HL Deb 15 November 1966 vol 277 cc1249-56

6.28 p.m.

LORD AMULREE rose to ask Her Majesty's Government whether steps cannot be taken to increase the co-operation between those working in the Hospital Service and those working in accommodation provided by local authorities under Part III of the National Assistance Act 1948, particularly in the case of the aged and infirm. The noble Lord said: My Lords, I rise to put the Question on the Order Paper. I should like to divide my remarks into two parts. First, I will read your Lordships a short quotation from the National Assistance Act 1948. Section 21(1) at the start of Part III, says: It shall be the duty of every local authority…to provide— (a) residential accommodation for persons who by reason of age, infirmity or any other circumstances are in need of care and attention which is not otherwise available to them…

The reason why I put this Question down is that it seems as if in a number of parts of the country, particularly in the Home Counties, there are not enough beds provided by local authorities under this section of the Act. Where one comes across it frequently is when one is trying to transfer from hospital to Part III accommodation patients who have been restored to health so far as they can be, though it has not been practicable to send them home again. As a result of this situation, it is claimed by some that the local authorities have not done their duty in this matter and have not provided enough beds under this section of the Act. But by the two points that I want to raise I think it can be shown that this is not necessarily the truth.

The two questions that I want to put, partly to myself and partly to the noble Lady who is to reply, are: first, are more beds needed? And, secondly, can one say that the proper use is being made of the beds which exist at the present time? To secure the proper use of these beds (it is difficult to separate these two points completely) it is necessary to make sure that the procedure whereby a person is admitted into a welfare bed is satisfactory. The most general way this is done is by the efforts of the welfare officer attached to the local authority. I have had a good deal of experience of welfare officers, and I am bound to say that I have always found them extremely helpful and courteous, and they always try to do their best. But often they tend to decide, with no consultation with the doctor in charge of the patient, whether the patient is fit to be moved from the hospital to a home. This can cause difficulty, because we on the medical side may say that the patient is quite fit, and the welfare officer, who is generally a person of considerable experience, though not necessarily trained, may say that the patient is not fit. The result in such a case is deadlock.

If we were to make more beds available in the country, great expense would inevitably be incurred, and I do not think it is necessary to incur that expense. Therefore the rules for admission to these homes must be tightened up—because it is becoming more and more expensive to entertain people in these homes. When one has visited these homes and talked to some of the people (I am talking particularly about the accommodation provided under Part III for people who are infirm and incapable of looking after themselves) one finds that they have got there for all sorts of curious reasons.

One reason is that they feel lonely by themselves—and that may well be true. Another is that they feel that their neighbours are talking about them. A common reason for admission is that other people are gossiping on the stairs, pointing fingers at them as they go up and down stairs. These are what I might call sentimental grounds. It seems that this power has been interpreted too liberally in the past. Sometimes the matron in charge of a home appears (I say "appears", because I do not know) to have a good deal to say about the type of person admitted, for matrons do not like people who will cause great trouble. I can sympathise with their feelings because they have difficulty in finding staff. But these homes were not intended for nice, kind people who can do a good deal for themselves: they were intended for difficult people.

The present teaching, I think, is that generally one should maintain people in their own homes for as long as possible. That can be done in various ways by laying on domiciliary services for them. I agree that it is not always possible to decide on the amount of domiciliary services required. But supposing a person requires a great deal of services, it may be more expensive to keep that person at home rather than care for him or her in a welfare home. I feel that this principle should be borne in mind more frequently when applications are made for admission to welfare homes. One of the difficulties is that the majority of people in the Registrar General's social class No. 5—that is, the lowest class of all—particularly when they are single, tend to get into these homes, because they find for various reasons that it is difficult to maintain independent life by themselves.

