COMMUNITY CARE OF THE HANDICAPPED

HL Deb 10 May 1972 vol 330 cc1023-124

3.4 p.m.

Lord GRENFELL rose to draw attention to the need for increased community provision of hostels to undertake the rehabilitation and care of handicapped people who do not need hospital treatment; and to move for Papers. The noble Lord said: My Lords, I am deeply grateful to my noble friends the Leader of the House and the Chief Whip for arranging this debate, and also to the House as a whole for its forbearance over the postponements which have taken place. I have worded the Motion to include all aspects of handicap within the auspices of the Department of my noble friend Lord Aberdare, and noble Lords will be speaking on many aspects. But, with the permission of the House and realising fully the wider requirements, I shall confine myself to the urgent needs of the mentally handicapped. My Motion calls for community care and I feel that we must consider what we mean literally by the words "within the community". They may be construed as anywhere outside hospital, but to my mind it would be disastrous to transfer patients from a large institution such as a hospital into a smaller one, such as a hostel, without ensuring that there were proper facilities for employment, recreation and all the other requirements of life which we consider proper.

Although national understanding of the problems of the mentally handicapped has shown tremendous advances, it will be some years before we are able to overcome the reluctance of the populace to allow hostels for the handicapped to be situated adjacent to their homes. This reluctance leads to all the difficulties of planning permission and lengthy public inquiries, which add so much time and expense to the completion of any policy of this kind. It is for this reason that I have suggested that hostels as a training ground—and I repeat, "as a training, ground"—for those who could be considered unable to live in the community, should be built in the grounds of those psychiatric hospitals which have ample space. I feel sure that such hostels would be invaluable in trying out borderline cases. I am also convinced that hostels should be incorporated in any plans for new towns or conurbations, which would overcome the problems of objectors. But here again I reiterate that employment and recreation are of paramount importance. I shall be interested to know whether the Government have given any further consideration to these suggestions. which I made some time ago.

Owing to the wonders of modern medicine, many of our mentally handicapped are living a great deal longer than in years gone by. But as they still need supervision many are taking up places in hospitals and institutions which are urgently needed for those who require nursing care. We cannot continue to delude ourselves that this problem does not exist. It is clear before us in all its stark reality and must be faced up to now. In view of the reorganisation of local authority boundaries and the White Paper on National Health, there is a fear that we shall be told that nothing can be done in the immediate future because of early legislation. It has also been said that there will be great difficulty in staffing hostels. My Lords, of course there will be difficulties, but I am certain that if real progress is made in planning there will be many people of good will who will come forward and be prepared to take over the management of hostels and to look after their occupants. While I fully understand the land and housing situation in our country, there can be no doubt that the need for accommodation outside hospital for handicapped people is urgent and we must not ignore it.

During the years in which I have been closely connected with hospitals for the mentally handicapped I have been deeply disturbed by the number of children and adults who are going into mental hospitals because they have nowhere else to go, either because their families simply cannot cope or, in some sad cases, because they have been abandoned. We must not be hard on these families. Their task is very difficult, as the children can never be left on their own and the freedom of action of the family is very restricted. Apart from this, there are great problems with other members of the family as they grow up, in the fact that they tend not to bring boy-friends or girl-friends to visit in case they should believe that there is an hereditary strain of mental handicap in the family.

My Lords, many words have been written suggesting that the right place for the mentally handicapped is in the home. Those who advocate this policy completely fail to appreciate the fundamental fear of all parents who have mentally handicapped children as to their future after either their sudden or their natural death—and, God knows! we live in an age when death may at any time come to us on the roads or in the air. The fact is that it is not fair to leave the mentally handicapped in the care of other members of the family. They have, or will have, children of their own, and they cannot deal with a mentally handicapped child or adult as well. Is this not a strong case for freeing hospital beds by building hostels, so that all families can be assured that, if they wish to keep their child at home and should any tragedy occur, there will be a place guaranteed for their child where it will be loved and cared for—and, if possible, in a place known to the family?

My Lords, we have all been deeply disturbed by reports of alleged cruelty of nurses to patients in hospital. These are highlighted in the Press, and we who are closely connected with hospitals, although in no way condoning these offences, wonder whether those who are so ready to criticise have ever closely studied the conditions under which so many of these nurses of the mentally handicapped work. They are the salt of the earth, my Lords, and if, very occasionally, the salt loses its savour, who is to be blamed? The blame lies firmly and squarely on all of us—successive Governments, local authorities and the citizens of our countries, who for generations have tolerated a situation in which these devoted people have worked in Victorian buildings, bursting at the seams with patients who in many cases should not be there intermixed with those who at times can be violent and need their constant care and love, and many of whom hardly know the light of day. Surely this alone cries out for some outlet, rather than death, to be provided for our fellow citizens in mental hospitals. I commend to all your Lordships that you should spend one day visiting a hospital for the severely subnormal; and I have no doubt that if you do you will feel, with me, great admiration for the love which nurses give to those under their care, in many cases under nearly impossible conditions. I would urge you, too, on your visit, to ask how many of those patients do not in fact need nursing care and could be accommodated in hostels.

I hope that I have said enough to convince the House that hostels are urgently needed where the mentally handicapped, both old and young, can be helped to live a life of dignity and happiness within the community. Before I close, however, may I say a few words on how I believe the hostels should be constructed? In my close association with the mentally handicapped I have come to the firm conclusion—and I am not alone in this—that, whatever their age, they are more at home with those in the same category of understanding as themselves, rather than being permanently isolated with those of normal intelligence. Of course they like social contact with all manner of people; but they like to live and work with their own kind so that they do not feel in any way inferior. In rural areas, and indeed on the outskirts of towns and cities, I believe that some form of village community should be considered, with ready access to the towns or cities but with its own industrial unit and its own agricultural unit, and with recreational facilities shared by both male and female members. Just as we all do, they enjoy the companionship of the opposite sex, and it would not be difficult to arrange for dining and recreational facilities to be shared.

My Lords, the mentally handicapped can, under supervision, turn out really first-class work, and in agriculture, horticulture, dairy farming and industrial workshops can be of infinite value to themselves and to the community as a whole. They love achievement and are tremendously happy in their work. It is of vital importance that their abilities should be recognised and fully used. Of course there will be some who will be able to work in industry, but in this age of automation I am sure that we should not rely on this in planning their future. We must give these people the privacy and dignity which we enjoy ourselves. We must ensure that they work within their capacity and receive a fair return for their labour. Try as we all do in the hospital world, it is not possible to employ fully the time of our patients owing to the great numbers congregated together in one place.

Some may criticise this scheme of mine and say that I am tending to isolate the mentally handicapped from the community; but if hostels are carefully placed within easy access to town or city, this should not be so. I do not believe that dwellers in villages feel isolated; in fact, many prefer it. Naturally, there will be many occasions when a hostel in a town or city will be the obvious solution; but my point, as I have stated before, is that there must be proper facilities, and we must not plan in the hope that industry will find work for them, because I do not believe that this will be so except on rare occasions.

My Lords, in the context of happiness and dignity, may I make a special plea for the old people of our land, many of whom are in mental wards because they have nowhere to go and are suffering from the normal process of old age and have no one to look after them? In many countries they are graciously looked after in the family; but, sadly, in this country, in many cases, they are not so welcome, and in fact do not wish to become a burden on their families. Surely we, as a nation, should assure them the happiness and dignity of old age, by accommodating them in hostels which will give them a feeling of home, with, as far as possible, some of their own belongings. Anyone who has visited a geriatric ward in a mental hospital must feel a sense of shame that this is all that we can offer to people who have given so much to so many in the past.

Finally, my Lords, may I say a few words on behalf of the autistic and psychotic children who, in many cases, are not catered for after school-leaving age, either residentially or educationally. The early education of the autistic child requires a ratio of one teacher to, at the most, three children. In most cases, if real progress is to be made a ratio of one to one is essential. If, after the age of 12 or 13, it is found that they cannot be retained in their schools they will be returned to their families and at the very best, go to an E.S.N. school; but it is more likely that they will drift into a subnormal hospital where they do not belong. In many cases these children are not in any way subnormal but are either highly disturbed or completely withdrawn.

To illustrate my point, may I tell your Lordships just one story of one boy whom we shall call Nigel? Nigel has been in care since he was about one year old. Sadly, his parents do not keep in touch. He is an intelligent boy but highly disturbed—not unnaturally in view of his family background. He was accommodated in a ward at a hospital in my group at Epsom which is rented to the county council as a psychotic and autistic day school. There were a few residential patients there who in the course of time left for different reasons. This left Nigel on his own. We had to find nursing staff day and night to look after him outside school hours. This became impossible; hence we had to ask the council to find suitable alternative accommodation for this boy. Some time after this Nigel left us. In telling you this, I am not in any way blaming the county council concerned, who are most progressive in the care of the handicapped and who, I understand, tried hard to find suitable accommodation. But in the end, Nigel was placed in Hay's Bridge Community Centre, which was formerly Court Lees approved school.

The headmaster and the staff did all that they could to help him; but, sadly, the boys were not so kind, with disastrous results for Nigel. We have now got him in a special ward for disturbed children in Queen Mary's Hospital for Children, Richmond, and he goers to school at Epsom every day. This is a temporary measure and we shall do all we can. But what of his future? Nigel now needs shelter accommodation where he can learn a trade such as agriculture or woodworking, but I have grave fears that he will end up in a subnormal hospital and lead a wasted and frustrated life. It is really not known how many there are of these children. However, it is thought that there are not a great number; and many can be saved to lead useful lives. But there must be accommodation and training for them outside the mental hospitals. It is hoped that with further training some will be able to return to their families; but there will always be the Nigels of this world and they must be our special care.

Here again the answer is the hostel; and the answer must be found. Hostel accommodation is in the hands of the local authorities, and if they do not produce the results which are so urgently needed some pressure must be brought to bear upon them. I now ask Her Majestys Government to set up a Working Party to consider urgently the whole aspect of this case of the mentally handicapped people in the community, and, above all, to set up a pilot scheme for the sort of community village for the mentally handicapped about which I have spoken. We must give these people a real chance in life. This experiment should be fully evaluated so that we can consider the results. I know that what I am asking will be daunting in a monetary sense, but the requirement is urgent; otherwise we shall have to build more and more hospitals at a far greater cost. I appeal to all our citizens to consider carefully this question; not to frustrate our efforts but to forward the cause of community care for all handicapped people in every way they can. It is a worthy cause and an urgent cause and I hope that this debate will do something to bring it to fruition. I beg to move for Papers.

3.26 p.m.

LORD GREENWOOD OF ROSSENDALE

My Lords, the noble Lord, Lord Grenfell, has chosen a subject which is very close to the hearts of all of us, but it is a problem on which I personally am even more than usually doubtful as to whether I know all the answers. The noble Lord speaks with such great authority and commands such widespread respect that I am glad that it is for the noble Baroness to reply to the points he made rather than for me to do so. I thank the noble Lord for the speech he made. I wish the noble Baroness well on what I think is her first speech at the Dispatch Box, and I regret the absence through indisposition of my noble friends Lady Serota and Lady Llewelyn-Davies of Hastoe. If they had been here it would have been not so much a debate, more a judgment of Paris.

I have listened with the greatest attention to the very moving speech of the noble Lord and I am in general agreement, if I may say so with all modesty, with the points he made but on some points I think that I would put a rather different emphasis. Perhaps I may widen the debate rather more. My own view is that in the case of the disabled or handicapped the hostel is often only a second best and the hospital the third best. The best, if it is feasible, is the disabled person's own home. But I accept what the noble Lord has said about the difficulty which exists in the case of the mentally handicapped. I agree that they may be in a rather different category from the other classes of disabled people.

The hostel has been described as the modern replacement of institutional care. I think that is certainly true of compensatory hostels which provide a permanent home for those who can never be rehabilitated because of the nature of their disability. I agree with the noble Lord that thousands of mentally subnormal people who should really be in hostels are in hospitals. I am told that anything from two-fifths to two-thirds of the patients in mental hospitals need no real nursing at all and could well be in hostels. The Government programme, as I understand it, is to increase the number of hostels for the mentally subnormal from 122 in 1965 to 545 in 1976. The number of patients will go up from 2,350 to about 11,600 over the same period. I wonder whether the Government will achieve that target? It is a modest enough one in all conscience, but I doubt whether the Government will succeed unless they themselves take a firm line and set a good example to the other people working in this field. In the long run, it should be a good financial proposition, as well as being in the interests of the disabled and handicapped themselves—which after all is the primary consideration.

There is scope, too, for rehabilitative hostels very much of the kind provided by the Richmond Fellowship which enjoys such great regard among your Lordships. I am sure that these rehabilitative hostels are especially valuable if there is a training centre near by. There is a need, too, for hostels for special classes of people who cannot really be trusted to withstand the roughness and the rigours of a competitive life—the psycho-geriatrics; the drug addicts; the alcoholics; the inadequate homeless families, often homeless simply because they are inadequate and unlikely ever to be fully capable of sustaining life in the outside world. So I agree wholeheartedly with the noble Lord that there is a great need for hostels, and a great need for extreme care in planning their provision. We do not want once again to have the largely fortuitous pepper-pot provision of hostels that we have seen in the past. Apart from that one proviso I do not want to discuss the administration of the system or the division of responsibilities within it.

I do, however, as I am sure will many of your Lordships, want to probe a little into the extent to which we can prevent the harsh outside world defeating the chronically sick and disabled and driving them out of their own homes into hospitals or hostels, often miles away from their homes, so that they are cut off from their families and friends. As I said a moment or two ago, to me in general the hostel and the hospital are respectively only second best and third best. We must use more vigour and imagination in enabling the disabled and handicapped to stay put in their own homes.

At the moment my wife, who herself teaches disabled people and is therefore very sensitive to their needs, is recovering from an eye operation and cannot bend down or lift anything heavy. This has brought home vividly to me how inadequate the average private house really is, and I am delighted that so many noble housewives are taking part in this debate to-day. The electric sockets are almost all at ground level. The oven is low down near the floor instead of being at eye level. Dust pans of the kind that are generally available tend only to have short handles. For the fairly typical old person the average house must be almost like purgatory; it is certainly far less convenient than it should be and could be. It is exceptional to find rails on the walls. Kettles are dangerous and easily spilled, often with dire consequences. Many baths have no hand-grips and the slippery bottom of the bath is dangerous. There is no real provision for refuse disposal of a type which avoids the need to carry what are, for the old and sick, heavy loads. The handle of a milk bottle holder is close to the ground. The taps have to be turned, although a lever would be much easier—even for normal healthy people. Indeed, all the things I have mentioned would be sensible and helpful for everybody, not just the sick and the old. And I agree so much with the noble Lord, Lord Grenfell, that all new buildings should be planned and constructed with the needs of the disabled in mind.

I know that the hardware industry and the electricity industry, and bodies like the British Council for Rehabilitation, the Central Council for Rehabilitation, the British Rheumatic Association, and other bodies, have all been working on these problems; but progress is painfully slow and I believe that official apathy at central and local level, and lack of encouragement, could perhaps be the cause. If we needed these things to win a war they would be provided within six months. But the old, and the sick, the mentally subnormal, and the spastic children have to wait.

I worry, too, just as the noble Lord, Lord Grenfell, worries, about the staffing situation in so many establishments. First, let me cite St. Lawrence's Hospital at Caterham. In the British Hospital Journal and Social Service Review of October 2, 1971, Dr. John Gibson described what he is trying to do there. He has adapted a house, "Greenacres", in the grounds of the hospital to provide for a family unit of mentally handicapped patients—twelve men, twelve women and twelve children. The need for such a unit is graphically illustrated by Dr. Gibson's evidence that in one children's ward there were 34 and in another 46 different people on duty in a single month—many with an imperfect knowledge of the English language. Incidentally, how very much we owe to those Commonwealth immigrants who minister to the needy in our hospital and our hostels! Dr. Gibson, my Lords, sums up the consequences as follows. He says: …each child is … being bombarded day after day by a succession of new faces, new methods, new languages. How would a normal child behave if he was got up the morning by a woman he had never seen before, put to bed by a second woman he had never seen before, and if he woke up in the night and cried was attended by a third woman, with a fair guarantee that at least two of these nurses could not understand what he was trying to say? The staffing problem in many old people's hostels is little, if any, better than that which Dr. Gibson describes so fittingly. I should like to remind your Lordships of Mr. Alfred Morris's noble words—I do not think there is any other adjective that can describe them—about his own Chronically Sick and Disabled Persons Act. He said that he wanted a society—and I quote: … in which there is genuine compassion for the very sick and the disabled, where understanding is unostentatious and sincere; where needs come before means; where if years cannot be added to the lives of the chronically sick, at least life can be added to their years; where the mobility of disabled people is restricted only by the bounds of technical progress and discovery; where the handicapped have the fundamental right to participate in industry and society according to ability; where sociably preventable distress is unknown; and where no man has cause to he ill at ease because of disability. Mr. Morris's Act is a magnificent Act, hut are we making satisfactory, acceptable progress in implementing it? Progress depends in large measure on the policy of individual local authorities—mainly the counties, the county boroughs and the London boroughs. Section 1 of the Act came into force in October. That means that health and welfare authorities now have a duty to keep themselves adequately informed of the numbers and needs of substantially and permanently handicapped people and to publicise the services that they can make available. I think that your Lordships will agree that in the past many local authorities failed to use their powers under Section 29 of the National Assistance Act 1948 to promote the welfare of the physically and mentally handicapped. It will be interesting to see what use they make of their powers under the new Act—for on the vigour they show will largely determine how many people can be kept in their own homes, and how many people in hospitals can move on into hostels.

My Lords, I believe that registration is absolutely essential. So long as there is no proper register in an area the needs of that area cannot be effectively assessed. If the registers are not compiled swiftly and comprehensively many disabled people will be denied the benefits for which Mr. Morris's Act provides, and those benefits are both great and many. Councils can, for example, help with the provision of television or a telephone in a person's home. The Post Office's new prohibitive charges have put telephones well outside the reach of most old or disabled people unless substantial financial help is forthcoming from one quarter or another. Councils can also help with providing facilities for travel to work; with equipping a house with the kind of apparatus which can make all the difference to a handicapped person's life; with the provision of facilities for holidays.

I was disturbed, my Lords, to read in the Sunday Observer last week-end of the extent to which old people do not claim their full rights. Mr. Andrew Leigh described the results of a review made by the organisation, Age Concern. He wrote: Most people over 65 years of age do not know that they can obtain heating allowances from the Government or that they can ask for home visits from an optician. One in three of the elderly doesn't know that a National Health hearing aid service exists, or that help can be obtained with dental charges. Later on he wrote: About half those interviewed had difficulty with prescriptions because they could not get to the chemist at all or had travelling problems. Half of them said they had difficulties in bathing, yet had no one to help them. My Lords, if those old people were helped in the respects of which I have spoken, many more of them would be able to end their lives in the secure, familiar surroundings which they know so well.

