuable, because these people are continuously disabled and cannot often be permanently rehabilitated. One has to keep them all the time in this sort of environment.

In addition to those who need care as a result of severe injury, there are those who need it because they are badly handicapped in one of three ways. I do not think I need say very much about the old, because my noble friend Lord Bowles gave them a fair run. Then there are the physically handicapped, and they include the congenitally handicapped—people who are born with a disability, whether 'because of the effect of drugs such as thalidomide, or congenital heart disease or what-you-will. Thank goodness! many of these can now be helped by surgery and completely rehabilitated, completely brought back into the community.

There are those with an acquired handicap, as a result of injury or neurological disease. The noble Baroness, Lady Elliot of Harwood, mentioned autistic children. Autism is, I suppose, one of the most awful handicaps anybody can have. It is a very rare handicap and, therefore, there is a need for very few schools to deal with them, but unfortunately there is almost nothing one can do for these children. They are completely devoid of any emotional reaction whatsoever, or their emotion, in so far as they express it at all, bears no relation to their environment. They do not speak, they appear not to hear, and yet appear quite normal in the way they grow up. Sometimes they have been thought to be juvenile schizophrenics. Fortunately, they are very rare, but they are one of those problems which we do not yet know how to deal with.

There is a further very important group. This includes the psychiatrically handicapped, the subnormal, or psychiatrically ill. Then there are those whose psychiatric illness has a social emphasis. These include the alcoholics, to whom my noble friend Lord Soper referred, and the psychopaths, who also, I think, sometimes appear among the alcoholics and methylated or crude spirit drinkers. They are quite incurable, I think, even with my noble friend's hostels. They do permanent damage to themselves and they really become tramps—almost vegetables, one might say—in the end. Finally, one might well include criminals among those who are both psychiatrically and socially ill. My noble friend Lord Soper spoke of these people also in connection with the after-treatment of discharged borstal boys and boys and girls from approved schools.

As I have been listening, I have felt there was one real point of controversy which emerged in this debate, and that was the controversy between my noble friend Lord Simey, in his extremely interesting maiden speech, and my noble friend Lady Summerskill, in her equally interesting, vigorous speech. My noble friend Lord Wells-Pestell, in his maiden speech, also contributed to this particular controversy. My noble friend Lady Summerskill said, and I am inclined to agree with her—


My Lords, could the noble Lord address the microphone? We could then all hear.


My Lords, I thank the noble Lord for that suggestion. I never quite know whether to reply to my noble friends over my shoulder, or to speak into the microphone in the hope that what I say will come back to them. I shall try to speak into the microphone.


The noble Lord was saying that he agreed with me.


I agree with my noble friend Lady Summerskill that there is not an indefinite reservoir of unemployed ladies and gentlemen who are ready to do voluntary social work. They just do not exist nowadays. Middle-aged ladies are fully occupied, very often in paid work; those who are not are doing social work already. To find the voluntary social workers to help trained social workers will be very difficult indeed.

There are, of course, limits to the speed at which any developments can take place; for instance, the amount of capital investment which can be spared for building homes for old people and handicapped people is limited, because these capital schemes have to compete with many other urgent calls on the available resources. In the same way there is a limit to the supply of potential social workers. We must therefore avoid call ing on social services whenever we can and must carry our own burdens.

My noble friends Lord Simey and Lord Wells-Pestell reminded us that, under the Children Act, it had been possible to relieve society of the burden of caring for children by the development of foster parenthood. My noble friend suggested that it might be possible to apply the principle, as it were, in reverse; that grown-up people should adopt old people to foster as parents in their homes. That seems to me a most intelligent and most thoughtful suggestion, which is well worth looking at and doing if it possibly can be done.


My Lords, I am sure the noble Lord realises that this has been experimented with in Exeter with great success.


My Lords, I did not realise that it had been done in Exeter, but I am very glad to have elicited the fact from the noble Baroness.

I want to be brief, and therefore perhaps it would be best if I looked through the points which your Lordsips raised and tried to answer these in particular. The noble Marquess, Lord Lothian, spoke about the patchiness of services. I think patchiness is one of the prices we pay for having services run by local authorities. One cannot avoid this patchiness, and the system which we have, which his Government used, and which we shall be using again, of calling for a plan to be submitted and then revised every year or so, with continuous stimulation by the Minister of those authorities which seem to be negligent, is about as far as one can go, while preserving local autonomy. I do not see how one can therefore avoid having some areas where things are going ahead faster than in others. I took the noble Marquess's point about the possible use of cottage hospitals as halfway houses for mental patients. That certainly is one possible use for them. They are also, of course, ideal old people's homes.