I now come to the second part of my Question. It is difficult to ensure that there is efficient and good co-operation between the welfare department of the local authority and the medical side taking care of the patient. I do not say for one moment that this is the fault of the service; the fault, I regret to say, is that of Parliament, which passed two Acts, the National Health Service Act and the National Assistance Act, and provided no means for them to meet together in the middle. This has led to a great deal of difficulty and trouble. One has seen the way in which this difficulty can be overcome. When I was engaged in medical practice, about once a year, when I became overcrowded with people who should be transferred, I paid a visit to the welfare officer of the London County Council, who was a friend of mine, and told him of my troubles, and they were solved temporarily by people being moved on the spot. But that seemed to be a cumbersome way to do it, and one that ought not to be necessary in the future.

Tied up with that is the fact that when patients are discharged, particularly the infirm, whether from their homes or from hospital, and are taken into one of these Part III welfare homes, they have no continuity of medical care. They pass from a fully staffed and equipped hospital department, where they have been got on their feet and assisted to move again, to the care, quite often, of a part-time general practitioner. It has been said that this is quite right, and is supposed to occur, because when they go home they do not get more than the care of a part-time general practitioner. But the point is that they are not quite fit enough to go home, and therefore I do not think that argument applies with any great force.

What one sees frequently is that though people become mobile under hospital care and can look after themselves up to a point, when they get into a welfare home, because there is nobody to carry on that treatment, they tend to get put back to bed and become immobile again. This is done for a good reason: the staff are not experienced in the care of elderly folk and are afraid that they may fall down and break their leg or that some other catastrophe may occur. A very sensible circular was issued by the Ministry of Health some time ago which said that it was not necessary to transfer from a welfare home to a hospital people who are dying or who have a mortal illness. There I entirely agree. But I think this can be carried a little too far. You find, in some of these big houses, particularly, a large number of sick people who are lying there with no particular care and attention. I do not say that at the moment a great deal could be done for them all, but a certain amount could be done for some if they were seen by somebody from a well-equipped department of a hospital. Something could be done for them, as it is for their more fortunate colleagues who happen to go into the other channel and go into hospital.

The person who controls where they go is the general practitioner. If he thinks that they should go to hospital, they go to hospital; if he thinks that they should go to a welfare home, that is where they go. This can lead to a certain amount of trouble. The suggestion I would make is this. Would it not be possible for the hospital authority to have some control over, or some say in, the care of the patients in Part III accommodation of the welfare homes? This is the first suggestion that I have made that might cost a little money. I am afraid it would cost a little money, because it would mean paying a doctor to do extra sessions there or employing extra staff. This would have to be worked out. I think it would cost more money also because, if they were looked after properly, it would be necessary in some of these homes for the patients to have something to do.

It is awful for so many patients to find they have nothing whatever to do, because although it is not impossible, it is difficult for local authorities to employ physiotherapists or occupational therapists, which could make an enormous difference. In one little home I know in North London there are about seventy fairly mentally degenerate old ladies. We got a voluntary physiotherapist to come and do a little bit of "fun and games" in the evening, and the result was extraordinary.

I should like to ask whether more co-operation between the medical and welfare side could not be encouraged and, supposing it is not considered possible to run it on the medical side, whether the admissions to these homes could not be given more to an experienced medical social worker, or somebody who has some idea of what can or cannot be done. The alternative, which I think is going a little too far, would be for the Regional Boards and boards of governors to take over the Part III accommodation from the local authority. That would probably require Parliamentary time and Parliamentary work, so I do not put that suggestion forward as a very serious idea, but it may be a suggestion worth thinking about.

Another way in which we might save people going into these homes from the world outside would be to have more of these consultative clinics for elderly people established by the local authority. I think they exist in about 25 per cent. of the country at the present time, and they are all on rather an experimental basis. For my final point I should like to ask whether something of that sort could be considered, because it might not only save the pressure on the beds but mean that the beds would be properly used for the right people; and in that event we might not need to say continually that we need more beds.

6.42 p.m.