There is the same sort of pattern in the case of the handicapped. From two books published by the Stationery Office, Handicapped and Impaired in Great Britain, by Amelia Harriss and others, and Work and Housing of Impaired Persons in Great Britain, by Judith Buckle, it appears that one in every five handicapped persons is living alone. In private households there are 25,000 badly handicapped people who need constant care during the day and usually at night as well. Only 18 per cent. of the severely disabled have registered with their local authority. The comparable figures for the severely handicapped and appreciably handicapped are 11 per cent. and 7 per cent. respectively. In a way, I think that saddest of all is the fact that less than a quarter seem to have had any changes made to their homes to make life easier.

My Lords, I have spoken longer than I intended, but this is a subject on which we all feel deeply. I had intended to curtail my remarks in view of the long list of speakers that lies ahead, but, as I say, this is something about which all of us feel deeply. It is a subject on which I do not pretend to be an expert, but it may well be the sort of subject on which the amateur can help the expert to make up his mind. I hope that the debate which we are having today in your Lordships' House will help the Government in finding solutions for some of the real problems and real tragedies to which the noble Lord has referred.

3.44 p.m.

LORD AMULREE

My Lords, the noble Lord, Lord Grenfell, has given such a full and admirable account of the problems that come before us in dealing with disabled people of all sorts that there is really nothing left for me to do except to cross the t's and dot the i's of one or two things which he said. But before I do that I should like to say how pleased I am that the noble Baroness, Lady Young, will be speaking on behalf of the Government, and I am sure that she will do it extremely well. I trust nothing that I am going to say will cause her any difficulty.

It has long been realised that there were a large number of people living or being maintained in hospitals who did not need to be there; and there has been a great deal of talk over the last 20, 30 or 40 years—long before the National Health Service came into being—about the possibility for some of those people to be taken care of in hostels. I remember particularly that at Bristol, in about 1937 I think, a plan was carried out whereby patients of the Bristol Royal Infirmary requiring radio-therapy did not need to be brought into the hospital. They were kept in hostels. That meant that no hospital bed was occupied and the patient could lead a much more free and normal life during the short time that he needed to be in the hostel. There has not been much spread of that practice. I suppose it was really put off by Part III accommodation under the National Assistance Act 1948, when the duty was laid on the local authorities to provide accommodation required for people in need of any sort, kind or description.

That is where I think that matters have not gone too well. A large number of local authorities have not discharged the obligations laid on them. There are various reasons for that; I am not saying this with any desire to attribute blame; I am merely stating a fact. Some hostels exist and do very well. I believe that there is one attached to the paraplegic department at Stoke Mandeville, where paraplegics may go; but that is not very big and I know that the authorities there would like more accommodation. We have heard about the autistic children who do much better in hostels than in hospital, but one wonders what becomes of them when they grow up and their parents have died. There is nowhere very much for them except, as the noble Lord said, a hostel for the subnormal, possibly the last kind of place in which they should be.

My Lords, I should like for a short time to discuss the care of the elderly. I entirely agree with what has been said: that those who can should live at home; that they should be encouraged to do so by the provision of all the assistance possible, either from a local authority or from voluntary organisations. But one has to be a little intelligent about this. The other day the question was put to me: what kind of life would a lonely, housebound, elderly woman lead who had no particular friends or relatives near and whose sole contact with the world was the home help who came in for a visit for one hour on five days a week? Would she not be better off in some kind of sheltered accommodation, rather than being kept on in a home where life could not be very attractive for her?

There is another matter about which I have been very impressed in the work that I have been doing recently for the Attendance Allowance Board—if I may refer to that. We have been very greatly impressed by the number of families who take care of disabled children, middle-aged and old people under what must be conditions of unbelievable strain and difficulty. Frequently they say they do it because they do not want the old person, the child or the relative to be taken to hospital. Much has been said about the so-called Welfare State taking away a good deal of family responsibility. My impression, gained not only over the last few months but also during the time when I was working at a hospital, does not at all conform with that. I have always been surprised at the amount of willingness shown by people to take care of the elderly and their young relatives. On more than one occasion we have had to stop someone from taking care of an elderly relative because he or she was not in a fit condition to do so. Of course, one finds the occasional bad family who will not do anything, but such families arc extremely uncommon.

For those who cannot live at home there are two alternatives. There is the long-term hospital bed for the so-called long-term or chronic sick—I do not mind very much what you call them, but I do not like the term "chronic sick". They are people who need prolonged nursing attention, not necessarily medical attention. The same applies to people who are mentally decayed. They need careful nursing attention, but not necessarily medical attention. They are people for whom we have to provide accommodation. There will always be a need for a certain number of long-stay beds in mental hospitals for this type of person. The time may come of course when one can cure this form of mental deterioration of the elderly, and then we shall not need to make any provision. But that is a long way off, and people need to be taken care of. Therefore I think we have to make provision for people in some kind of—not hospital, and "hostel" is not quite the word, but a place where they can get proper nursing care.

Then there is the other type of person who is relatively well physically but not quite fit enough to live at home. These are the people who would go to hostels. This is now called "accommodation under Part C" of the National Assistance Act, but there is no reason why that phrase should not be modified into "hostel". I think very good work is being done for these people at these places at the present time. The bulk of them are provided by the local authorities, but the voluntary bodies provide about one-third, and about one-fifth are run by private people. They are open to inspection and so a certain standard is kept up. But what worries me is this. Supposing that at one place the standard is found to have fallen and the conditions are not very good. What is to be done with the people in that place if it is shut down? Somehow another home has to be found for them. This is the way in which one gets into great difficulties: one comes up against these dead ends all the time.

I think also of importance is what is called sheltered housing, where people live in groups of bungalows or flats by themselves with a warden in charge, rather on the principle of the old-fashioned alms-house, which I am pleased to see is coming back into popularity. There was a time when local authorities looked down on alms-houses and thought that they were not quite the proper thing; but now they are realising that it is an extremely good way for people to live, and where they have someone to care for them if they are taken ill.

One has to be careful in dealing with mental hospitals not to discharge people in large numbers too quickly because they are not really in need of mental care. I came across one example which occurred after the passing of the Mental Health Act. There was a big hospital in the country where there were a lot of elderly women who had gone in 20, 30 or 40 years before. They really had nothing much wrong with them at that time, but because they had been living a sheltered life all their lives they could not be discharged. The county council were compelled to take a place which had been a workhouse, built at the time of the Act of the Union of Parishes some time in the 1830s or 1840s. It was a rather attractive building, but it had been closed as being unfit for human habitation some time before the war and was used as a county council store. When this enormous flood of mental patients had to be accommodated they had to be housed in this building, which, as I say, had been declared unfit for human habitation. I remember going to see a patient there, and the council had done a very good job. But we do not want to see that sort of thing happening again. I do not say that it is a common occurrence, but one has to bear in mind things of this sort when dealing with these matters.

There is just one other thing that I should like to say. The other day I was reading a report about Denmark. The Danes are rather good with their care of the elderly. The Danish people said that they thought that the old people's homes and hostels had become superfluous and old-fashioned; that what was needed were places for those requiring nursing care, mental or physical, which they called nursing homes—a rather different phrase from the one we use—and that the rest could be accommodated for the most part in sheltered housing of one sort or another. They thought that the future of the old people's homes was not really very encouraging.

3.56 p.m.

BARONESS YOUNG

My Lords, I should like to begin by thanking the noble Lord, Lord Greenwood of Rossendale, and the noble Lord, Lord Amulree, for their kind and encouraging remarks, and to thank, too, the many other noble Lords who have sent their good wishes to me. I am indeed most grateful. We are all indebted to the noble Lord, Lord Grenfell, for introducing this debate to-day. So many noble Lords have expressed an intention to speak that I am sure we shall have a useful and well-informed debate. Much social legislation since the war has been based on the belief that it is not enough simply to provide the basic necessities of life, such as food and shelter for those who, for one reason or another, are handicapped and need help. Rather, society should first try to provide for those yin need the nearest equivalent to the help given by a truly caring family, and at the same time provide the circumstances in which they can live as normal a life as possible within the community.

The terms of the Motion are wide-ranging and cover many aspects of Government responsibility and interests. It is, howevere, mainly through the health and social services that care is provided and the initial steps taken towards rehabilitation. I shall therefore speak mainly of what is being done, and is planned to be done, in these services, and my noble friend Lord Aberdare will speak later and answer any questions which occur in the course of the debate. I want to acknowledge the long-standing interest and help given by the noble Lord, Lord Grenfell, to the improvement of the services for the mentally handicapped. The Department of Health and Social Security is indebted to him for his help as a member of the Training Council for the Teachers of the Mentally Handicapped, a body which in the past has supervised the training of teachers for what are now special schools for children and continues with its work in training teachers for mentally handicapped adults.

I turn, first, to the needs of the mentally handicapped. Last June, the Secretary of State for Social Services and the Secretary of State for Wales issued a Command Paper, Better Services for the Mentally Handicapped. It provides a complete survey of the services to-day. It sets out what is required to improve them and the action to be taken. The first of the main objects of the Paper was described as to explain why the present services need to be extended and improved and the shift in emphasis from care in hospital to care in the community accelerated. It is no new policy to want to see mentally handicapped people living, so far as possible, in the community and staying in hospital only when their need for medical or nursing care requires it. The way in which the Command Paper represents a landmark is that it sets out for the first time quantitative targets for the provision of residential accommodation and training centres by local authorities. The authorities now have figures based on population that they can use in planning their extended services.

This problem is a formidable one. It is esimated that local authorities in England and Wales will need to provide residential care for nearly 6,000 children up to the age of 15, and for nearly 37,000 adults. This compares with the present provision, including some placed in voluntary homes, for 2,200 children and for under 6,000 adults. Not all this accommodation will need to be in residential homes. Some mentally handicapped people may be able, with supervisory support from a social worker, to live in lodgings or group homes, or be boarded out in private households which can, when suitable, offer the nearest equivalent to a normal home. But for the most part homes will need to be provided. It envisages that such homes should be small: a maximum of 25 residents for adults and 20 for children. Many are, and will be, smaller than this, and the larger ones will often allow for a considerable degree of "family" size grouping. Fresh guidance on the planning of these homes is in preparation. Homes will be in residential areas, looking like other homes in the area rather than like institutions. Children in them will go out to school, like other children. Adults will attend training centres or go out to sheltered or ordinary employment. At this point I should like to say how valuable I consider this debate to-day for educating public opinion to understand the need for hostels or homes and to accept them in residential areas of towns.

To lay down targets for the provision of residential homes and to describe their nature and purpose is an important step. It is then necessary to translate this into action. The Command Paper has been sent to hospital and local authorities, asking them to review their plans and programmes in the light of the recommendations and in particular to arrange joint discussions to plan the future service on a co-ordinated basis. Progress reports show that in most areas there is a willingness to tackle this problem and that a good deal of the preliminary work has been done. More detailed reports will be drawn up during the year. But with these objectives the Government have greatly increased the resources available. Capital investment in local authority services for the mentally handicapped has increased from less than £1 million in 1959–60 to nearly £5.2 million in 1970–71 and is expected to reach over £7 million this year.

The local authorities' present plans in England and Wales provide for an increase of 6,250 places in adult homes, which is an increase of 150 per cent. over the present figure, and for over 1,400 places for children—almost double the present figure—by the end of 1976. Thereafter we expect investment to continue to increase at a reasonable rate so that many authorities should reach their target figure within 10 years. A period of this sort seems a long time to those of us who are aware of the need, but many of our social services are also in need of development. The Department of Health and Social Security will shortly be asking local authorities to prepare 10-year forward plans for the whole range of their social services, balancing the claims of different groups—the mentally handicapped, children, the elderly, the physically handicapped and others—and trying to secure the development that is needed for each group. What the Government have done and what they will, I am sure, find they must do, is to give the provision of accommodation for the mentally handicapped a higher priority in the next 10 years than they have done in the last decade.

My Lords, the need of residential care in the community applies particularly to the mentally ill. Work is well advanced on the guidelines for the scale of provision by local authorities for homes and other types of residential care for the mentally ill. The need for considerable expansion is accepted and progress is being made. The latest figure available of the number of places in local authority and voluntary homes in England and Wales is 2,840. Local authorities plan to increase their own provision by over 65 per cent. by 1976. This indicates clearly the importance they attach to this part of their services.

Last December the Department issued to hospital and local authorities a memorandum on hospital services for the mentally ill. Its main purpose was to outline the essential elements of a comprehensive integrated hospital and community service based on a department in a district general hospital. The provision of adequate community services by local authorities includes hostels, group homes, sheltered housing and supervised lodging schemes. Without this an effective comprehensive scheme cannot be provided. It puts on the local authority social services department responsibility for finding suitable residential accommodation for patients discharged from hospital. Local authorities have been asked to co-operate with hospital authorities in implementing the advice and in promoting parallel development of community and hospital services.

I now turn, my Lords, to the provision of residential accommodation for the elderly. Some people consider that the number of homes for the elderly should be reduced and that this kind of provision should be largely replaced by warden-assisted housing. The Government do not share this view. We recognise the need for the provision of more purpose-built housing for the elderly, but we also see a continuing need for modem old people's homes for those frail elderly people who are no longer able to look after themselves and who need the care and attention which cannot be provided within their own homes, even with the help of the local domiciliary services. The Government have no reason to be ashamed of what they have done so far to encourage the provision of more new homes. On the contrary, in the three-year period 1967–68 to 1969–70—the last full year of office of the previous Administration—the capital expenditure approved for loans for homes for the elderly in England was £13 million, £13.2 million and £12.2 million respectively. In the financial year 1971–72—the first full year in office of this Government—we gave loan approval for over £18 million capital expenditure. This is a substantial increase, even allowing for the increases in prices which have occurred over the period.

Many of these new homes will replace former public assistance institutions. Most of these are quite unsuitable by present-day standards and their replacement is long overdue. A great many have already been replaced but there still remain about 120 in which there are some 13,000 residents. As noble Lords will know, the Secretary of State announced last November that he was making substantial additional loan authorisations available to local authorities to replace these former institutions and other unsatisfactory buildings, and to increase their overall provision for homes for the elderly. We shall shortly be publishing revised design guidance in graphic form to assist authorities in the planning of their new homes.

There is of course a considerable overlapping between groups needing accommodation, and it is often difficult to make a clear distinction between people who need accommodation because they are elderly and people who need it because they are handicapped. The national survey of the physically handicapped carried out in 1968–69 by the Office of Population Censuses and Surveys, and published last year, indicated that there are over a million handicapped adults in Great Britain who are living in their own hones. The million includes a majority who at that point in time did not need residential care but, for obvious reasons, the problems of the physically handicapped occur among the elderly. Residential provision for them must take account of the problem of mobility. Mental infirmity in the elderly is an increasing problem which must also be taken into account in future building programmes.

The number of younger handicapped people is substantially smaller than the number of elderly handicapped people, and although many of them continue to be able to live in their own homes, with the help of their families and the support of the health and personal social services, there is a percentage who are in need of residential care. It is increasingly being recognised that in some respects they need accommodation with special provisions to meet the needs of their age group, and the plans of local authorities reflect this.

The majority of homes specially for the physically handicapped are provided by voluntary bodies, but local authorities are developing plans for providing their own purpose-built homes. Although there are at the present time only 18 local authority homes specially provided for the physically handicapped, a further 13 are under construction or about to be started, and a further 50 have been accepted for loan in the current three-year period. I may say that all the homes included by local authorities in their current capital building programme have been accepted for loan approval by the Department of Health and Social Security. The national survey of the handicapped to which I referred earlier could not inquire in detail of many of the needs of handicapped people. The position varies from one local authority to another and it is necessary for each authority to inform themselves of the numbers and needs of handicapped people living in their areas. This duty is laid on them by Section 1 of the Chronically Sick and Disabled Persons Act which came into force last October. The duty extends to handicapped persons of all ages, including children, whatever their handicap. I was glad that the noble Lord. Lord Greenwood of Rossendale, referred to this Act.

My right honourable friend the Secretary of State for Social Services issued Circular 45/71 on September 16, giving advice to local authorities on the discharge of their duty under Section 1 of the Act. He has suggested that one way of obtaining information about the numbers and needs of handicapped people would be to carry out local sample surveys, and to help them in doing so he has sent them a booklet prepared by the Office of Population Censuses and Surveys and containing detailed guidance on how such surveys may be successfully conducted. The carrying out of surveys using sampling techniques will still leave authorities with the task of identifying all handicapped people who both need and want a service, and some authorities may feel able to embark upon this at an early date. But even the more limited method should add enormously to the information local authorities possess about the needs handicapped people have or are likely to have, including the need for residential accommodation. This will help them to plan more effectively to meet this need it will also help them to plan more effectively the provision of services designed to help people remain independent and in their own homes.

My right honourable friend has asked local authorities to report to him on progress made up to April 1 in implementing Section 1 of the Act and on any problems which they have encountered. Reports are now being received but it is still too soon to form a complete picture of the position throughout the country. It is, however, already clear that authorities have, in general, been putting a lot of effort into implementing the section.

One important need for hostels and homes is in the provision for short-term care. Hostels and homes are needed for people who live at home for most of the year, but who for a few weeks would benefit from a short change of surroundings. Such provision would also for a short period relieve families from the daily responsibility of caring for children and elderly or handicapped relatives. At present about 40 per cent. of all admissions to old people's homes are short-stay admissions. As noble Lords have said, we are all impressed by the devotion shown by some husbands, wives, parents and children who gladly and lovingly care for their relatives at home throughout most of the year. In the standards we are setting for all types of hostels, provision is being made to allow a proportion of the places to be set aside for this short-term care. It is already a well developed practice in the field of child-care is growing rapidly for the mentally handicapped, and a start is being made for the elderly and the physically handicapped. Many of the special holiday homes already in existence ale run by voluntary organisations. I look forward to the time when by a combination of statutory and voluntary provision, short-term care or holidays will be available for all handicapped people.

Finally, I want to say a word about voluntary bodies. In all the services to which I have referred voluntary bodies play an important and essential part. Not only do they provide a wide range of accommodation but they have a vital role in enlisting the support, sympathy and help of the public. Many noble Lords give their support to a great variety of voluntary bodies and I know from experience how much this help is appreciated. Voluntary bodies are often forerunners in problem fields of residential care—for example, they have been first in the field in the care of drug addicts and alcoholics, dominate the field of prison after-care, and are beginning to work with such difficult groups as the homeless, rootless "inadequates". Many of these people often need tolerance and understanding from the public. It is the voluntary bodies and their supporters who are most prominent in achieving this by their own good work and by their example to others.

My Lords, this is necessarily a very wide-ranging debate on a subject about which many noble Lords have personal experience and care deeply. I hope that in this survey of residential provision for those in need of care or rehabilitation I have said enough to indicate the Government's concern to demonstrate their determination to see improvements made by making additional resources available and by fostering research and inquiries to guide the way for further progress on sound lines.

4.16 p.m.

THE LORD BISHOP OF COVENTRY

My Lords, as the first speaker to follow those who have spoken from the Front Benches I should like on behalf of all noble Lords to express our deep gratitude and appreciation to the noble Baroness, Lady Young, who has spoken for the first time from the Front Bench. As we listened to her clear and lucid exposition I am sure we all hoped that she would make frequent valuable contributions to debates in this House. We hope that she will be with us for many years on one side or other of the House. We are most grateful for what she has had to say. I was much encouraged by all that the noble Baroness said with regard to the Government's concern about this problem. I came here somewhat depressed by the apparently slow progress being made in this important field. I hope that noble Lords will forgive me if in this wide-ranging debate I concentrate once again on the somewhat narrow field of care for the mentally afflicted who are at the moment occupying beds in hospitals but for whom hostel treatment may be a very necessary next step.