My noble friend Lord Simey spoke about the importance of community associations, and the possibility of community associations playing their part in preventing the deterioration of old people. I should like to agree with him, but to say that the successful running of community associations is a very difficult job indeed in my experience. I have seen four community associations working in one town—namely, Harlow where I used to work—and each of those community associations covered a population of about 20,000, yet I do not think any of them had more than 1,000 active members. In other words, to make a real impact on the community is very hard indeed, though many of the things the community associations may do can of course affect people who are not members. Running community associations is a skilled job, and one cannot expect to get people of the quality one needs at the figures which can now be offered.

The right reverend Prelate the Bishop of Lichfield, in his account of the work of his Regional Hospital Board, spoke of the increasing use of an outpatient department at Stoke-on-Trent as a comprehensive treatment centre, and I am quite sure this is the way that outpatient departments will develop in future. I think this is a glimpse of the future. He spoke also of the remarkable work which is done by voluntary organisations for the deaf and dumb and for the blind. Indeed, when I got my brief from the Ministry of Health, like those mayors whom he visited and who, at the end of their terms of office, realised how much was done, I, too, realised how much was done, and also how much there is to do. The work of the welfare officers of the local authorities, specially trained in the teaching of the blind and in the care of the blind in the home, is, I must say, really remarkable.

My noble friend Lady Summerskill spoke about the need for a register of old people in every area, and I agree that this is something which may be needed. But it is not easy to say how it might be achieved. The problem, I think, is ascertainment; and, short of making a complete census of every room in a borough, I cannot see that one could pick up the needs of all the old people, particularly the cases one wanted to pick up-the non-communicating old people. It is possible to arrange for general practitioners, on a voluntary basis, to notify the names of old people in need of care, and that, I believe, is done in Newcastle, although I do not know how successful it is. But I should like to tell my noble friend that the question of a register for the aged is something that the Government are now considering. She will also know that a Bill on the reform of abortion law is before another place now, and that the Government have said that they are strictly neutral on the subject. She will know also that there is a committee on the pharmaceutical industry, under the chairmanship of my noble friend Lord Sainsbury, which I hope will give her some of the things she wants.

The noble Baroness, Lady Swan-borough, had to leave but she spoke particularly of the admission of old people into hospitals and long-stay homes when they were in a state of confusion, and of when this confusion was due to an organic cause; and she suggested that they should all be properly examined and assessed. Of course, she is right; they all should be: but I must say that I think the great majority are. The noble Lord, Lord Amulree, will know better than I the drill and the growth of geriatric units where such assessments are made extremely efficiently now. So, provided the old person goes through a geriatric unit, there should be no failure to ascertain a physical cause of mental confusion.

My noble friend Lord Wells-Pestell, besides his very interesting observations to which I have referred, told us about Severalls, a mental hospital which has improved beyond all knowledge in the past ten years, and told us about their success in boarding out 30 elderly patients at a cost of £5 per week per patient instead of £12 per week—and I must say that I thought that was a very interesting achievement, and something which can obviously be developed. The noble Baroness, Lady Elliot of Harwood, referred to the difficulty that arises when old people are rehabilitated from a mental hospital and are brought back into a community, and asked where they could go. The truth of the matter is that, with modern treatment, it is increasingly possible to socialise old people who would previously have been regarded as hopeless. This presents precisely the problem of where they are to go; and, if the Severalls solution can be applied generally, there is a very good one.

I unfortunately missed the speech of the right reverend Prelate the Bishop of St. Albans, but he told me beforehand that he was going to deal with mental health halfway houses. Here I should like to say that it is easy enough to see how the halfway house acts for the old person, for the physically disabled and for the physically handicapped, but for the acute mentally ill it is not quite so clear yet what is wanted of a halfway house unless the patient has been confined in hospital for a very long time. My psychiatrist friends assure me that, with modern psychiatric treatment, they can get almost every patient, other than the psychopaths and the elderly confused, well again within three or four months and back to their own homes in this sort of time, although they may relapse.

If they can do this, and if one has acute psychiatric wards in general hospitals, there should not be this building up of resistance to their return, and there should be no necessity for industrial retraining because they should not have lost their skills in this period. But, although it may be easy enough for a person who has been depressed, for example, to go back to his old work quite satisfactorily, it is more difficult with schizophrenic patients, who are naturally rather withdrawn; and they may place a considerable burden on their families. If, of course, they have no family, or if their family refuses to take them, the need for accommodation for them is manifest and obvious. But with these short stays in hospital that is much less likely to happen.