BARONESS PHILLIPS

My Lords, before I reply on behalf of Her Majesty's Government, I should like to say how grateful we are to the noble Lord for raising this point to-day, and how we all salute the way in which he continually brings it before us. As a poacher turned gamekeeper, I must say that this would have been my role had I not been stand- ing at this Dispatch Box. The noble Lord might like to know that, before I was part of the Government, I was very much concerned with this problem. Only today I received a report of the Old People's Welfare Conference, Putting Planning into Practice, one session of which—I did not speak at that one—was devoted to the subject which the noble Lord has so ably put before us this evening. We are, of course, all aware that the noble Lord is a practitioner of many years' experience in the field of geriatrics.

Where both hospital and local authority services for the elderly and chronic sick are well developed little, if any, difficulty is experienced in ensuring that patients are cared for in the way that is best for them. But where services are deficient on either or both sides, it is inevitable that there are difficulties such as the noble Lord has outlined: for example, misplacement, blockages of hospital or welfare beds, waiting lists to both hospital and residential accommodation and delays over urgent cases for transfer. There are particular difficulties in those areas which are short of geriatric beds but still have large, former Public Assistance, institutions in use as welfare homes. While co-operation in these circumstances between the respective authorities can do much to ensure that the difficulties are minimised and that the best use is made of the accommodation available, it is also necessary to extend the services themselves as the noble Lord has truly said. This is one of the objects of the hospital building programme, and of the plans for development of community care.

It would not be inappropriate, I think, for me to recall to your Lordships the recent action which the Minister of Health has taken to promote the care of the elderly in hospitals and in residential homes provided by the local authorities. In September last year the Minister issued to hospital and local authorities a Memorandum on the Care of the Elderly in Hospitals and Residential Homes. This Memorandum restated in more definite terms the responsibilities which both partners ought generally to accept. But it went further. It also contained a final section advocating joint planning and joint operation of the two services, and it suggested in detail administrative arrangements for achieving these objectives.

May I quote from one section of this which impressed me particularly? Referring to the difficulties, the circular said, in these very strong words: The difficulties may arise because of the defects in past admission arrangements and in part because of mistaken assumptions by each service about the functions and limitations of the other. The response to the Minister's advice has been encouraging. A number of Regional Boards and local authorities had, well before the issue of this circular, established joint working groups to survey the services available and to bring to light difficulties and deficiences. In some cases, therefore, existing machinery has been put on a more formal basis. In other parts of the country planning or working groups covering suitable geographical areas have been set up in response to the Ministry's circular of last year, with of course general practitioner representation. I think it is fair to say that almost throughout the whole country machinery for co-operation, which is so essential between hospitals, local authorities and general practitioners, is already getting firmly established.

I turn now to more detailed forms of co-operation, in which I know the noble Lord is particularly interested. In a number of areas there are joint appointments of geriatric physicians between local and hospital authorities. In one hospital region, for example, the majority of the areas are covered by joint consultant appointments. In another area—I know this will hearten the noble Lord—a geriatric physician has recently been appointed as a Co-ordinator of Geriatric Services covering the interests of the Regional Hospital Board, the local teaching hospital and the local authority. The effects of this imaginative appointment are being watched with keen interest.

In other areas geriatric physicians visit welfare homes at the invitation of the welfare authorities, and of course they advise on cases referred by the general practitioner. The Minister welcomes such co-operation between the two authorities. He very much hopes that local authorities will not hesitate to seek the advice and the assistance of the hospital geriatric physicians whenever necessary. Their help and skill, based on their wide experience, will prove of benefit to individual patients in residential homes, and may well enable them to suggest methods of prevention which might retard or even prevent deteriorating processes, thus lightening the load for the staff of the residential homes as well as possibly obviating the need for hospital admission.

The Minister shares the view that cooperation between the staffs responsible for hospital patients and for residents in welfare homes should be increased by all practicable means. But let us remember—and I know the noble Lord has underlined this—that while a pattern of co-operation can be laid down, its effectiveness will always depend on the resourcefulness of the different partners. The Minister appreciates the need for the continuing study of all practicable measures which will enable progress to be made. He also relies on the enthusiasm, willingness and good faith of those working in the services to put them into effect. I know that Her Majesty's Government will take note of the practical suggestions put forward by such an eminent worker in this field as the noble Lord who has introduced the Question this evening.