This is not a new problem. As far back as the coming into force in 1959 of the Mental Health Act, wider powers were given to local health authorities to provide care in the community for the mentally sick. At that time there was a wide expectation that there would be a big swing from care in hospital to care in the community. Unfortunately—at east until recently—that swing has not taken place. I suppose people, perhaps too naïvely, expected hostels to pop up like mushrooms almost overnight and were somewhat disillusioned when this did not take place. In June, 1971, eleven years later, the White Paper, Better Services for the Mentally Handicapped made it clear that the problems were still acute; there was a shortage of beds; there had been years of starvation of funds and inadequate and outdated buildings. It has been estimated that some 60,000 patients live in hospitals for the mentally handicapped, while 6,000 others await admission into residential care. Of this total figure a high proportion do not require intensive nursing in a hospital setting but could be cared for in the community if a realistic attempt were made to provide hostels and group homes. I was much encouraged on hearing the noble Baroness describe the Government's intentions in these coming years.

The noble Lord who initiated this most valuable debate said that the attention of the nation had been drawn to unhappy events in some of the older hospitals. He and other speakers, quite rightly, have shown that the real blame was not to be attached to the doctors and the nurses but to the great populace of this country who have not demanded sufficiently strongly that the hospitals should be improved and the conditions under which doctors and nurses work made easier. Nevertheless, those "scandals"—as they have been called—have at least drawn the attention of the community to the urgent need for small hostels which can be integrated more easily into the local community than the big institutions. There is a great opportunity to-day to establish smaller community-based homes, as opposed to the larger, monolithic, isolated and often out-moded institutions where so many mentally handicapped patients are at present cared for.

The Secretary of State for Social Services, Sir Keith Joseph, in the same year, 1971, spoke of the need for, "homely homes—not called hostels—of a homely size". But in December of that same year, 1971, a memorandum by the Department of Health which attempted to plan a timetable for the Minister's hopeful forecast at that time was criticised by the National Association of Mental Health as being, "vague and dangerously superficial". So much, then, for the facts as I saw them before coming into your Lordships' House this afternoon—overcrowded mental hospitals; tragically inadequate provision of smaller, community-based homes.

This leads me to the second point that I would make in the form of a question. Why are smaller, community-based homes so urgently needed? My answer is that mental subnormality is not primarily an illness. The aim therefore should be what one might call normalisation, to use a somewhat ugly word; in other words, allowing the various grades of the subnormals as much freedom and opportunity to develop to the very best of their potential. To this end residential care must be flexible enough to provide maximum or minimum supervision as required by individual mentally handicapped persons. Some people, for instance, as we have heard, will require sophisticated care and the constant attention of dedicated and trained personnel to look after them almost all the time. Others, however, could have, so far as is possible within the limits of their disability, an opportunity to enjoy the freedom and the services available to ordinary people. And with this in mind, a group home or hostel, near to a training centre or sheltered workshop within a local community, would provide for far more normal social contacts, to the great benefit of the subnormals concerned. It is surely wrong and wasteful to detain able-bodied mentally handicapped persons in a hospital setting if they do not need this type of intensive care. A high proportion of hospital inmates have no business to be there, and would not be there if a sufficient number of homes and hostels were set up. Could it be, I ask, that the subnormal person is yet another victim to the bifurcation of responsibility between hospital and local authority?

In a community-based home the subnormal can, as I said, more easily relate to normal society than is possible when he is put away in a large mental hospital. Furthermore—and this is an important point—in these community-based homes volunteers can play a very important part in training the mentally subnormal to play their full part in society. May I give your Lordships an illustration from my own diocese? A day centre for the mentally sick has been set up in a Baptist church with no fewer than 50 volunteers giving sterling service in many different ways to the mentally ill, most of whom have been for varying lengths of time in a mental hospital. This type of concern could be mobilised equally well elsewhere within the community to help the subnormal. One Anglican church in my diocese, and a Congregational church, are involved in an integrated youth club attended by subnormals from the local hostel and training centre. Furthermore, when and where the subnormal people are living in a community-based home they are more easily able to reach local churches, places of entertainment, parks and sports grounds than would be possible if they were occupying beds in a large mental hospital.

Next, when we turn from what has been called the subnormal to the mentally ill, here, too, there is the beginning of a change, as has already been indicated, from long-term in-patient care to shorter but more frequent spells in hospital. That has already been indicated in this debate. But this new kind of treatment brings with it a most important question; namely, where do these people live during their periods out of hospital? It is clear that many families just cannot cope with the strain. There is an acute need for the provision of various kinds of sheltered housing for these people in between their spells in a mental hospital. Again, if I may illustrate from my own diocese, in recent months in the central part of my diocese, following steps taken, I am glad to say, by a clergyman to reduce the number of patients unnecessarily remaining in the local psychiatric hospital, a committee embracing hospital, social services department and the Churches is at this very moment establishing five group homes which will accommodate about 25 former mentally sick patients to enable them to live there during the periods between, if you like, visits to the mental hospital. No capital is involved, in that the houses will be rented from the local authority. Volunteers and social work support are being made available and carefully selected patients will be discharged from the hospital to the community. Such group homes can be speedily, cheaply and efficiently established for the mentally sick and can be equally valuable for certain grades of mentally handicapped persons. Voluntary organisations such as the Church Army, the Salvation Army and many more informal bodies are tackling this problem on a fairly wide scale.

Before closing I should like, as other noble Lords have done, to touch on one more aspect of this very sad problem; namely the aged mentally confused—not just the aged, but the aged mentally confused. There is no need, my Lords, to emphasise the well-known fact that many long-term mental hospital beds are taken up by old people who have nowhere else to live. In other words, there is no provision for them in the community. The mental confusion of many of these old people is not an illness. It frequently varies from moment to moment and has been found to improve, or even to disappear, quite often when the person concerned finds himself or herself in secure surroundings in which he or she encounters love and respect. I read only two days ago of an interesting experiment in Devonshire in the care of the elderly and mentally frail. In a psychiatric hospital a survey made in 1962 of 1,600 patients showed that about half of them no longer needed hospital care.

As a result, the experiment which has come into being and which has been built up into an established piece of community care, has consisted of finding small, residential private homes to accomdate these elderly ex-patients permanently. The first principle was to find a home—not a substitute hospital or even a hostel. The second principle was that the residential homes must be well integrated into the local community; and here, again, there is a place for Church groups and volunteers to play their part. The third principle is that each place is chosen to match the individual's needs. I am not going to touch on that problem which I was most grateful was raised; namely, the care of autistic children when they grow beyond a certain age, and I hope very much that it will be looked into very carefully. It seems to me that that is quite an acute problem.

To sum up all that I have tried to say, my Lords, it seems to me that the main purpose of community care is that the individual or family in need should not be isolated, labelled, put in a kind of ghetto, rejected as different, but rather loved in the true Christian sense. In recent years society has been slowly feeling after this rather new concept, and I believe that it is in small community hostels and homes that this community care is best expressed. To conclude, whether one is thinking of the mentally subnormal, whether one is thinking of the mentally confused elderly, whether one is thinking of mentally handicapped children, or whether one is thinking of the mentally ill who have been in a mental hospital, I plead that the Government do their utmost, as I feel the noble Baroness has indicated they are beginning to do, to develop the whole concept of smaller hostels and homes for the care of these mentally sick and mentally subnormal.

4.30 p.m.

LORD GARDINER

My Lords, the length of the list of speakers shows the gratitude which the House feels to the noble Lord, Lord Grenfell, for raising this subject for discussion this afternoon. I want in a very few moments to invite your Lordships' attention to a small but special group of the mentally handicapped—those who are released from Broadmoor or one of the other special hospitals. Some of your Lordships may have seen a recently published book. Bound for Broadmoor, written by Mr. Peter Thompson. His case was perhaps an unusual one. He had his briefcase stolen with some money in it. He got to know the man who had stolen it, and refused to prosecute. But the police prosecuted. Mr. Thompson paid for the man's defence, visited him in prison and became interested in those discharged from prison. As a result, he and my noble friend Lord Longford together formed what was called the Pakenham-Thompson Committee on those problems.

Years later, Mr. Thompson himself became mentally ill and was under treatment by a psychiatrist. There came a day in 1965 when he both lost his job and, on the same day, his wife said that she was going off with somebody else. In the evening he attempted to commit suicide and was taken to St. Bartholomew's Hospital, and although there, as he explained, he felt the urge to commit assaults on people, he was put out from the hospital the next morning. Within 24 hours he had stabbed two girls whom he had never seen before. While on remand, he again attempted suicide, and at his trial the judge said, "There are other people who should bear responsibility for what has happened." I suppose that was a reference to the unfortunate way in which Mr. Thompson had been turned out from St. Bartholomew's Hospital.

In 1966 he applied to a mental health review tribunal for his release, which was refused—as he recognises, quite rightly. In 1969 he applied again and, rather to his surprise, I think, his release was ordered. He was told to go in an hour, and he and his effects were put outside the gate. It did not in fact matter to him because he had friends and somebody met him with a car; but many who are released from those special hospitals have nowhere to go at all. They have been in one of these hospitals for years. They are, I think, something of a special case, partly because (although this is one of the reforms suggested by Mr. Thompson) the name "Broadmoor" remains and because of the position of a man who is asked by a prospective employer who is thinking of giving him a job, "What have you been doing lately?" When the man replies, "I have just come out of Broadmoor", that is the end of his prospects. Although Broadmoor used to be a criminal asylum it is not now; there are many in Broadmoor to-day who have never committed any criminal offence at all, and why in those circumstances the name should remain, with all the difficulties that it entails, I do not know. There is a special need for those who are released from the special hospitals, maybe after many years, to have a special halfway home to which they and others of their kind can go.

As Mr. Thompson says: The second area of responsibility which I feel my case opens up is the whole question of the after-care of patients discharged from the Special Hospitals". He goes on to say that he was told by the chairman of the National Association for Mental Health that there were 60,000 patients in mental hospitals who were almost cured, and certainly fit for discharge, but needing community care, who had to stay in hospital simply because there was nowhere for them to go and no one to care for them if they left hospital. That. I maintain, is a scandalous situation. if only because we can ill afford 60,000 hospital beds occupied by patients who do not really need them. My Lords, I am glad that the Secretary of State for Social Services, Sir Keith Joseph, has been good enough to see him and has considered these questions. Mr. Thompson says: I asked for a national organisation to be responsible for mental after-care. Subsequently I have had a letter from Sir Keith saying that the study of mental after-care is a continuing process and that no special report on the subject is required. He also said that he would arrange to contact former patients of Broadmoor to find out if half-way hostels would have helped them. My Lords, the noble Baroness, Lady Young, in her, if I may say so, admirable speech which we all so much appreciated, spoke of the need for short-term care. I am sorry that owing to other engagements I shall not be able to hear all the other speeches but I shall certainly be here when the Minister replies, and I hope that he may be able to tell us that the Minister has reconsidered the special position of this fairly small class of people and, if so, what his latest views are on the proposals which Mr. Thompson has made.

4.36 p.m.

LORD MAYBRAY-KING

My Lords, the noble and learned Lord, Lord Gardiner, has done some of us a great service in making known yet another aspect of this immense problem of the mentally handicapped. May I join in congratulating the noble Baroness, Lady Young, on her maiden speech at the Front Bench. We all expected her to acquit herself well and she has certainly done so. May I also say how greatly I welcome the opportunity of paying tribute to the noble Lord, Lord Grenfell, for his great services, not only to the hospitals but also to the cause of the mentally handicapped. Those of us who serve in this field in a much smaller way are indebted to him for all his life's work; for the work of his colleagues, like the noble Lord, Lord Segal, and the noble Lord, Lord Platt, and for initiating what I believe to be an important debate to-day.

The noble Baroness, Lady Elliot of Harwood, who I understand will be speaking later in the debate, includes among her many activities Presidency of the National Autistic Children's Association, of which she was indeed a founder. That society and its local branches, under her leadership and with the support of Members of this House, especially in the debate of February, 1970, have helped to make Britain aware, as it never used to be aware, of the special problems of autistic children and of their parents. The word "autistic" does not occur in the New English Dictionary the word "autism" gets half a line in the 1970 edition of the Encyclopœdia Britannica. It is only recently that we have called this special group of children to the attention of the nation. The autistic child lives in an inner world of his own; he is cut off from human relationships, and those who work in this field, including the parents, are trying to cut in and bridge the gap between the child's lack of communication and real life.

Everywhere in the country parents' associations and friends of handicapped children are raising funds and either creating new institutions or acting as friends of hospitals which care for the mentally handicapped. This is true of the parents and friends of autistic children. For example, in my city of Southampton a group has raised funds to create a school for autistic children, now ending its first successful year. Just over a year ago in Christchurch, Hampshire, I had the pleasure of attending a function when the noble Lord, Lord Belstead, opened there an autistic children's school which had been built by funds raised by voluntary gifts.

I have in my hand reports produced by the National Society for Autistic Children of some of the voluntary hostels which exist in the country—heart-warming reports. Edmund House in Cambridge, bought and fitted out by a voluntary body, is now providing the kind of hostel that the noble Lord, Lord Grenfell, dreams of. I read one sentence from the handbook: This home has demonstrated that an environment can be created which provides a favourable setting to a happy and useful life for those who otherwise might be left in institutional care. That is the heart message of this debate.

In Aberdeen there is a village trust, run by the Rudolf Steiner Foundation, which caters for handicapped people aged between 15 and 45 years. It is a most successful venture, but there is a waiting list of 700 adolescents who would like to get into it. At Potter's Bar a group of Catholic monks run a sheltered workshop which could not be financed if the monks were not voluntarily giving, as their Christian service to humanity, hours and hours of labour which the State could hardly afford to pay for.

But, my Lords, whatever the voluntary workers of this country do—and those of us who know them are very proud of what they are doing, and hope that this debate will stimulate others to join in the voluntary societies which care for the mentally handicapped—voluntary effort, no matter how splendid, can be only a tiny fraction of what has to be done. And so to-day I want to confine what I have to say to the autistic child, and especially the autistic adolescent child. There is no doubt that where special autistic schools exist the children benefit. I have seen that at first hand. New ways of educating these children are being discovered. The therapy of music is just one example. I know a very autistic child in Southampton who spends most of her time vibrating, pulsating, agitating, moving about, and who has been taken to a special school and is now learning to play the piano. When she is playing the piano she plays well, and all the symptoms of autism vanish. Equally, there is no doubt that when children benefit from the autistic child's school the parents benefit. They are freed for some time from their 24-hour responsibility, I would say their vigil, and they find the special provision of education for their children a great relief, a great comfort, especially if the child can be boarded in such a school. Perhaps of all mental handicaps suffered by children, autism, and for the parents the care of this in-centred child, communication with whom is almost impossible. is about the most grievous burden any parent can bear.

The greatest anxiety facing the parent of an autistic child is that which faces the parents of so many mentally handicapped children: what is going to happen when the child reaches school-leaving age. We have extended this school-leaving age for the handicapped, for the autistic child especially; we have said that there should be special education to the age of 19. But so far we have only said it; we have not yet carried it out. Last year the Society to which I referred published a report, and this gives a sad picture of the present situation of adolescent autistic children. Nearly half of them are in hospitals catering for the mentally subnormal and those with psychological troubles. But, as has been mentioned, autistic children are not necessarily unintelligent—far from it. Just as in the case of the spastic child, the handicap may conceal behind it a very keen and active brain.

Some 10 per cent. of our autistic adolescents are at home, cared for by loving parents, who, in addition to the burden which they bear with so much patience and courage, have always in their minds the thought that some day they will grow either too old or too weak to carry on, or will themselves die, and then they wonder who will care for their surviving children. Some 8 per cent. of autistic adolescents are working regularly in the community, which indicates that, given the necessary special instruction and education, quite a number of autistic children can take their full place in society. Five per cent. of them are in sheltered workshops. A very small number are fortunate enough still to be at school.

So two lines of development are urgently called for. First, we want a rapid increase in the number of special school places for autistic children. Hospitals have too many kinds of abnormality and subnormality to deal with, and while I would pay tribute to our staff in the mental hospitals, the unsung heroes and heroines of the National Health Service—and how happy I was to hear the noble Lord pay tribute to the devoted work of those who work in our mental hospitals under conditions of extraordinary difficulty which no one who has not seen them can imagine—and while I yield to no one in my praise of what goes on in our mental hospitals, I share the view of the National Society for Autistic Children, that autistic children want special education; not care in a hospital but education in a school.

Recently we asked the parents of adolescent autistic children what they required most, what they most wished for. More than half of them said "residential help". They wanted their child either in a hostel or a sheltered community, but outside a mental hospital. Quite a number still say that they would like to have their adolescent autistic children at home, provided that they can be given expert advice and that the adolescent can continue to receive education and training. So in this debate we would call on the local authorities, in co-operation with the State, and knowing that they can have the eager co-operation of voluntary bodies, rapidly to extend the provision of hostels for the adolescent, to provide extended education for young autistic children and to carry it on to the goal which we have laid down for ourselves, the age of 19. A child who has received special education in his younger years and is turned out at the age of 15 or 16 often drifts back; he has not been long enough at school to have had the full benefit of the training. Some local authorities are beginning to take a keen interest in this problem; others are still unaware of its special nature.

Many of us were greatly encouraged to read the report of the speech by the Secretary of State, Sir Keith Joseph, some days ago—Sir Keith, whose keen and warm interest in this and all similar matters he shows constantly. I know, too, that the noble Lord, Lord Aberdare, takes a deep and sympathetic interest in all matters affecting the handicapped, not only those born handicapped but those handicapped by war service. The House of Commons is at its best and most humane when it is discussing the problems of the handicapped. I experienced this when I presided over the debates on the Chronically Sick and Disabled Act. The fact that we are again debating this topic shows that this House yields nothing to the other House in its humaneness and human kindness.

We need facilities for the early diagnosis of autism. We ask for remedial teaching, for specialist teachers until the end of adolescence. We ask for the provision of sheltered workshops. Those who have visited a Remploy factory know how wonderful a sheltered workshop can be. We need residential hostels for the autistic for their own sake and for the sake of their parents. I was very interested when the noble Baroness, Lady Young, put out the idea that we might provide short-term stays in hostels so that parents could be relieved for at least two or three weeks of the burden some of them carry fifty-two weeks in the year.