The noble Baroness was right in saying that the growth here has been much slower than in the case of the mentally subnormal, where the services have been growing rapidly in the last two or three years. Here, things are going much more slowly, because we do not yet quite know what is required; what is the proper way of halfway house between the mental hospital or the acute psychiatric ward and the return to home. It may be that they are not invariably required for anything like all the patients. I hope they are not.


My Lords, may I ask the noble Lord one question, as he was not here when I spoke? I raised the question of the Richmond Fellowship, because I am interested in that, and I made the point that that particular halfway house has found difficulty in finding suitable accommodation, partly because of the resistance of the residents in the neighbourhood. They feel that there is something "funny" about a halfway house for people who have come from mental hospitals, and they are inclined to resist. The particular point I wanted to make was that I hoped the Government could do something to encourage such districts to think again before taking such a line.


I would entirely agree about that; and may I say that one knows from one's own family experience that getting hostels for borstal boys and girls is inclined to meet with exactly the same kind of resistance from the neighbours, perhaps even worse resistance sometimes. If I can help at all practically in the case of the Richmond Fellowship, I will certainly see what can be done, although the acquiring of premises by these voluntary bodies is often the most difficult thing they have to do because of the capital cost of the buildings and the value of the site of the place where they want to go.

My Lords, I do not think I should continue any longer, but I must say one word in reply to the noble Lord, Lord Sandford, who is just opposite me. He was kind enough to make some references to my work in Harlow. I want to say two things: first how much I admire the work of the Fulbourn Mental Hospital and the work that is done there. It is an extremely good mental hospital. Also I should like to say a word about his street observers. I happen to live in a long street. I reckon that there must be nearly 2,000 people in my street in various blocks and flats. I do not know how his street observers know when somebody wants a screwdriver or is in some other social trouble at the other end of a long street, but no doubt the scheme is more practicable in a country town.

I should like to say something further, if I may, to the noble Baroness, Lady Brooke of Ystradfellte. It is just a word of praise and admiration for the Hill Homes. They are wonderful institutions. Mrs. Hill is the wife of Professor A. V. Hill, whom some of us who were in the other place knew well; I think I knew him when I was a student of physiology, which was a very long time ago. He is a Nobel Prize man. He is still going strong; so is she, and so are the Hill Homes. May they continue to flourish and serve the old people of North London in this wonderful way!

My Lords, I think I really have said enough and I should draw this very interesting debate to a close. But before the noble Lord, Lord Amulree, winds up and says the concluding words I should like to say how valuable the Government found it, how many stimulating ideas we have had injected into us. We will look at everything that has been said; nothing will be wasted. I can promise noble Lords and noble Ladies that we will make sure that if answers appear to be called for which I have failed to give, we will try to give them in letter form. But action is really more important. I feel we have had here a series of bases for action, whether by voluntary societies, by local authorities or by the Government themselves. We have had so much that is useful, so much that is stimulating, that I think the noble Lord, Lord Amulree, can congratulate himself on a really successful debate.

7.33 p.m.


My Lords, I should like to thank the noble Lord, Lord Taylor, for his kind speech in summing-up. There are one or two brief points that I wish to make. The noble Lord looked to me as if the words "community care" came from me. They are words that I dislike intensely. I saw them for the first time on a large book published in 1963. I do not know what they mean. That is what I have been trying to find out to-day. I trust that we shall one day be able to banish them from normal talk.

The other point I wish to make is that the object of my speech in this debate was not to try to get more places built; but to get more people going from the places that have already been built, so that we should not want any more hostels and institutions, so that people would continue to live in their homes and so that those who, unfortunately, were in hospitals would be able to come out of them. I was not putting forward the plea that more should be built. Thirdly, the noble Marquess, Lord Lothian, referred to the patchiness of things, and the noble Lord, Lord Taylor, also referred to that. Surely that is partly due to the vice of permissive legislation. If you are going to permit local authorities, rather than to say to them, "You shall", then you are going to get into trouble. I know that you are also going to get into trouble if you say, "You shall"; but one must take a chance.

Before I sit down I should like to thank the large number of noble Lords who have come and supported me. I am pleased that so many noble Baronesses took part, and particularly pleased that we have had such a large number who have come along and made maiden speeches. I would particularly refer to the maiden speech of the noble Baroness, Lady Strange of Knokin. It was rather a remarkable effort and I was very pleased that she was able to come along and say a few words in support of my Motion. With your Lordships' permission, I beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.