Nobody has expressed more clearly and more eloquently the case that I have tried to put than the noble Lord, Lord Aberdare. On February 17, 1970, he said in this House in the debate on autistic children: The more willing and self-sacrificing the parents are … the greater the worry is that when they are not there the child will be left on its own and may well fail to cope.… At the age of 18, they are still mentally years younger.… I would hope that some provision could be made for them, after they leave the special schools…where they could find pleasant hostel accommodation and be sure of a home base for the rest of their lives."—[OFFICIAL REPORT, 17/2/72, col. 1122.] I like that expression "home base". This is what we seek for the children. The doctor who presented the report to which I referred this afternoon ended it by saying: These autistic youngsters represent a seriously neglected group of handicapped people, and the majority of autistic adolescents are in mentally subnormality hospitals and psychiatric hospitals simply because the required facilities do not exist. It is time that Government help was made available to ensure that local authorities—and some are very sympathetic—are able to meet these needs. I am honoured to be allowed to speak in this debate.

4.52 p.m.

LORD O'HAGAN

My Lords, it is rather impertinent of me to speak in this debate. Here I am, an ignoramus, in a star-studded list of experts. However. perhaps I can at least provide a brief respite for those who have listened all afternoon and will be reading what will be said in the rest of this long debate. Perhaps, too, I can give some substance to the hope of the noble Lord, Lord Greenwood of Rossendale, who said that there might still be a place for the amateur in suggesting ideas for residential care. Perhaps I can add one new element to the mixture to which we have already listened, because I have interpreted the words of the Motion—particularly the word "handicapped"—in a rather wider sense than did the noble Lord, Lord Grenfell. What little I have to say may well not apply to the mentally handicapped, and particularly the mentally sub-normal, about whom he spoke with such deep knowledge and feeling.

I tried to prepare myself for this debate by doing some background reading, and the extent of what is already being done is truly impressive. However, there seems to me to be a gap—and I wonder whether this point has struck other Members of your Lordships' House as it has struck me—in that so many local authority hostels seem to cater for one type of problem only: the ex-mental patient or the ex-prisoner. This may well be necessary, but I feel that if people with problems live together before rejoining the world at large, surely sometimes they will be helped to re-integrate themselves if the problems are of different sorts. Recently I had the opportunity of hearing about something called the "Patchwork Community". This is a new venture which tries to overcome the limitations of ordinary residential care in two particular ways: its aims are to bring into the community—that is, the residential community—people with a variety of problems who can help each other as well as being helped; secondly, by having only a small number of paid staff but a much larger number of volunteer residential staff who have ordinary jobs in society but who think they have something to offer the group and something to gain by living in the community. When this community starts work, which I hope will be soon, it should provide a half-way house between society and the institutions; and from what I have seen of the people involved its aims and its methods are highly practical. The organisers suggest that 35 is the optimum number, and it would be run by a committee of the Patchwork Housing Association.

There are two points that I would particularly stress to your Lordships. Those who are being helped would have a variety of problems, while the staff would also be varied. There would be a salaried administrative and care staff of social workers, residential domestic staff drawn from the residents, and voluntary staff—people doing ordinary jobs in the ordinary everyday world. I do not mean to decry what is being done already, but more is needed. When "more" comes in the hostel world, I hope it will include Patchwork, and schemes like it. There will be difficulties in any such effort, of course, but Patchwork underlines two important ideas whose value I am sure your Lordships will appreciate. A community of this sort which looks after people with different problems approximates more closely to everyday life. Secondly, the distinction between a helper and the person who is being helped is blurred by Patchwork's idea of attracting people who work outside but who live in the community itself.

There is plenty of idealism to be tapped among the people who are doing ordinary full-time jobs but who feel able to bring hack to a community of this sort a reinvigorating outlook and a breath of the outside world which would help combat institutionalisation. Patchwork does not have a monopoly of excellence, and I hope that by giving it a brief "commercial break", as it were, I have not given the impression that it has all the answers: but the noble Baroness, Lady Young, did say in her interesting speech that the voluntary movements were often the forerunners in residential care. I think that the Patchwork idea might well provide the proof of the rule that she was referring to, and I hope it will be given a chance.

4.58 p.m.

BARONESS BROOKE OF YSTRADFELLTE

My Lords, before I launch into what I want to say I must apologise to the noble Lords, Lord Aberdare and Lord Grenfell, that I shall be unable to stay to the end of the debate. In my capacity as a grandmother, I promised some weeks ago to baby-sit to-night in order to release parents for a celebration. But I shall read the remainder of the debate with great interest to-morrow. In this debate we have heard, and shall be hearing, the voices of experts, as well as those of amateurs, for this is a subject which requires knowledge of the size of the problem, and the experience gained by those who have been working at it and who may by now be seeing possible solutions. The encouraging words spoken by the noble Baroness, Lady Young, in her first speech from the Despatch Box, have let some sunshine into a dark world. I am no expert, but I do have a very real desire to help; and it is from that base that I would like to speak.

My Lords, the problem of handicap, be it physical or mental, is one of people. Primarily we must be aware of the involvement of the parents of the handicapped child—and how poignant and desperate that can be! Subsequently we must consider the diagnosis, treatment, training and caring for the handicapped individual, through childhood and adolescence and on into later years. I am not going to speak at length about the young handicapped child, except that I would suggest that every one of us who is fortunate enough to be more or less normal, and to have normal children, should never forget that there are others who do not enjoy our good fortune.

I want to speak about the future of the handicapped child who has reached school-leaving age. Up to this moment, the parents may have been helped with advice and some support, though there are still many parents who somehow seem to get very little help, either from the welfare departments run by local authorities, or from education authorities or, indeed, some times from hospitals in which the children have been. Those parents appear to be left Ito find out for themselves and to have to keep knocking at the doors of the various departments which they feel ought to be able to help them if only they would open. Some of them may not have the intelligence or the peristence to do even this. Some just do not know where to turn for advice, and they feel that they are being left high and dry and that their child is being denied the assistance he so desperately needs.

As the child grows older, the problem for the parents becomes more and more pressing. All through this period of growing up there must have been constant bouts of gnawing anxiety whenever their thoughts turned to, "What happens when our child leaves school?" It is during the parents' period of apprehension as to what happens next that help is urgently needed, for some assessment as to ability must be being made by someone, and guidance should be available as to which means of training or gainful, or partially gainful, occupation the handicapped boy or girl can undertake. In some parts of the country, this much needed advice is available either through a voluntary organisation or through the appropriate department of an enlightened local authority. But this is not universal, and I feel strongly that nothing but good can come out of complete co-operation between the voluntary organisations—who are usually inspired, informed and supported by the parents and friends of handicapped individuals—and the local authorities who have a statutory obligation to help. This constructive co-operation exists in some places and it is nearly always the outcome of inspired and imaginative leadership from the voluntary organisation or from one or more of the members or officers of the local authority, coupled with a white-hot determination to get things done.

To give an example, I should like to draw your Lordships' attention to the work being done through the combined efforts of the Wirral Society for Autistic Children and their neighbouring local authorities. The National Society and the more local societies for autistic children are determined to get things done, as your Lordships can see by the way in which the various Members of your Lordships' House have been briefed for this debate to-day. And I say good luck to them, and may they get rewards for their efforts. Last summer, a very useful meeting was held between senior officials of Birkenhead, Wallasey and Cheshire Councils, representatives of the Wirral Society for Autistic Children and the National Society. Some of those who were present felt that wider development of fruitful co-operation between such voluntary organisations and local authorities could speed up the provision of facilities for the handicapped in many other parts of the country. Anything that can be done by Ministers to press upon local authorities all over the country the idea of arranging such meetings with representatives of voluntary societies concerned can achieve nothing but good.

It is at the moment when school days are over, or nearly over, that the need for hostel accommodation becomes urgent. I have no real quarrel with the word "hostel", but I should welcome a change to the word "home", which somehow conjures up a warmer picture. For parents of handicapped children, be the handicap physical or mental, the moment of parting with their child must be a terribly difficult one. Will he be happy in the new environment? Will he be understood? Will allowances be made for him? Will he be shown affection? And if he is going to a home rather than to a hostel, how much relief may be felt by the parents of that child? If only there were enough of these hostels, they could continue the remedial teaching techniques which are proving successful wherever they are available. In addition, the children could receive training for useful occupations according to their varied abilities and the hostels could provide continuing care, as a permanent home, where this was found to be essential.

The geographical situation of these hostels is important. They need to be in areas well served by public transport or accessible by car. This enables parents or friends to visit and often to help in the actual running of the house. It enables staff to come and go easily. The hostels need to be intelligently staffed with people who have been trained in the field of that particular handicap, and the staffing must be generous enough to allow good off-duty time. These hostels should not be regarded in any sense as custodial, but as forward-looking centres where individuals can be taught and encouraged to become as independent and self-supporting as their abilities allow. And, as my noble friend Lord Grenfell has suggested, we, the general public, must be encouraged and educated to be co-operative and sympathetic in our attitude towards the establishment of such hostels in our midst. "Anywhere but here" must no longer be heard. Once the hostel has been started, the likelihood is that the local community will take an interest in it and will even feel a personal regard and possessive quality towards it. The difficulty is at the very start, when the proposal is first mooted.

I believe that many parents warmly welcome the hostel idea. Some feel, and some feel that they ought to feel, that the parental home may be the right place, given appropriate help and supervision according to the degree of handicap. But even those parents frequently add the obvious qualifying phrase, "So long as we are able to cope." Hospitals are not the solution, though some parents are now left feeling that there seems to be no alternative. Camphill, Steiner, the Richmond Fellowship and other inspired bodies, with their villages and training and rehabilitation centres, are the ideals to which many parents would aspire, but, alas! there are not enough of these available. And yet the problem is not only with us; it is growing in size as more research is carried out and more diagnoses are made.

I am indeed grateful to my noble friend Lord Grenfell for giving us the opportunity to discuss this problem. For me, it is crystal clear that hostels should be encouraged; hostels with manageable numbers, not too large and not too small; staffed with competent people and having links with local voluntary organisations, so that they are automatically associated with people living in the neighbourhood and are not looked at askance. And if anybody asks why all this effort and expenditure are necessary, the answer is that we who are lucky have a debt to pay to all those families who, through no superior merit of ours, are less fortunate than we.

5.9 p.m.

LORD HAYTER

My Lords, the timing of this debate is very fortunate, for in 1974, two years from now, we come to the integration of the services, and the same year sees a reform of local government. The theme of my speech this afternoon is that of integration for the handicapped in general, and perhaps the mentally handicapped in particular. To put the matter at its simplest, we know that the three elements that we have been discussing to-day are the hospital, the hostel and the education service in the specialised way in which it has to be made available for the handicapped. Yet each of these three elements is under a different Government Department; and I do not quite understand what are the specific means for central Government to influence local provision of local authority services.

I quite see that the Secretary of State can give directions to hospitals about the use of capital, and that a certain proportion is to go to the mentally handicapped. But can he say that to the local authorities? As I understand it, he can indicate the need and he can sanction the necessary grants. For instance. He can lay a duty on the local authorities to provide a full range of community services for the mentally handicapped, including residential accommodation ". Ultimately, however, as I understand it, it is the local authorities who are responsible for this residential care. It is they who have to balance the needs for residential care with those of education, training, sheltered workshops and other kinds of social services; and the natural reaction of us all, I think, is to take the line of least resistance.

What of course the Secretary of State can do is to create the hostel environment in hospitals: for this, money and good will are needed. The large ward spaces can be reduced and broken down into smaller areas. The groups of patients can be carefully chosen; some excellent hospitals are already doing this, and it is a worthwhile object in itself. Indeed, a good hospital which is not institutionalised is preferable to an institutionalised hostel. But in the long run such schemes are no substitute for community development. The reason for this is not just that of general benevolence. If we think back to our childhood, we realise that we learned from our environment: the use of the spoon and the cup, and how to eat bread and butter, how to wash up dishes—the simple things of home life. The easiest way to teach these people who have been in hospital for all their lives is to try to get them to do these same things in small groups. Those who have lived literally all their lives in institutions have lived in large dormitories, in large refectories, with rows of lavatories, and they have not learned to live in the same sense as we have been lucky enough to do ourselves. An illustration of this came to me when I went to one of Lord Grenfell's hospitals and saw a child cutting out pictures of dining room furniture and bedroom furniture. When I asked why she was doing that. I was told that it was because she had never seen these things in the way that you and I have done.

Mention has been made of the White Paper, Better Services for the Mentally Handicapped; and, like other noble Lords, I am glad to hear of the steps that are in progress towards these great ends. I would just emphasise, in passing, that one of the difficulties of overcrowding in hospitals is that of under-staffing; and it means that nurses are now being forced to be custodians, whereas their natural inclination is to be creative in teaching and training. If it were possible to move half the patients out of the hospitals, as this White Paper suggests, then so much could be done to remove the institutionalised effect of the hospitals themselves.

Just one word, my Lords, on the subject of the voluntary hostels in the community. The point has been made by several noble Lords that what has been done so far is really a drop in the ocean. These hostels are excellently run by two entirely different types of organisation. There are the religious philosophical societies, and there are the others who are tackling the job more from the health angle. I have a suspicion that many of them would like to be relieved of some of the work they are doing now, and that if they could be sure that the Government were tackling this hostel problem in a positive way they would turn their attention partly to staffing those hostels and partly to doing more to relieve the parents of the young children who are in these hostels. What a long way we have to go if we turn our thoughts overseas! I was getting some information about the situation in Sweden and Denmark, where there is one service for the mentally handicapped, not three. Community provision there is taken to its ultimate. When a new block of flats is built, three of those flats may be earmarked for the mentally handicapped, with one discreet woman in another flat providing the social support. There is no argument among the community as to whether that is right or wrong; it is just done—and in point of fact it is approved. One curious thing is that in the British Isles the one place where there is a truly integrated service for the mentally handicapped is Northern Ireland. There, education, social and health services are combined in a Special Care Service.

I keep on corning back to this point of co-ordination. Unfortunately, hospitals for the mentally handicapped are not always tidily deployed throughout the country. Nor are they necessarily deployed tidily in relation to local authorities. This fact, I think, will become generally apparent in 1974, though it is already apparent to those of us "in the know", with this very heavy concentration of mental hospitals in the South-West of London. But it means that it will be very difficult for the various authorities to work out formal means of communication. At the moment many of them seem to operate separately. If there is an aim of releasing half of the patients from hospitals into hostels, there must be some means of inter-communication between the hospital service and the local authorities. Formal machinery will be needed for the representatives of the health, social and education services to work out their day-to-day tactics and their long-term strategy. In the Health Service it may well be thought that the new Regional Councils might be responsible in part, but once again there does not seem to be this element of compulsion on social authorities or education authorities to collaborate.

May I just make the point that the establishment of hostels for handicapped people in the community is not a thing in itself? It is part of a total policy for the various public services. The King's Fund, of which I have the honour to be chairman, recently produced a publication, called Room for Improvement, stressing this environmental factor that has been talked about this afternoon in the relationship with the child or the patient coming out of hospital. The King's Fund will always hold itself out to give whatever help it can in the whole of this difficult field. Not long ago we had an exhibition called "Learning to Live", which dealt with the mentally handicapped, and as a by-product of that a working party has been set up from three of the Regional Hospital Boards plus the National Association for Mental Health, the National Society for Mentally Handicapped Children and the Spastics Society. These bodies intend to try to design courses to widen experience to other forms of residential care, and the King's Fund will be sponsoring these courses. We have also been studying caring for the profoundly handicapped and the "security" patient. We are trying to direct sharp focus on the "direct care" staff's need for close working relationships in hospital and in the community. The development of these relationships can be so easily impeded by exclusive professional training, by institutionalised attitudes and by administrative separation of services. I hope that this will not be so, and I can assure noble Lords that the King's Fund will do everything it can to help the Government forward in this very enlightened programme that they have ahead of them.

5.19 p.m.

LORD AUCKLAND

My Lords, whenever my noble friend Lord Grenfell initiates a debate on any aspect of the mental health service the House can be assured of a most valuable discussion, and to-day is certainly no exception. The Hospital Management Committee of which he is chairman has benefited enormously under his stewardship, and I have the honour to serve on the house committee of one of the hospitals in the group. I am particularly pleased to follow my noble friend Lord Hayter, because his wife is also a member of this house committee. This debate also gives me an opportunity to congratulate, in her absence, my noble friend Lady Young on a most distinguished first speech from the Government Front Bench. It is quite obvious that we have somebody who is well versed in this great problem.

My Lords, over the past decade or so enormous therapeutical advances have been made in the mental health services, so that custodial care is no longer the order of the day for the majority. That is why the key word of this Motion, in my opinion, is "rehabilitation". I agree with my noble friend Lady Brooke that "hostels" is a word which ought to be replaced, perhaps, by "home" because it is going to be a home, particularly for such a child, for in the last resort it is the parents who still retain the love and affection of the child even though, for a variety of reasons, they cannot properly care for the child themselves. These hostels provide a valuable service, but with a number of reservations. The first, of course, is that they must be properly equipped—and I think the noble Lord, Lord Greenwood, made some very important points when he mentioned, for example, the height of a stove, or something like that, when the older children, if they are able, are learning how to boil a kettle, and that kind of thing, which is all part of rehabilitation. Therefore, design is extremely vital.

The noble Lord, Lord Hayter, mentioned Scandinavia. I recall, when in Finland some years ago, going round one of these centres and seeing there a type of hostel where these very things were given preference. The thing that was thought of most was to make sure that the adaptation of the kitchens and everything else was such that the maximum use could he made of them by the inhabitants. It is also vital that these hostels should be sited, so far as possible, in pleasant countryside because those who are going to use them will doubtless benefit by good fresh air and decent scenery. This has a very important psychological effect. At the same time they want to be reasonably near a town centre and reasonably near a centre where perhaps they can be taught how to do simple shopping, and where they can visit local places for entertainment and education. All these matters are vital.

I can recall my first visit to a mental hospital. It was about twenty years ago when that terrible word "asylum", was still used. This was a hospital in Bedfordshire where one of the patients acted in a capacity as farm manager. He was a man I remember very well who gave the outward appearance of complete normality but who every now and then had hallucinations. The fact was that he had nobody to look after him. His family had disowned him and there was nobody to whom he could turn. Therefore it was necessary for him to be a residential patient at this hospital. But his capacity for work was something quite fantastic. I live in an area in Surrey where there are some eight mental hospitals—I have mentioned this before in your Lordships' House. In one of them there is (or there was when I last visited it) a ward in which there are a great many geriatric patients. The devoted work of the staff who look after these patients should be stressed. Mention has been made of one or two hospitals (there was one in the West Country) where there have been instances of ill-treatment of patients. These cases are of course to he deplored but set against them are the many untold and unsung instances of extreme devotion by the nurses and doctors for these patients, some of whom are completely helpless.

We are more concerned to-day, however, with those who will benefit by rehabilitation. As the relevant report on the health and welfare services shows, in 1970 some 4,600 places were found for residential, younger mentally handicapped people in these centres. Improvements are going on, but it is extremely difficult to keep up with the need. It is vital that there should be local acceptance of these places and local contribution to them, and there are definite signs, I think, that the general public are now beginning not only to understand the implication of mental illness but also to contribute themselves to helping these people. It is a telling fact (and I think I have my figures correct) that something like one in nine people at some time or another in their lives need some form of treatment for mental illness, be it a nervous breakdown or something more serious. I think it is this kind of statistic—and it is a shock figure—which should make not only the Government, not only Parliament as a whole, but the community at large take a real interest in this problem. If this can take place, and if the interest can grow, then I believe that much can be done to make the lot of these people much happier.

5.29 p.m.

BARONESS MASHAM OF ILTON

My Lords, I should like to add my thanks to the noble Lord, Lord Grenfell, for initiating this debate and, in particular, for making it wider than at one time it was to have been. I would also say how delighted I am to see him looking so well, and to add my congratulations to the noble Baroness, Lady Young.

My Lords, before speaking on hostels I should like you to know that I feel that the first aim of our society should be to try to get as many as possible of those who are physically disabled back to their own homes. It has been the attitude of some people to take the easy way out and place disabled persons in institutional care. A concerted effort by the family and by statutory bodies should be made to resettle the patient in his own home. I was delighted to hear the noble Lord, Lord Greenwood of Rossendale, stress this point so strongly. With the increase of modern ideas and the advancement of technology, the future looks brighter for the severely disabled person. Encouragement should be given to housing associations and any organisations providing fiats and independent accommodation for disabled people. All handicapped people need varying degrees of rehabilitation so that they can develop to the full their potential. I feel that the increase of hostel accommodation could help to achieve this aim.

My Lords, as the field of the handicapped is so varied, so is the need for different hostels. To mention a few, there are the blind, the physically disabled— which consist of many disabilities—the mentally handicapped, the alcoholics, the drug addicts, the homeless and the ex-offenders. Many of these people will have passed through an institution of some sort or another but will still be in need of further rehabilitation and care. Others will not be lucky enough to have homes and relations to go to, or the homes may have rejected them. Some will have had homes and loving relatives who have cared for them for a long time and, through advancing years, find they can no longer cope.

I hope that this debate will help the public to accept the need for hostels within their particular community. In many areas local authorities are providing good Part III accommodation in the form of hostels for badly disabled people. One such hostel which will give the young disabled a chance to live an independent life and go out to work from, has been planned by the City of Leeds Social Service Department. The most suitable site which has been selected is on corporation ground. The building of this much needed hostel means the removal of a few trees, some of which are diseased. A campaign has been run against the erecting of a hostel in that area because of the trees. Even a local newspaper and school joined in the campaign which has upset the Social Service Department and made the disabled feel that they are not wanted by that community.

My Lords, many young people who want to be trained for a profession or work need hostel accommodation. Some universities are becoming aware of this problem and are incorporating suitable accommodation on ground level in the universities. I know of several very handicapped students who have successfully passed through universities and have now obtained degrees. But all young people do not manage to go to a university. There are some who would benefit greatly from courses at polytechnics or other training centres but find it impossible, because if they live in a rural area or little towns which do not have training centres, they have to live away from home which they often find impossible because of the lack of suitable accommodation. The disabled then find themselves all lumped together in a residential training centre especially for disabled people.

My Lords, please do not think that I am criticising these centres. They do an excellent job. But it is segregation, and if disabled people and able-bodied are to work together and be properly integrated, I think they would be better to train together—certainly the ones who are able to survive in unsheltered employment. I should like to see these hostels mixing disabled and abled-bodied students as is being done in some progressive universities.

I should now like to speak in a little detail on the severely disabled spinal patient who may need hostel accommodation. I know that the noble Lord, Lord Aberdare, has been to visit Stoke Mandeville Hospital, and I think the noble Lord is beginning to understand the special difficulties which can arise from spinal injuries. For those of your Lordships who do not know, a complete tetraplegic is a person who is paralysed from the neck down and cannot feel or move from that area.

I should also like to mention the link between hospital and the patient going home. This difficult transfer could be made much easier. It is unlikely that the hospital will discharge a patient who is to remain disabled until his home has been adapted. Therefore, these patients remain in hospital blocking the acute beds. This, I think, is a very urgent problem. One doctor in charge of a spinal unit had a list of acute patients who were in need of specialised treatment. He was not able to admit them from other hospitals to his hospital and they have since died. If each specialised unit had a hostel attached, the patients who were ready for discharge could be transferred, in that way releasing the acute beds, and they would also be given a stepping stone to the outside world. At the moment, this problem is frustrating doctors and social workers in many hospitals.

Not only would this help the staff but also the patients. To be in hospital too long in the very organised and secure routine of a ward is very dangerous for patients who arc to remain disabled. They can so easily become institutionalised, and the longer they are there the more difficult it is to get back into the community. Because an acute ward must have a stricter routine because it is dealing with ill patients, it is difficult to give the patients who are shortly going home the more liberal facilities which help rehabilitation to the full. From a hostel, introducing the patient back into the community is so much easier. They should be able to go out to the cinema, shopping, or the pubs, and get used to the pressures of life before having to cope with them completely. In hospital, it is much quicker if the nurse helps the patient. In the hostel, the patient can find out just how well or how badly he can cope before going home.

My Lords, there are the unfortunate complete tetraplegic patients who, because of social factors, can never go home. The lucky ones with technical aids and devoted relatives to look after them can be discharged home. Those who are not in this fortunate position either stay in a hospital centre or are discharged to a long-term hospital or hostel. A survey of some of these patients has been carried out. Of the 29 patients discharged to another hospital or hostel, 13 are dead; of the 79 discharged home, only 10 are dead.

There are several reasons for the poor prognosis of patients discharged to long-term accommodation. When a patient is admitted to such accommodation it can be considered a failure of rehabilitation and patients often give up their wish to live. If a patient is discharged home, there is at least one full-time person to look after him, and what these relatives lack in skill they make up for in affection. When a patient is admitted to long-term accommodation, the average nursing care that is available is only three-quarters of an hour a day and that is not sufficient to keep a tetraplegic in good health. At present, local authority homes and Cheshire homes are not usually able to take on the care of a tetraplegic—as a rule the nursing staff is insufficient and particularly so at night.

With the rise of accidents due to the tempo of our modern living, more leisure activities and the advancement of medical treatment, many high lesion tetraplegics are living and the number will increase even more in the next few years. Many of them are young. They are mentally bright and alert people. Surely, if they are kept alive in the initial stage, it is the ethical duty of our society to give them a life worth living rather than a place to exist in. It is possible to do this with such aids as P.O.S.M.—patient operated selector mechanism. A severely disabled person may be able to work a typewriter, a radio or T.V., or ring a bell, or operate an electric chair, or work all sorts of gadgets with his mouth. This gives him a much wider independence. I wonder whether the Government have done anything yet about the provisions of Clauses 17 and 18 of the Chronically Sick and Disabled Persons Act 1970. I know that throughout the country there must still be young patients tucked away in geriatric wards. Perhaps we should think of Shakepeare's phrase which applies so well to geriatric wards: Where age in unregarded corners lies. If only getting young disabled people out of geriatric wards could be felt to be an urgent priority, progress might be made. When the Government want to act fast in finding special accommodation they can; this has recently been proved.

My Lords, until local authorities and Regional Hospital Boards have supplied adequate accommodation for the young disabled who are still in unsuitable wards and who could be in Part III accommodation could not the Minister allocate one large building where every young person who wished could live with other young people? Last week I had dinner with a friend who the next day was going to visit a young woman of 34. She has been in the same geriatric ward since May 1968. She is surrounded by old people whose numbers change constantly, due to death. She is the only young person in the whole hospital. I should like to ask the Minister whether he knows the number of young people who are in geriatric wards or hospitals. If the noble Lord could find a building—and I can think of a few—it could act as a sort of clearing house.

There seems to be a remarkable lack of residential facilities for the tetraplegics. Only one of the spinal units in this country has a hostel attached. This is at Stoke Mandeville Hospital and it is completely full. After I had been speaking to a group of people in the Wakefield area about the benefits of hostel accommodation, a hospital social worker said, "If I had a hostel attached to my hospital I could fill it to-morrow." I hope that the Government will look into this problem of the tetraplegic patient from a national point of view. There can be nothing more worrying for a relative who is growing old or is ill and who may die than not knowing that the tetraplegic in his care has somewhere acceptable to go. This, of course, applies to anyone who has a dependent with any disability who relies solely upon them.

Hostels for the disabled, apart from tetraplegics, seem to be progressing in the right direction. The badly disabled need care and attention but, in addition, a hostel provides company for some people who would otherwise lead a very lonely life. I feel it is important that these hostels should be designed very carefully for the type of people who are going to use them. They do not want to be too large, and they should be as homely as possible. The hostels should be near to work and recreational facilities, and efforts should be made to make them part of the community. My Lords, I am very pleased to hear that this is the view of the Government. For any local authority or voluntary group which is thinking of building a hostel I recommend a visit to the new ones at Papworth Everard, near Cambridge, and the Thistle Foundation in Edinburgh. Both have a high standard of living accommodation. The financing of hostel projects is the most restrictive obstacle. If capital grants were made available for their building perhaps it would be possible to complete many more projects.

Another consequence of modern medicine is that there are people who do not fully recover after resuscitation, including intensive care. Many have head injuries, the most dreaded result of any accident. In many such cases the most difficult handicap is that of emotional disturbance which can vary from destructive behaviour to almost complete apathy. Several times I have been telephoned by mothers whose teenage children have had such injuries. I feel quite inadequate to try to tell your Lordships of the stress and absolute heartbreak that some of these families have to bear. Because of big compensation grants often money is not the problem. Many of these people had good prospects before their life was shattered. They need occupation and often accommodation.

I hope that the Minister will be able to give encouragement to the Department of Health and Social Security and the Department of Employment so that support may be given to such places as the Birmingham Accident Hospital. This hospital is trying to establish hostel accommodation with workshop facilities for people suffering from head injuries. At the moment there is residential accommodation for four people. I share an interest with the noble Lord, Lord Donaldson of Kingsbridge, in that we are both members of NACRO, the National Association for the Care and Resettlement of the Offender. The noble Lord is the President. I have worked for years at a borstal establishment. The most deprived and disabled boys in this group are the homeless ex-borstal lads. They are disabled through their circum stances in life. Very often it is impossible for the ex-borstal boy to survive in society without a certain amount of guidance and support. Most of his life will have been spent in institutions, starting from children's homes.

My Lords, I think that the Government know of this need, but I should like to put forward a suggestion. It was spoken about by the noble Lord, Lord O'Hagan, to-day, and I have seen that it can work. Badly physically disabled people who need looking after take up a good deal of manpower. Orderlies, under trained supervision, are well able to do this job. Homeless ex-borstal boys also need a home and employment. Could not hostels be utilised to serve both these needs? I think that both parties would gain from such a scheme. The physically disabled would be looked after and have the satisfaction of knowing that they were helping a group of young people who have to be given confidence and a feeling of being needed. The young socially disabled men could be given a chance to help others and would come to understand that they were not the worst off members of society. Such hostels serving a dual' purpose would, I am sure, never be short of staff so long as the person in charge was dedicated to the challenge.

It seems that we need rehabilitation and assessment centres spread over the country, including hostels for disabled people who do not get admitted into hospital. For example, there are those with progressive diseases who do not need to be hospitalised in the early stages. At present they often struggle on in their homes not having the chance to learn to cope with their difficulties. Even if there were only crash courses taking a few weeks, it would help. They could be assessed through their need for aids, and such courses would be beneficial to local authorities in regard to the selection of correct equipment. Disabled people at the centre could experiment to discover what helped them most. The recommendations from the assessment centres could then be sent to the local authorities who supply the equipment. The young adult seems at present to be the most ignored, children and the elderly being better catered for. Does the Minister not think that it would be possible to create a national rehabilitation section of the Department of Health and Social Security? This section could gather together all aspects of rehabilitation, retraining, resettling and residential care of the severely and longterm handicapped. Does the Minister think that it might be possible to have a career structure for a professional rehabilitation worker? There certainly seems to me to be enough scope to make a very comprehensive service. May I ask the Minister one further question? Does he not think that, rather than "the Department of Health and Social Security", the title "Department of Health, Rehabilitation and Social Security" sounds more efficient and complete?

My Lords, I am sorry that I have spoken for so long, but I feel that there is a great deal to say on this subject. The Minister and his Department have been very helpful and successful in several cases where I have asked for help. I hope that the Minister will be equally successful in tackling some of the problems brought to his attention by this debate.

5.51 p.m.

LORD DONALDSON OF KINGSBRIDGE

My Lords, I should like to congratulate the noble Baroness on a major speech of great importance and one which was extremely moving. The debate has been very moving. The noble Lord, Lord Grenfell, who opened it, made a most moving speech, referring particularly to the mentally handicapped; the noble Lord, Lord Maybray-King, referred in moving terms to the appalling problem of the autistic child; and the noble Baroness has just been very moving about the tetraplegics. I was wondering how to descend from those major tragic conditions to the more petty form of disability about which I want to talk: but the noble Baroness very kindly gave me a superb lead in by talking about NACRO and the borstal boys.

I think the suggestion that there is room to combine the socially inadequate, particularly with the physically handicapped, is one that ought to be followed up. The mentally and the physically handicapped overlap the socially handicapped, and it is with the latter that I have had most to do. I think it would be foolish to discuss the noble Lord's Motion without reference to the work done in this field, even though, unfortunately, there is a Departmental barrier which the noble Lord has put upon us: that we are to confine ourselves to those things with which the noble Lord, Lord Aberdare, can deal. I may go a little across that line, but I am sure the noble Lord will forgive me. One of the things that worries me is this barrier—and I shall come back to that later.

Let me begin by convincing your Lordships that the group of socially handicapped closely overlaps with the mentally handicapped and the physically handicapped. We all know that among our friends and people with a little capital, a little income, in a more or less protected sector of society, a mental handicap or a physical handicap really means no more than the words describe. But if you go into circles which are less well defended, these handicaps can lead straight to that dark area on the edge of the criminal. We all know of the restless army of the mentally disturbed who shuffle from mental hospital to prison and back again and who find no relief in either. Neither institution is really able to do much to help them. In just the same way, physical handicaps of quite modest kinds—an ugly birthmark, squint eyes, bat ears, flat feet—in certain circles can bring you to the bottom pecking order, and in those circles that can be a very savage situation. I remember talking to a man in the hospital at Grendon, who had his face sewn up in every sort of way. I said to him: "What have they done to you?". He said: "They have removed a birth mark." I then said to him: "It doesn't look as if it was worth it." He said, "It was, sir; I need not now sit with me back to the wall any more." In certain circles physical handicaps of this kind do lead to persecution.

One must admit that few men come out of court, with or without a prison sentence, or come out of prison without some traceable physical or mental handicap. I do not pretend that it is necessarily the whole cause, but it is a contributory factor. Any system, therefore, which insists that a breach of the law should be a factor of classification is unreal. People believe that the fact that they are handicapped is one of the factors leading to the breach of the law. The responsibility for dealing with these people is divided between the Department of Health and Social Security and the Home Office on these lines: the Home Office deals with people who offend against the law, but the D.H.S.S. deal with people who do not. In the case of drunken offenders, it has taken the time since the 1967 Act was passed to get this matter sorted out. It has now been sorted out, more or less, but there has been a five-year consideration and discussion of how to deal with this perfectly simple thing; that is, not to send drunks to prison, but to send them somewhere else—which involves having somewhere else to send them to which did not exist. A problem which you or I could solve in seven or eight minutes discussion has taken five years to settle, chiefly because there were two Departments concerned in doing it. I do not want to make too much of it, but that is basically the reason. This is why we were so pleased when we heard that the noble Lord, Lord Windlesham, before he was whisked over to Ireland, was going to co-ordinate the support given to the voluntary movement, whatever Department was concerned. We are also delighted now that the noble Viscount, Lord Colville of Culross, is going to bear this burden; and I think we shall keep him fairly busy.

There is a good deal of experience on the Home Office side of this particular area in running voluntary hostels—voluntary in the double sense that they are run by voluntary groups of citizens and that the people who use them are free to go away if they want to. This does not of course apply to phases like probation hostels, where there is a condition of residence. It does apply, however, to all types of hostel that we have been talking about under the D.H.S.S. At the moment we have 122 voluntary hostels, about the same number that we were told the Department of Health and Social Security have, but whereas they see this number rising to 500 in the immediate future, we have only 17 extra planned because we cannot get the money to do more. It is perhaps worth mentioning that the cost of keeping a man in a voluntary hostel is £8 a week, and in a probationary hostel £19 a week. No doubt they are better kept in the probationary hostels, but it seems a little different. So the voluntary hostels certainly labour from an appalling difficulty of capital. I understand from what we have heard in the debate to-day that that is not the case with the Department of Health and Social Security hostels: they are financed by local authorities. Therefore I hope that this particular problem does not arise, because if it does they will not get their 500.

As I say, we have 122, with 17 in the pipeline, and we have places for about 1,300 people. It is worth while to mention briefly what sort of hostels they are. There are 30 for homeless young men; 55 for homeless adult men; 14 for women and girls; 2 for elderly ex-offenders; 14 for male alcoholics; 6 for drug addicts; 1 for gamblers and 1 in the pipeline for epileptics. Your Lordships will see that those catering for alcoholics, the old, the addicts and the epileptics ought properly to belong in the Department of Health and Social Security. As things are, an alcoholic coming to a Home Office centre for alcoholics can be refused help on the ground that he has not yet got himself into prison. This is really rather ridiculous. The authorities are as reasonable as they can be about it, but where Departmental votes are concerned there is very little freedom for the civil servant.

Hostels are not the answer to everything, whether for the physically, the mentally or the socially handicapped, but there is no doubt that we need many more. At the moment, the accommodation for homeless men is decreasing rapidly. The Rowton Houses are converting into junior hotels, and the number of beds in the various conurbations is going down by about 10 to 15 per cent. a year. That means that my particular sort of client, who in many ways is the same as the type of person whom we have been talking about, who is not in the acute stages of either mental or physical illness, is getting less and less opportunity for looking after himself. I should like to endorse what the noble Baroness, Lady Young, said: that the correct way to deal with this sort of situation is to have a group of different hostels which vary a certain amount, because the type of person one is catering for is restless and often cannot settle down with one hostel warden and has to go over to another. It should be combined with a "subsidised landlady scheme", to which the noble Baroness also referred: we call it "a hostel without walls". It should be combined with a club and, above all, with a sheltered workshop. At the moment I do not believe that the Department of Health and Social Security have sheltered workshops which cater for the socially inadequate. I should like to ask about that. If you are an awkward chap who comes out of a borstal and cannot be placed, and if you are obviously disturbed though not psychotic in any way, I do not believe that you can be housed in one. I am sure that this system has to become integrated.

There are three problems in running a hostel, and we have not heard of them in our debate to-day. The first is capital, and we hope that this will not be a problem for much longer. The second one is staff. The job involved is difficult and very demanding, and to a married couple it is intolerably intrusive. It is perfectly clear to me that life as a warden should be only part of a career, and not a full career. Therefore we want a career structure which will enable people such as probation officers, health visitors and social workers to do a spell of residential work and then move back to their own job. Thirdly, as alternatives, there must be places to pass people on to, because all hostels inevitably have to become selective. They find that having too many people of one sort bursts their seams. They have to be able to pass people on. Therefore we must have g roups of hostels with suitable facilities, with some way of passing people on.

Finally we in the penal field badly need the help that is being given in the health field. The health field is better financed, is in many ways more varied, and gives, as the noble Baroness said, scope for our self-centred awkward people to do something useful—which very often they like very much. I am extremely keen that we should be integrated more closely with the whole hostel scheme. I ask to-day that in making plans to extend the whole hostel system throughout the Department of Health and Social Security, a hard line should not be drawn between those hostels and the Home Office hostels which are dealing mainly with people who have broken the law. If we could run the system as a whole we should get greater variety and greater career prospects for the wardens, and we should also gain a great deal of experience. I hope very much that something along these lines will be done.

6.3 p.m.

THE COUNTESS OF LOUDOUN

My Lords, I was delighted when I heard that the noble Lord, Lord Grenfell, had been given this date for his postponed debate on hostels. There is much rethinking and restructuring going on at present in the health world, and with the extra money which has been allocated it is very important that the whole picture should become clear. The more discussion we have, the better. Too often in the past matters have been swept under the carpet.

I am rather worried about our list of priorities when we talk about hostels, especially hostels for the mentally handicapped. Have we got them right? It is now generally accepted that small residential-type houses would provide better living environments than our present-day large, barrack-like hospitals. I think this is true. But although one must commend the attempts made to put this idea into practice, I also feel that some caution must be exercised to make sure that one is not exchanging something that works reasonably well for an ideal which, though extremely good in itself, when implemented with too much haste and not enough forethought might not be so good for some of the patients involved. Some of these patients have had endless care and attention spent on them, sometimes over a space of years, and must of necessity be acclimatised slowly to any change. I am sure there are a large number of people in our hospitals to-day who could live happily in small houses or hostels with a minimum of supervision. I should like to think that we could do away altogether with the subnormality hospitals, but I find this quite impossible.

Then there arises the very important question of sites for these hostels—sites acceptable to the general public. The public are now much more aware of the problem, and it is generally agreed that these hostels are necessary; but as soon as the question of "Where?" arises, no one wants a hostel in his own vicinity. The general public must be educated. Much has been done over the last few years, but we must continue to try to dispel the fears and doubts which arise when this matter is broached, and which are quite understandable. Some hostels need peace and quiet, while others need to be actively involved within the community if their residents are to reap the full benefit of the scheme. Here I should like to mention the Peredur-Home School, near East Grinstead in Sussex, the first one of its kind in the country, which is now threatened by the new East Grinstead by-pass. This school, which also has a hostel, farm and craft centre, takes in autistic children as well as others from mental hospitals and maladjusted school-leavers. It has been financed chiefly by private donations. It would be tragic if all these efforts were rendered useless. For this type of hostel, peace and quiet are absolutely essential; and this scheme is only one of many in the country. I am pleased to hear that some alternative routes for the by-pass have been suggested, and I would ask the noble Lord who sits on the Front Bench to stress to the Department involved the importance of giving very careful consideration to this problem before a definite decision is reached.

Lastly, my Lords, I come to the subject of staff. It will take an enormous increase in numbers of staff, in every category, to be able to cope with this scheme. I hope very much that, with so much emphasis being placed on the wellbeing of the patient, the wellbeing of the staff will not be overlooked: because without them the whole project collapses. More money must be allocated for this; the overall pattern must be considered, and the question of retirement should also be looked at. Most people are able to collect a home together during their working lives, but what of the married couple running a hostel? When their retirement age arrives they have nothing of their own or, at best, very little. What can be done to help them? We must not become discouraged by these problems, but must continue to press on with all these improvements. Every patient who can be moved out of hospital into a hostel will, I trust, be taking this step, justifiably, with renewed hope.

6.9 p.m.

BARONESS ELLIOT OF HARWOOD

. My Lords, I rise with great pleasure to take part in this debate. It has been extremely interesting and has covered a very wide range of subjects. As the noble Lord, Lord Maybray-King said, it is amazing how interesting are debates of this kind, both in your Lordships' House and in another place. I think that today's debate has also proved that we can show as keen and wide an interest in the question of handicapped people, whether they be mentally or physically handicapped, as in any other subject debated in your Lordships' House. It is now about two years since we had such a debate and many things have happened: some good, some not so good. The less good things have drawn attention to the problems of hospitals for the mentally subnormal. I am glad that so many of your Lordships have paid tribute to the people who have great problems and difficulties and who are responsible for hospitals for the mentally subnormal.

We have a most vigorous Secretary of State for Social Services in Sir Keith Joseph. He has managed to extricate from the Treasury—one of the most difficult things any Minister can ever do—large sums of money in order to help with the work of both local authorities and voluntary organisations. I want to stress that because I am exceedingly anxious that co-operation between the voluntary organisations and the statutory authorities should be very close indeed. The Minister of Education has also taken a very keen interest in the education of mentally handicapped people. I took a deputation from the National Society for Autistic Children to her not so very long ago. As a result of that visit, a circular went out to all local education authorities pointing out their responsibilities for the education of autistic children. In the past two years we have moved some way in the direction in which we are all so anxious to go.

I have two main interests in taking part in this debate. First, as the noble Lord, Lord Maybray-King, has so kindly said, there is my responsibility as President of the National Society for Autistic Children and my keen interest in the development of training and teaching for such children. Secondly, as chairman of the social work committee of my county council I do my very best to bring together all the voluntary organisations and also get the county council keenly interested in everything to do with social work, and to make both the statutory side and the voluntary side work closely together. I am sure that it is only in that way that we shall be able to get (a) enough help and (b) enough money because many of the voluntary organisations have a know-how and a call upon voluntary people to help which no statutory authority can achieve. The statutory authorities have access to money, particularly for capital enterprises, which obviously is exceedingly helpful and useful when enterprises, whether hostels or other capital expenditure, are required.

I agree in principle with all that has been said about the treatment of mentally and physically handicapped people. It is our great desire that they should not be kept in hospital unless there is no other alternative. The circular from the Ministry of Education to which I have referred estimates that 700 autistic children are in mentally subnormal hospitals who would not need to be there if only there were sufficient accommodation and teachers to help them outside the hospitals. The Ministry of Education circular urges the provision of teaching for autistic children. This is a great step in the right direction. It has made local education authorities conscious of their responsibilities in this connection. But issuing a circular and finding the teachers and accommodation to carry out the policy are very different things indeed. We still need a tremendous number of people who are trained in the very difficult techniques of teaching autistic children, otherwise no local education authority can implement this circular.

As has been said already, it is now a statutory responsibility of local education authorities to educate mentally retarded or mentally ill children if they are educable—as nearly all of them are—up to the age of 19. All too many have to stop their education, for instance in the case of autistic children, at the age of 11. After that they have to go either to classes for educationally subnormal children or, if those are not available, they go into hospital. For autistic children this is one of the most unfortunate and difficult things that can happen. The great difficulty about autism is to prevent children from becoming more and more withdrawn. One wants to keep them in a community where they are continually brought into the general pattern of education and not by any manner of means put into a large hospital where, for no other reason than that the nurses have no time because of their other duties, the children will go backwards and become less normal than they were previously.

Paragraph 19 of this circular contains a reference to a study which is being carried out in three different units concerning different approaches to the education of autistic children. I wonder whether the Minister, when he replies, will be able to tell us what has happened to this study? Has it been completed or is it still being carried out? It could provide us with valuable information. Paragraph 21 contains a reference to the need for more information about autism for the benefit of local education authorities and for those families who have autistic children. One service that the National Society provides is an information service. They are overwhelmed by inquiries from all over the country. If more support could be given to this service, and if more finance could be given to the Society so that more information such as the Ministry of Education finds extremely valuable could be provided, it would be very valuable indeed in spreading the knowledge about what can and is being done for autistic children throughout the country.

It seems to me that the priorities in this debate are for the provision of more education, which is badly needed for children of the age of 11 plus. There is also the importance of the provision of either hostel accommodation or some form of sheltered homes for the young adult of post-education age. I support all that has been said by the noble Lord, Lord Grenfell, and others regarding residential hostels. They are not at all easy to run; it is exceedingly difficult to get staff and it is no doubt very difficult to integrate those who are in the hostels with the community outside. This can be achieved, and it is much more likely to be achieved if it can be dealt with through hostel accommodation rather than in hospitals for mentally subnormal people.

There are three groups of mentally subnormal people for whom we have to provide accommodation. There are the normal school-leavers who probably could live at home and take a comparatively simple job. That does not present so great a problem, provided that some help can be given in their homes. Then there are the moderately handicapped children whose speech and understanding are not good but who do not need to be cut off completely from the world. They would undoubtedly benefit very much from a hostel where helpful supervision would be available and from which they could perhaps go home at weekends. That is quite a possibility and I am sure that accommodation of that kind would be readily taken up. Then there are the multiple handicapped and the very severely subnormal. These cases are more difficult, but here again, in many cases (someone has spoken about the Rudolf Steiner School in Aberdeen, which I know something about), these children also can be accommodated if there are sufficient staff to deal with them and if there is understanding and the possibility of sheltered work in sheltered conditions. In all these cases, I believe that hostel accommodation could provide a secure background for those with these disabilities; and sheltered employment (of which there is now great knowledge, because the Ministry of Labour have for many years been running sheltered workshops) could be organised so that interesting experiments and interesting work were carried out in these conditions.

There are two or three experiments, or experiences, actually going on at the present time which I should like to mention. The Balderton Hospital for mentally subnormal patients is now running a communities section where the nurses act as teachers. They wear no uniform, and the activities are more in the nature of club and community activities. The success of this is, I believe, quite remarkable. As to the Wessex Regional Hospital Board, Dr. Albert Kushlick is doing a controlled experiment by taking adults and children out of hospital and putting them into a hostel right in the heart of the community, and then comparing the results with adults and children who have been left in the mentally subnormal hospitals. Probably much will be learnt from that experiment. In the Wirral, in Cheshire, provision is now going to be made for a sheltered community which will be very valuable indeed. No doubt experiments in sheltered training and sheltered workshops will be carried out. The South Thames Hospital Board is to have a hostel for school-leavers and young adults. A great many experiments are going on, and I hope very much that the Department will watch the results in order to see how worthwhile schemes can be repeated, where they go wrong and where they could be successfully carried on.

However, my Lords, I believe that the key to the whole matter is co-operation between the local authorities and the voluntary societies. This is something that can be developed. Often voluntary societies cannot provide the capital, but they can provide the expertise, the training of teachers and the kind of knowledge to which a local education authority may have no access. I hope that, alternatively, where the local voluntary organisation manages to get the capital for a hostel or a school the local education authorities will then pay the per capita fees for the children who go to the school. Whatever happens, if only we could bring about close co-operation it would prove to be very important indeed. In this matter, we have in this country so much good will, so many voluntary organisations longing to help, and so many people who are anxious to do all they can to help, in this very big field which is developing all the time. I am quite sure that, with the help of local authorities, and the help of the Minister of Education and the Secretary of State for Health and Social Security, as well as of my noble friend Lord Aberdare here in this House, we really can do something. With their assistance, and their knowledge of the subject, much can be done that will lead to a great development of this idea of the hostel.

6.25 p.m.

LORD BURGH

My Lords, I want to speak briefly about the category of people who are handicapped by a mental disturbance which, as an admission of ignorance I think, is labelled schizophrenia or schizoid. This is a particularly important area because those who suffer from this kind of disturbance may well turn out to be in many cases among the most potentially creative members of the community. I believe it is becoming clear that what these people need is not a hospital in the old-fashioned sense, although there are hospitals which contain communities which do work of very great value. Nor do they need hostels—this term has a clinical and official connotation. What I suggest these people need is houses. People with this kind of mental disturbance differ from the physically handicapped in that they do not need the physical trappings to enable them to live somewhere. What they need are people of the right kind around them. The right kind of people are rather difficult to define. But to say that these people need a house brings out the important point that the unit is the physical house or building, with perhaps the garden land around it, or whatever the arrangement may be. Within this area all the community will be equal. This includes the patients (although I am not going to call them "patients") as well as therapists. This is already being done in some places; therapeutic communities are being run on a basis of equality, so that before a new member joins the community there must be agreement from all concerned. Somebody may come in for a trial period, but the patients have as much say as the therapists do in accepting a new member.

I do not think one need (indeed, here I agree with the noble Lord, Lord O'Hagan) keep the categories too rigid. It might well be that people with mental disturbance of a schizoid nature would benefit from living with people who suffer from physical handicaps, with educationally subnormal children, as well as with people who might be classed as normal. This is the other great advantage of the house concept. Houses can be of a tremendous variety. There can be variety of interest, variety of approach, variety of life style, and the common denominator remains common although the people who live in the place may come and go. The greater the variety of houses that is available, the better. Of course, this presupposes some information-gathering service so that hospital almoners and social workers can have an idea of which house to suggest for which patient.

Let us say that such houses exist in London. They may be ordinary terraced houses with perhaps six or eight people living in each house. One could visualise, as a next step in geographical expansion, an increased number of people interacting—something on the almshouse lines, with independent living units and perhaps common workshops, dining rooms, kitchens, and so forth. As a step up from the almshouse we get to a village community. All these communities necessararily must be sheltered in order to be able to help the patients. But whereas with physically handicapped people I think it is reasonably clear, and we can see the technological means we need to provide an environment which the person can handle, in the case of the mentally disturbed patient we must give a lot more thought to exactly what we mean by "sheltered". What in fact are we trying to shelter these people from? Many of them come from ordinary, good, family backgrounds. They have probably had all the advantages. What is it in the world that they are reacting against? What is it that we need to exclude from the sheltered community? This needs a great deal of thought, and I believe it is thought that is especially worth giving; because if we can decide on the requirements of the sheltered community it may well be that we shall find that the lessons learned can be applied with advantage to society as a whole. If urban industrial society is one in which intelligent and creative people cannot cope emotionally, then it is time to find out why, and to find out how it can be rectified.

6.32 p.m.

VISCOUNT DAVIDSON

My Lords, it is generally accepted that those who bat first make the most runs. Coming in so low in the batting order means that one is more likely to excel as a bowler than as a batsman. So as most of the runs have already been made I shall just content myself with bowling a quick over, the last ball of which will be a googly for my noble friend Lord Aberdare. But first, my Lords, I should like to add my thanks to those already expressed to my noble friend Lord Grenfell for initiating this important debate.

The reason for my intervention in this debate is that I have been involved for a number of years on the management committee of a large group of hospitals for the mentally handicapped. I have also been on the management committee of a group of hospitals which included one for the mentally ill, and I am also concerned with two schools responsible for educating educationally subnormal and maladjusted boys and girls. This experience has, I hope, enabled me to take a fairly broad view of the problems involved in dealing with various degrees and categories of both physical and mental handicap from, as it were, the grass roots. As a layman in these matters I hope, too, that the judgments which I have formed are objective rather than subjective. What I have to say in the next few minutes is concerned solely with the problems of the mentally handicapped.

My Lords, as has already been said in this debate, there is little doubt that there is a large number of mentally handicapped people at present in hospital who could and should be housed and cared for in hostels in the community. The actual numbers vary from region to region and from hospital to hospital. In a remarkable piece of research called the Report on the Newcastle-upon-Tyne Regional Aetiological Survey 1966–1971, which contains a mass of interesting statistics and valuable conclusions—and which I commend to your Lordships—the author, Mr. George McCoull, gives the following statistics showing the reasons for admission to hospital in 4,806 cases of mental retardation: rejection by parents, 2.2 per cent.; inability of parents to cope, 41.3 per cent.; illness or death of parents, 19.1 per cent.; needing constant medical or nursing care, 15.4 per cent.; disturbed behaviour, 17.8 per cent.; temporary care, 3 per cent., and other reasons, 1.1 per cent.

Mr. McCoull goes on to analyse those figures in some depth, but the general conclusion is that many of those in the first two categories—that is, rejection by parents or inability of the parents to cope—could, after proper social training and with proper community programmes, be discharged to their homes. The patients in the third category, those who are there due to the death or illness of their parents, and are probably in the age group of between 40 and 50, are considered essentially to be types of patients for whom hostel accommodation should be made available in the community. So in this particular region it is suggested that in all there are 3,007 patients (or 62.6 per cent. of those in hospital) who need not be there, and that of these, 741 could go straight away into hostels. Multiply this situation throughout all the regions and it becomes clear how enormous is the problem.

Unfortunately, it is also quite clear that at this moment in time the policy of reducing overcrowding in the hospitals for the mentally handicapped has not yet been matched by the provision of hostel accommodation. It takes a long time for a local authority to approve, plan, build and staff a hostel, and although there are signs that some of the more progressive councils are getting on with the job I fear that we are in for a period of considerable pressures for parents who have mentally handicapped children. Indeed, I wonder whether the provision of hostel accommodation at the present rate will ever clear the waiting lists (and I am sure that we are all agreed that these are the ones who should have the priority) let alone allow even a small exodus of those less severely handicapped who are in hospital.

It may interest your Lordships to know that in the group of hospitals with which I was involved there have been for many years—since before the last war—a number of higher grade, or less severely handicapped, patients living in large suburban houses which have in fact acted as hostels or, as I prefer to call them, "halfway homes", and these are managed within the hospital group. These patients live in a homely, comfortable atmosphere and many of them go out to work. These houses do not perhaps provide ideal accommodation measured by modern standards, but I suggest that an extension of this idea could help to alleviate the situation in the short term. It certainly takes less time to buy a house than to build a hostel, and this type of house is one of the least popular in the residential property market. Indeed I would go further, and would seriously suggest that the whole question of the siting and land usage of hospitals and hostels for the mentally handicapped should be looked at in depth. Perhaps this is a job for the Working Party suggested by my noble friend Lord Grenfell. earlier in the debate. My guess is that there are thousands of acres throughout the country which are occupied by old-fashioned, out-of-date hospital buildings, sited in development areas, which could be sold off for residential development and the proceeds used for building the modern accommodation, whether hospitals, villages or hostels, which is so urgently required.

This brings me to the nub of the matter, and I am encouraged in my views by what I have so far heard to-day. I believe that the time has come for a new, radical and practical approach to the whole problem of mental handicap on a national basis. It is not just a matter of injecting more money into the service. It goes deeper than that. It involves a complete reappraisal of the needs of the mentally handicapped. I am, for instance, far from convinced that what some social scientists say, using what Mr. McCoull, to whom I have already referred, calls "psychiatric Esperanto", is necessarily best and coincides with what those patients would actually prefer. I have certainly seen a happier community spirit inside a so-called institution than I have seen in the community outside. I am far from convinced that the solution lies in further integration into the reorganised National Health Service. What is called for is an integrated, unified, national policy for the mentally handicapped, embracing all the disciplines involved and covering all the different forms of accommodation. This pre-supposes a separate authority responsible for the planning and financing of the whole service for the mentally handicapped, working in close liaison with the Departments of Health, Education and Social Security, as well as with all the voluntary organisations. My experience in hospital management has taught me that the problems of hospitals for the mentally handicapped are totally different from those of other types of hospital. Indeed, the only points of contact seem to be concerned with the joint supplies of stores, the sharing of laundry facilities—although this in itself presents very great problems—and the use of essential pharmacy.

The care of the mentally handicapped calls for special skills in nursing, medicine, education and training, and at the moment we are seeing all three departments being involved in this work. These skills should be looked at as a coherent whole and not split up into separate parts. I am quite certain that, whether in hospitals or hostels or villages, there is a fund of help and good will among those who are involved in the care of the mentally handicapped, and that they will respond both positively and enthusiastically if given the encouragement. I am sure that we are all agreed that the objects of Government policy should be not only to relieve hard pressed parents but to make the lives of those who are permanently handicapped and of those who look after them more comfortable and rewarding and worth while. I feel that the debate to-day has given us an opportunity to examine constructively, and perhaps critically, as to how best these objects can be achieved.

6.42 p.m.

LORD SOPER

My Lords, in adding my own sense of obligation to that which has already been expressed many times in your Lordships' House this afternoon to the noble Lord, Lord Grenfell, the initiator of this debate, may I specially thank him for the wide coverage of his Motion, which enables me to talk quite properly about the problem of alcoholism, to which I will address some remarks in a moment. Perhaps you will allow me to say how much I appreciate what has been so movingly said, not least by the speaker who has just sat down, about the peculiar needs that have to be met by those who would seek to succour the mentally defeated or afflicted or distressed. If this is so, and I believe it is, I think it calls more clearly for an understanding of what we mean by the word "hostel", or what we ought to mean by it, for it is not a word which is self-defining.

My experience of hostels goes back some 45 years, and I confess to an increasing bewilderment in some areas as to what ought to be meant by this omnibus word. Certainly there are vast changes that have taken place since first I began to take an interest in hostels. The emergence of television has destroyed the lounge, and therefore if a hostel is to have any community life it must provide at least two public rooms. Otherwise the silence, at least of those who are watching, is demanded in the television room, and there is no such thing as a community of fellowship. Secondly, in every kind of hostel (and I refer intimately to the hostels of which I have personal knowledge: hostels for boys out of borstal who are homeless, hostels for delinquent girls, old people, unmarried mothers, alcoholics and so forth) the do-it-yourself impetus has been vastly strengthened over the years, and I welcome it.

The kind of hostel which I believe has permanence and validity to-day has more in common with the "bed-sit.", with a Mother in Israel or a Mother-in-God to take care of those who are there being cared for, than the old-fashioned type of closed community. Furthermore, I was immensely impressed by what the noble Lord, Lord O'Hagan, and the noble Lord, Lord Burgh, had to say about the need to-day for recognising that hostels should not necessarily be isolated in terms of the particular impediment or the particular difficulty expressed by those who seek refuge in them. It is a matter of some interest to me that the noble Lord, Lord Burgh, referred to a terraced system of hostels. We have appropriated just that not so very far from your Lordships' House, and we have found to our astonishment and pleasure exactly what Lord O'Hagan had to say about the value of mingling various types of people in various kinds of need in hostels, and not segregating them too much in proportion to the particular need from which we assume they suffer. We have found that alcoholics have a particular penchant for caring for old people. It is also very interesting that those who are at the moment under our care as homeless ex-borstal boys have developed an amazing capacity for organising their own affairs with a sense of responsibility they never expressed when they were under somebody else's authority. This is a very pleasant reflection and has much hope in it.

But to turn to the main problem, on which I think these sidelines are not inopportune comments, the noble Lord, Lord Rosenheim, the other day gave further evidence of the seriousness of one particular kind of handicap and disability; namely, the widespread permanence, in fact the growing menace, in our society of alcoholism. He calculated out of his expert experience that there must be about 350,000 alcoholics. The Carter Foundation estimates the number to be 400,000 and the National Council against Alcoholism calculates it at 500,000. And this is the male calculation. We have no knowledge as yet how many bottles in how many cupboards represent female addiction to alcoholism, though I suspect it is very large among suburban house-wives of a particular age. I do not know, but inasmuch as we have made an experiment in running a hostel for women alcoholics, we have a considerable amount of evidence, that is now growing day by day, that this is a problem which sooner or later cannot be brushed under any carpet.

What I have to say is this, that there is a particular relevance in the word "hostel" when it is applied to the problem of alcoholism at its three stages. When I began to take an interest in alcoholism my main equipment was that of a Band of Hope background, not I think the best. I was surrounded at the same time by a number of very dogmatic statements by medical people who should have known better. They had an inordinate belief in the nauseating efficiency of apomorphine and antabuse and other drugs, and they were eloquent in saying at that time what were the physical characteristics of this disease, which of course it is. They were right in saying that there was no point in appealing to the alcoholic to put his backbone into the recovery and into going "on the water wagon", because his backbone had long since disintegrated.

We made innumerable mistakes and we have learned from our experience. I would, if I may, put that experience to your Lordships, and say, I think not too arbitrarily, that there are three stages, and they are all hostel stages in the development of at least some attention to, and hope for, the recovery of the alcoholic. The first is the drying out stage, when he comes dishevelled, in a state of collapse and indeed a miserable and pathetic object. And if a male alcoholic is a pathetic object, then I will not endeavour to wring your withers by saying that there is nothing so heart-rending as the condition of a woman alcoholic in the tertiary stages of that disease. It used to be thought that the first stage for drying out a patient must be a medical stage and that it ought to be in hospital. I do not believe that to be true. I think that laymen in constant touch with doctors can provide the therapy which is much more effective than antabuse or any other nauseating drug. It is a fellowship of belief, of friendliness and of protection.

When the drying out stage has been accomplished, after a few days the second stage has to be entered upon. That is the stage of rehabilitation. That is a hostel procedure for many who have irretrievably lost the opportunity of recovering in the bosom of their families. This process of rehabilitation is possible when there is a dedicated and environmental kind of atmosphere in which encouragement can be given to the man who wishes to recover, and when he can be protected against the hazards and temptations to which he would so easily succumb if he was on his own. This kind of hostel accommodation ought to take about five weeks to two or three months.

Then comes the tertiary, the third stage, because the assumption that an alcoholic recovers is dubious. It is much more likely that he will arrive at a kind of plateau, at a kind of permanent convalescence. The idea that he will become radically changed reminds me of a legend which I saw in an American city over a créche in which little children were being cared for while their parents worshipped the Lord. It read: We shall not all sleep, but we shall all be changed. The fact of the matter is that a great many of these alcoholics are temporarily recovered, and provided they have a sheltered opportunity of living afterwards are likely not to relapse. We have set up a couple of hostels in which these recovered alcoholics, both men and women, can begin to make a fist at living in the big world once again. The embarrassingly hopeful fact is that they do not want to go, and consequently these hostels are now full. There is no prospect of their being emptied because the alcoholic can move on into the full rigours of the world which has accomplished his defeat so often in the past. There is a constant and growing need for this kind of hostel, not for every kind of alcoholic but for a great many of those younger alcoholics who have almost permanently destroyed the kind of domestic happiness and opportunity to which they were accustomed and from which they are now prohibited.

In all these circumstances it is the proper kind of hostel which appears to us, out of our experience, to be what is required. I understand from the Minister that there is something like £2 million lying about somewhere, and I should like to get my pious hands on it, if the Minister will tell me how I can do that, because at the moment we are operating the second stage of our alcoholics' redemption or rehabilitation work in an old workhouse. Though it has been vastly improved it is not an ideal place, and there are many things that we have learned about what is required if we are to make a better job of that rehabilitation process.

I venture to delay your Lordships a little on this subject because 500,000 male alcoholics—to say nothing of the women alcoholics—is a very large figure, and some quite startling evidence has now come out of France. It is not that France is better than we are or worse than we are—indeed, I suspect that they are somewhat worse than we are. We used to say that at least they knew how to drink in France, but the fact is that they do not, and there is a greater problem of alcoholism in France. In the Department of Paris—these are facts which can be found in Figaro; whether that is a reliable document or not I pass it on, for what it is worth—they have come to the conclusion that 77 per cent. of all the road accidents in the Department of Paris have at least some connection with over drinking. I have just quoted their figure; I do not know what the figure is in this country. I do know that the noble Lord, Lord Rosenheim, was eloquent in the evidence he presented of the economic disasters that begin long before the black-out prevails in the condition of the alcoholic. It would be an immense saving to the community, quite apart from any other more moral or spiritual consideration, that such hostels should be provided in greater measure and with greater competence than hitherto. May I offer to the Minister a comforting piece of advice? It is highly likely that any hostel set up in the third stage would be self-supporting financially, for the curious and rewarding fact is that many recovered alcoholics have apparently a better chance of getting a remunerative job than people who recover from other disabilities. We are pleased to have found that to be true.

May I end with two comments; one has to do with the problem of training. I am immensely proud of the team that runs the St. Luke's and St. Mary's hostels. Those who run these particular hostels are youngsters; not one of them is more than 30 years of age. They do a colossally impressive job and have a maturity of judgment and a kindliness which would put a great many oldsters to shame. But we cannot depend on a permanent flow of such extraordinary young men and women. There is a paramount need, if I may suggest this to the Minister, for training in the equipment which is slowly being acquired and recognised in this treatment of alcoholism. It is not necessary now to repeat the stupidities and failures which accompanied many of the voluntary attempts in the first instance some years ago to deal with this growing evil. There is great need for training and understanding, and the staffing problem of hostels generally has not been overstated by my noble friend when he was speaking on this subject. If anything, it has been understated.

I recognise that ultimately the community itself must make itself responsible for this kind of problem, and cannot leave it to the voluntary bodies, however excellent and however enthusiastic and dedicated they are. But I suspect that in whatever degree the community does make itself responsible, there will be a predilection on the part of many sufferers from this and like handicaps to prefer the voluntary association to that which they would still regard as having something of the stigma of officialdom. I am not saying that they would be right in that; I am only saying that that is one of the conditions which might well prevent them from arriving at the door of a hostel, or from being prepared to take the initial step of coming within its friendliness and its help. I believe that voluntary bodies can be stimulated by a debate such as this and can be encouraged, I hope, to make experiments in this field.

If I may interpolate another comment, some of your Lordships will know that a certain Church of England last week failed to recognise the excellencies that would belong to any realisation that the Methodists had much to offer to them. I will acquit, of course, the Bishops; they were on the right side for once. It was the laiety which let you down—not that we were impeccable ourselves; we had our own Lord's awkward squad. But if there is to be a further development in the voluntary provision of hostels, what better way of bringing voluntary bodies such as the churches together than to persuade them to forget for the moment their metaphysical difficulties and get down to the ordinary jobs which belong to the Kingdom of God? There is a great well of untapped resources in the voluntary bodies. There is a fellowship that those voluntary bodies can add to the expertise of those who, with admirable motives, are seeking to operate a scheme, any scheme, of social redemption because it is the right thing. But may I add that there is a particular quality which I have found in the dedication of those who believe that this is their bounden duty and service and which can add imperishably to the efficiency of any community recognition of an evil and any community attempt to deal with it.

6.58 p.m.

LORD PLATT

My Lords, I must of course begin by adding my thanks to the noble Lord, Lord Grenfell, for initiating this debate. In the splendid and understanding speech which he made he very largely restricted himself to mentally handicapped people, but he made it quite clear that it was open to any of us to discuss other problems which came within the definition of the care of handicapped people who do not need hospital treatment. I should like to take a few minutes of your Lordships' time in referring once again to the problem of the socially handicapped, which has to a very large extent been the theme of the noble Lord, Lord Soper, and of the noble Lord, Lord Donaldson of Kingsbridge. I am indeed rather surprised that more people have not referred to this problem of the socially handicapped.

The "single homeless" is a phrase which also fits most of the kind of people to whom I am referring, and for whom in the past the common lodging-house has provided many with a kind of solution to their problems. It is mostly a problem of men. They are a mixed lot. Some of them are mentally or physically handicapped or in some way inadequate. There are personality disorders; there are alcoholics; ex-prisoners; and they have in common an inability to find and keep regular work or to establish a normal home life. In addition, they usually do not want to be helped in any formal sense of that word. I want to call attention to the dwindling amount of accommodation of the common lodging-house type in the whole country, which gives these people less and less opportunity of "looking after themselves", to use Lord Donaldson's phrase.

Many years ago, between the wars, I lived in Sheffield, and that was during a period which included the 1930s and the great unemployment. We used to get many rather down-and-out people calling at the door, asking for a few coppers or a little silver to help them to find a night's lodging. Some of them were rogues, and I know perfectly well that if I gave all and sundry the odd sixpence or shilling they would tell all their friends. But I was fortunate enough to have a friend who was in charge of what was called a working men's hostel in Sheffield, which had been started by his father. The accommodation was simple and clean, and bed and breakfast were provided for the very small sum of, I think, about Is. 6d. The men could also buy their own food, and there were facilities for cooking it. Some were regulars, some were practically permanent residents, and a good many were casuals. But whenever someone asked for money for a night's lodging, I used to say that I did not give away money, but that if they went to the hostel at West Bar, and if the hostel would take them—which was an important provision, because the people at the hostel knew all the old lags and the "bad hats"—then I would pay for their lodging. About half of them never turned up at the hostel, but I was only too glad to pay my few shillings for the others who did.

There is still, I think, a very great need—and, so far as I know, there is no evidence that the need is growing any less—to see that there is accommodation of that kind available for these social misfits, and thereby keep them from sleeping rough, and keep them out of the prisons and the mental hospitals from which many of them have come in the past. The need has been brought to my notice recently by the closure of Butterwick House, in Hammersmith, which catered for between 700 and 750 single men, though rather fewer in the summer. That hostel has fallen under the development plans of Hammersmith (to which I am not of course raising any objection), which have necessitated the compulsory purchase of existing buildings, including this hostel. Accommodation was provided for those men at a cost of 45p to 55p. Many of the inmates had mental or physical handicaps, and were obviously the same kind of people as my friend used to cater for in his hostel in Sheffield. Both that hostel and the Rowton Houses have been run independently, on their own funds. The closure of these beds has led to there being a large number of people for whom it is difficult to cater. I think that most, or all, of them have been offered some alternative accommodation of other kinds, but many have not taken up the offer. They are the kind of people who prefer to seek something for themselves rather than to be helped. Many of them go away during the summer to coastal places, where there may be more opportunities for casual work of various kinds.

The case of Butterwick House was discussed in another place in an Adjournment debate, initiated by Mr. Ivor Richard on March 24 of this year. The problem in the country is illustrated by some figures that have been given to me from a survey undertaken by the Christian Action people which I believe is shortly to be presented to the Secretary of State for Social Services. The survey is concerned with common lodging-house accommodation and compares 1962 with 1972. I will give your Lord-ships only four examples. The number of beds in Manchester has dropped from 1,523 to 293; in Liverpool, it has dropped from 1,024 to 782—not so bad; in Glasgow, from 2,087 to 812; and over a period of twelve years the Rowton House accommodation in London has dropped from 4,536 to 2,180.

Replying to Mr. Richard's debate in another place, the Under-Secretary of State for the Environment gave some assurance that the Government and local authorities had taken steps, but admitted that there was a large waiting list for housing in Hammersmith, and a countrywide shortage of accommodation for the homeless single of this kind, especially in London. I understand that a working party on homelessness in London, set up by the Department of the Environment, will be reporting in the near future (perhaps I have missed it, and it has reported already) and that a survey of lodging houses by the Department of Health and Social Security should appear very soon. I should like to be told whether we may very soon expect to see the survey. I believe that another working party has been set up by the London Boroughs' Association, which is also due to report. The Government have promised to deal expeditiously with these surveys as soon as they are available. I admit the great difficulties, and the need for facts before expensive action is taken, but those who are interested in this problem await with some mounting sense of urgency a little further assurance of positive action.

7.8 p.m.

VISCOUNT GAGE

My Lords, I apologise to my noble friend Lord Grenfell because, owing to another engagement, I did not hear his speech. But I have heard sufficient to make it obvious that this is a very vast subject, and that it has attracted a great deal of interest, sympathy and support. For the moment, I am concerned only with what might be termed the post-hospital period, when the patient no longer requires constant medical supervision but is not quite ready to go out into the world. As often as not, this seems to be more of a housing problem than a medical problem. It is a problem of finding the right type of house in the right place and at the right cost.

I had occasion recently to ask Her Majesty's Government and your Lord-ships for some support in legislation dealing with housing associations. Now that support seems to be forthcoming, I should like to suggest that the small home, which I think many of your Lordships have in mind, can be supplied more efficiently and cheaply by the specialised housing association than by any other agency; and I speak as a member of a local authority. Of course I am not suggesting that we could take on all of the 37,000 which the noble Baroness, Lady Young, said needed new accommodation, but we could make a substantial contribution to their rehousing. I say that because we have a certain expertise in finding sites for new buildings, for putting up new buildings, and for converting existing buildings. We have a certain expertise in getting Government grants and, as the noble Lord, Lord Soper, pointed out, that is quite an expertise in itself. We can also find voluntary help. I think my noble friend Lady Elliot was perfectly right in saying that there are great numbers of people who are prepared to do this sort of work. Then we have certain limited central funds. We have a good deal of experience in dealing with the Abbeyfield type of home, originally conceived as a remedy for loneliness. What is now wanted seems to bear some analogy to those original Abbeyfield homes.

We are already in negotiation with some of these rehabilitation societies. It would be foolhardy to make any firm predictions at a time when local authorities, housing finance and medical services are all in different stages of reform. But one of the beauties of the housing association is its great adaptability, and at least I should have thought that before trying to raise large charitable funds, and even before attacking too violently the local authority, these promotional groups might possibly find it worth their while consulting the National Federation of Housing Associations.

7.12 p.m.

BARONESS HYLTON-FOSTER

My Lords, may I start by adding my congratulations to the noble Lord, Lord Grenfell, for initiating this debate again to-day, it having been put off owing to his illness. There are many speakers on the list, and I hope he is gratified by the number. I also hope it is not more than he bargained for. May I say how much I enjoyed the speech of the noble Baroness, Lady Young, and how encouraged I was by the plans she talked about for the future? I would congratulate her on her first speech from the Government Front Bench. I should now like to draw attention to a section of the community who are not normally handicapped for any length of time. I refer to those patients who are discharged from hospital at short notice and who have no one to care for them when they get home. In 1969 the Dan Mason Research Committee carried out a pilot study to discover, among other things, what happened to patients when they were discharged, and the results were published in a little book called Home from Hospital by Muriel Skeet. I should like to try to explain how some of these patients would benefit from a short stay in a hostel. I will list very briefly the points brought out in this little book. First of all, there are the discharge dates. Most patients are given one to three days' notice of discharge—probably 48 hours' notice—and no more. This gives them little time to think about all their problems. Very often the consultant has done his round before they know they are going to be discharged and so they have no opportunity to ask him the final questions. Patients living alone and with no telephone start worrying about getting the food in at home, and other domestic problems; and other patients fret lest their families have not heard that they are coming home and will have a fit when they get there.

This report also brought out the question of advice given to patients leaving hospital. Although sometimes they received some advice, very often they were merely told, "Do not do too much" or, "Take care of yourself". Over 60 per cent. of the patients discharged were discharged with either medicines or tablets of some sort or another to take, and only some of them received advice on possible side effects. Some patients were taught to do their own dressings, but many patients were far too excited at the idea of going home, or sometimes too worried at the idea of going home, really to take in the verbal instructions. Then there is advice on treatments and diets. This was seldom taken in properly, and many patients did not realise how expensive it could be if they were on a diet. As to advice on appliances, there has been some mention of this subject earlier to-day, but I should like to draw attention to crutches, for instance. When in hospital, it is fairly easy for people to manage on crutches. The odds are that the floors of the hospital are non-skid, and if the crutch falls down there is probably somebody to help the patient pick it up. But when patients go home straight from hospital—catapulted, almost, from hospital to home—what happens is that they arrive and have to walk on their own floors, which are nice and shiny but are not non-skid, and they probably have loose rugs which, when the crutch goes on them, slip. They can very easily have another accident and be back in hospital again.

Another problem was advice on drugs. I have already mentioned this matter and said that patients were worried about side effects. Very often they had not been warned that they might suffer from, perhaps, dizziness or some gastro-internal upset. It was probably all quite in order, but they had not been warned that it would happen, and they were largely very reluctant to get in touch with their local general practitioner who, the odds were, did not even know that they were home and so had not called. Then, the last thing was the need for nursing equipment. Few patients, it turned out, had sufficient knowledge of what they could get and where they could get it, and some, in their panic, spent ill-afforded money on it—and that just at a moment when they probably had not very much money anyhow. These are just a few of the problems, and the noble Lord, Lord Greenwood, mentioned others when he was talking about the illness of his wife, who I am sure we all hope will soon be quite restored to health again.

These are some of the problems facing patients on leaving hospital. Most of these people would benefit from a spell of convalescence, but there are far too few convalescent homes and there are many patients with families dependent upon them who could not possibly afford the time to reap the benefit of a proper stay in a convalescent home. If only they could go to a hostel for just a day or two they would probably gain self-confidence. While they are in hospital, I am sure noble Lords will agree, there is always somebody to help, somebody to encourage, somebody to advise, somebody to take responsibility and somebody to make decisions. But when they go home there is nobody to do this; there is nobody to reassure and nobody to take responsibility. Surely all this anxiety could be lessened for those patients if they could have a short spell in a hostel. There, they would not be alone, but they would be on their own so far as looking after themselves was concerned. Presumably there would be a warden or a matron of whom they could ask all the questions that they had forgotten about before they left hospital. My Lords, I wonder whether a few days in a hostel would not cost the Exchequer much less than a bed in a convalescent home, or perhaps the patient's going back to hospital again. So I ask the noble Lord who is to reply for the Government to recognise the problems that some patients have to face and what a help to many sections of the community would be some sort of halfway house or hostel.

7.20 p.m.

LORD SEGAL

My Lords, it falls to my lot this evening to wind up what I am sure we all agree has been a most valuable and constructive debate. We have heard many excellent speeches this afternoon from all parts of the House. I feel that there is no subject on which this House can speak to better purpose and with greater unanimity than in pleading the cause of the under-privileged, of the suffering, of those who are deprived in our community. Although I am very conscious of the fact that I ought not to detain the House from hearing the reply that we all await from the noble Lord, Lord Aberdare, I cannot refrain from also expressing my own indebtedness to my noble friend Lord Grenfell (and he will always be my noble friend, on whichever side of the House we may be sitting) for initiating this debate. For the last seven years I have enjoyed the great and valued privilege of close collaboration with him as the honorary treasurer of the National Society for Mentally Handicapped Children, an office in which he served with great distinction for over 12 years. Never could I have sought for a more devoted and dedicated colleague. All the good wishes of our 40,000 members go out to him in wishing him good health and every happiness in (if I may call it so and as this afternoon's debate so well demonstrated) his future period of "non-retirement".

Secondly, may I also congratulate the noble Baroness, Lady Young, on her supremely sucessful début at the Despatch Box on behalf of the Government. I have long enjoyed a very close and happy connection with her family. I should like to wish her every success in her new office. I feel that I must also congratulate the Government in selecting her to adorn and invigorate their Front Bench, sadly lacking as it has been for far too long in more than one Lady occupant.

My Lords, my main purpose in speaking at this late hour is to stress the urgency of this problem. For many years now the National Society for Mentally Handicapped Children has been seriously worried by the number of our local branches which, out of a sense of frustration and despair, have been driven to establish hostels of their own. Many of these attempts, launched with such high hopes, have foundered through lack of Government support, through lack of trained staff or through sheer lack of funds. It is one thing for an organisation to launch such an hostel; it is a totally different matter to maintain it efficiently afterwards. These hostels were born out of sheer desperation by parents of mentally handicapped children, embittered and frustrated by constant delays in Government action. These delays lie at the door not only of one Government but, I am sorry to say, of successive Governments.

Nor can these parents even now derive much comfort from the latest Annual Report of the Department of Health and Social Security. I quote from page 46 of the 1970 Report: During the year, Boards"— that is to say, Regional Hospital Boards— reported on their programmes of improvement mentioned in the Annual Report for 1969. These showed the extensive thought being given in all regions to current problems and the determination to deal with them. There is not much comfort there for parents of mentally handicapped children, parents who are living in a state of constant tension and anxiety, hoping for some rapid action on the part of the Government. Again I quote on the subject of hostels from page 24: In 1970, local authorities in England opened 100 new homes for the elderly with accommodation for 4,544 residents"— roughly 45 residents to a home— and three purpose-built homes for the younger physically handicapped. During the year 14 former Public Assistance Institutions and 1,991 places in them and other unsuitable premises were closed. There was thus a net gain of some 2,550 new places established during 1970 for old people as well as for young handicapped persons. Not a very impressive figure, my Lords, considering the size and urgency of the problem! But how many new places were established for mentally handicapped adults and, secondly, for mentally handicapped children during 1970? The figures can hardly be reassuring. I only hope that the Government will redouble their efforts in the years to come.

A paper on this problem read last month at the Royal Society of Health Conference at Eastbourne was singularly unhelpful. It was claimed that if the proposed transfer of patients to hostels was to take place on the scale suggested the number of hostel places would have to be increased from 6,770 to 67,000—a tenfold increase; that the capital cost would be over £120 million; that staffing of the hostels would be a major problem; and that the running cost of the hostels would be astronomical. And the paper concluded with the strange assertion, in this day and age, that: Most patients like living in hospitals for the mentally handicapped where there is a happy atmosphere with plenty of interesting things going on. Even if hostel places were available patients would strongly resent being transferred to them. This is to my mind an indictment of the mental atmosphere created in these hospitals. We know that to-day there is an incessant demand for patients to be brought to the end of their hospital existence so that their future may hold out some hope of a better life.

The whole problem of hostels has assumed a different character in the last ten to fifteen years. No longer is it solely a problem of providing hostels for children under 16 years old. Since the Act of 1959 these children have now grown up. The problem of making provision for young adults of over 16 who are undergoing training in sheltered workshops has become more urgent than ever. For these people hostels are not enough. What the Government must aim at, as the right reverend Prelate the Bishop of Coventry well remarked, is to promote the normalisation of the lives of these mentally handicapped adults. Our own National Society for Mentally Handicapped Children pioneered such a workshop many years ago at Slough, with young adults, both men and women, working together and living in adjoining hostels. They shared their recreation, they shared their meals, they shared their leisure time. There was thus created a community spirit which was aided enormously by a nearby club founded by normal children who were able to help and befriend these youngsters who were mentally handicapped.

We in this country still lag far behind the Scandinavian countries in their provision for adults. Their normalisation of the mentally handicapped has developed along many different directions. In addition to hostels, mentally handicapped adults have been placed in private homes with suitable foster parents, often themselves childless couples, where they can be visited by their parents and by trained social workers. Others, specially selected, have been boarded by the local authorities in private flats, under the care of a skilled nurse, where they could each have a room of their own yet mix freely together whenever they felt so inclined. Above all, they were not segregated exclusively to one sex alone. We in this country are still sadly lacking in provisions of this kind, yet they are very urgently needed. When mentally retarded adults have acquired special skills in sheltered occupations and have become self-supporting, they need a room of their own. The minimal requirement is that each should be able to develop his own individual personalities and be able to find some degree of privacy whenever he may need it, instead of being forced to live constantly in the company of others. We allow this privilege of a private room to many mental patients in Broad-moor. So why should we deny it to mentally retarded patients who have never committed any wrong against society?

I doubt whether we shall in my lifetime reach a state of affairs where a nurse is allowed to distribute a contraceptive pill to mentally retarded women patients before they retire for the night, but in Sweden this is accepted as a basic human need in certain selected cases. Indeed, many retarded adults need the company and companionship of members of the opposite sex and are very greatly improved thereby. Even the smallest degree of female companionship is to some of these men a solace far greater than anything appreciated by normal persons. It is, in my view, utterly wrong to segregate them entirely from the opposite sex. In this respect, factors of staffing and hospital management should be adapted to meet these patients' needs. I am hopeful that these considerations will be borne in mind by any humane and understanding Minister in the future provision of hostels for mentally handicapped adults.

So my Lords, our problem of hostels for the mentally handicapped has long passed beyond the realm of provision for children alone; the core of the problem has now been extended to include mentally handicapped adults. Whether we establish complete village communities or settle these people in hostels or in urban flats near to their place of work, local circumstances must determine—particularly in the case of varying types of mental handicap, such as the autistic patients, to whom reference has already been so widely made this evening. Certainly there is a crying need for all these types of projects to be carried into effect simultaneously. We are constantly reminded of the need to aid the underdeveloped countries. These countries soon resented being categorised as "underdeveloped" and were designated as "developing" countries. The present Government, like previous Governments, have been generous to other countries less fortunate than our own, and with the wide approval of all sections of opinion in this country. But we also have developing territories that need our aid here, within our own community. To-day, with the enormous advancements that have been made recently in the field of education, training and normalisation of the mentally handicapped, these have now become a vast developing territory in our own midst. Surely they have a first claim on the Government's aid and action support. I would urge the Government to come much more vigorously to the aid of these sections of our people, this country's mentally retarded, both children and adults, who now constitute a developing area in our own community, and to provide for them as urgently and generously as they possibly can.

I should like finally to acknowledge the fine tribute paid by the noble Baroness, Lady Young, to the work of the voluntary organisations in our midst. I am convinced that the scope for voluntary effort is likely in the near future to increase. In my own particular organisation we have been gratified to realise the enormous support that we have received from the younger people who have come in in large numbers to help us in our work. The work of the voluntary organisations must now develop into a two-way traffic to try to influence the Government, if necessary to exert pressure on the Government, and in return we look forward to the active encouragement and support of the Government themselves. And I feel convinced, my Lords, that we shall not look in vain.

7.35 p.m.

LORD ABERDARE

My Lords, this has been a very wide-ranging debate and I am somewhat daunted at the idea of trying to wind it up in a reasonable space of time. We have heard pleas from all sides of the House for different sorts of hostel for every different sort of client imaginable. In fact, I would not have been surprised if someone had asked for a hostel for those of your Lordships who are detained here sometimes late at night.

If I may borrow a word from the noble Lord, Lord O'Hagan, in whose remarks about the Patchwork idea I was certainly interested, as indeed in a number of original ideas which have been put forward in this debate, this has been a veritable "patchwork" of debate. I was also interested to hear from the noble Lord, Lord Burgh, about his sheltered community idea. The debate has also been very powerful because all of your Lordships who have spoken have been extremely expert in your own fields and have put your points not only forcefully but briefly and there has been no need for these ominous-looking clocks to tick. But I think the debate has emphasised the tremendous variety of needs that there are in this field and the colossal task that we face in seeking to meet them. I would acknowledge straight away what the noble Lord, Lord Segal, said in winding up for the other side, that indeed we have a long way to go.

I should like to join with all of your Lordships in thanking the noble Lord, Lord Grenfell. It is a great pleasure that he should have got his debate after a considerable waiting period. He was indisposed on the first occasion he put down his Motion, and it was a great pleasure to welcome him back here. He has initiated a most interesting debate. He has called for the increased provision of community hostels. Certainly I would not wish to dispute that; nor would anybody else who has spoken this afternoon. But I think it right at the end of this debate that we should remind ourselves that the great majority of the elderly and the physically or mentally disabled—those for whom social service departments may find themselves providing residential care—are in fact able to live at home. Many live with their families; some live alone—often with the support of their family. I echo the words of my noble friend Lady Young, earlier in this debate in paying tribute to those members of the family who give such loving care to their elderly or handicapped relatives at home. It is certainly the first priority of the social services to help such people to continue to live in the familiar surroundings of their own homes and to provide help not only to them but also, where necessary, to their families.

I was very glad that this was a point strongly made by the noble Lords, Lord Greenwood of Rossendale, Lord Amulree, and Lord Auckland, and by the noble Baroness, Lady Masham of Ilton. There is a wide range of services for this purpose available to the social service departments. They include the home nurse, the health visitor, the home help, Meals-on-Wheels, clubs, holiday homes, day centres, appliances, adaptations to buildings, and, not least, the advice and understanding of the social worker. I think it right to mention also the existence of the new attendance allowances which will gradually be extended to cover severely disabled people who need a great deal of help from another person by day or at night and also the new invalidity allowances for the chronically disabled. Nevertheless, as this debate has highlighted, there are many whose needs can be met only by the provision of residential care. Although none of us may be content, undoubtedly it is true that both quantitatively and qualitatively there have been great improvements in our residential services.

I was very pleased that the noble Lord, Lord Donaldson of Kingsbridge, the noble Countess, Lady Loudoun, and the noble Lord, Lord Soper, spoke of the staff of these hostels. In terms of quality they are even more important than the buildings. Life in a hostel will not necessarily be any better than life in hospital or other large institutional buildings unless there is the right kind of staff. The quality of life of the residents, regardless of the type of handicap involved, depends very largely on the care and interest shown by the staff with whom they share their daily lives. I should like to acknowledge gratefully the work of our hostel staff, often under conditions which are not easy, and in particular the efforts they make to create a homely atmosphere and a life as near as possible to that of the surrounding community. The right reverend Prelate the Bishop of Coventry referred to this as "normalisation".

The expansion of residential community care will call for a corresponding expansion in the number of residential social workers and a move towards the use of qualified staff in areas of residential work where this is still a new development. There has been a tendency for residential social work to be regarded as a separate junior partner of social work in the field. This has been reflected not only in the role assigned to residential social workers but also in the provision of training for them. The integration of local authority social services departments has led to the reappraisal of the relationship between residential and field social work. The recently established Central Council for Education and Training in Social Work is giving special attention to the development of training opportunities for residential social workers.

The Council is at present evaluating the experiments which were undertaken under the ægis of the Council for Training in Social Work and the Central Training Council in Child Care; experiments in establishing a two-year residential work training course, as recommended by the Williams Committee; in providing joint training for field and residential social work with children; in securing opportunities for serving staff to undertake part-time training and in encouraging the wider provision of staff development activities. The exacting nature of the demands of residential and social work is now understood and there is a very urgent need to provide wider opportunities for training.

My Lords, the provision of hostels, which we have been discussing, is almost entirely the responsibility of the local authority and in particular the very new and hard-working social services department. Despite the difficulties which have faced them good progress has been made and they well deserve to be commended for what they have already achieved.

My Lords, I should like to say something briefly about the relationship between the central Government and local authorities in this matter, a point which was touched on at the beginning of his speech by the noble Lord, Lord Hayter. I should like, while mentioning his name, to acknowledge the valuable help which we get from the King's Fund of which he is the chairman. We have to rely on two methods of stimulating local authority activity on any particular subject, such as the provision of hostels. We can use our powers of persuasion by means of circulars, Papers of various hues and personal visits by Ministers and officials, and all this we have done and are doing. Secondly, we can provide more money to make their task easier, even though in the end it is the local authority who decide how their available resources shall be spent.

It is said from time to time—I saw it in the Press the other day attributed to Mr. George Lee of the National Association for Mentally Handicapped Children—that the Government are not providing financial assistance to local authorities. I should like quickly to try to put the record straight. In our public expenditure survey published in November, 1971, we provided for a phenomenally high rate of expansion of both capital and also revenue expenditure on the social services, a rate of growth of the order of 10 per cent. per annum in real terms over four years. This increase is taken into account in both rate support grant negotiations and also in the authorisation of borrowing on capital account. It was our belief in responsible local government that led us, on April 1, 1971, to introduce a new system to give local authorities greater freedom in deciding priorities for capital expenditure.

Within what is called the key sector they still require permission to borrow, but within the limits of their non-key sector allocation they may borrow money on their own decision. This means, of course, that projects in the non-key sector have to compete with each other for priority; and to ensure that this does not slow down capital expenditure on social service projects new arrangements now operate, from April 1, 1972, so that local authorities may purchase sites for such projects as health centres and hostels outside their discretionary allocation. This means that, broadly speaking, only the cost of furnishing and fitting the hostel has to be found by a local authority from its own key sector allocation. But, my Lords, borrowing entails loan charges, and often it is on its current account that a local authority finds the tightest financial constraint. The subject of rate support grant is immensely complicated and it is easy to fall into the trap of oversimplification. Basically, it depends on the negotiation of total relevant expenditure, taking into account existing expenditure, additional inevitable commitments and new developments; and on this grand total the Government pay a proportion which is currently 58 per cent.

As a result of the additional £110 million for health and personal social services, which I was able to announce in this House in November, 1970, we were able to increase the amount negotiated for relevant expenditure on them in the rate support negotiations by £5 million in 1971–72 and by £6 million in the current year. This increase was specifically made to help the elderly, the mentally ill and the mentally handicapped. These were real increases in the resources available to local authorities for health and welfare purposes. In addition, we make considerable sums of money available for voluntary bodies. In 1971–72 these amounted to some £282,000 exclusive of grant to the King Edward's Hospital Fund and voluntary bodies for the welfare of the blind. Of this total, about £162,000 was given to organisations operating in the local authority social service field.

For 1972–73 the total provision has been increased to £1 million with the same two exceptions, and all fields of voluntary activity concerned with health and personal social service should benefit from this increase. May I say with what pleasure I heard from the right reverend Prelate the Bishop of Coventry of some of the projects being undertaken by the Church in the field of voluntary effort. May I also acknowledge the tribute paid by the noble Lord, Lord Segal, to the efforts of voluntary bodies in this field. I was very grateful to my noble friend Lord Gage for directing our attention to the possible help which could be given by the National Association of Housing Associations.

My Lords, my noble friend Lord Grenfell, in opening his debate, mentioned specifically the problems of hostels in hospital grounds. Many of the larger hospitals for the mentally handicapped already have units which are referred to as "hostels". Often these are on the periphery of the site, with a separate entrance from that of the main hospital, although some are off the main hospital site altogether. I acknowledge the great benefit that can be brought by having a hostel working in close conjunction with a hospital. But the object which both he and I have in mind is not likely to be very satisfactorily achieved in a large hospital which is often isolated from the community. The best siting for a unit used in this way is in or near a centre of population, where employment or outside training facilities are available, and where the residents of the unit will be able to meet ordinary people, visit shops and take part in other activities of the local community.

I know that my noble friend has always made tremendous efforts to help the patients at his hospital, St. Ebba's, and I very much respect his initiative in seeking to provide a hostel within its grounds. But, as he is I am sure aware, there are certain doubts in our minds. Unfortunately, as my noble friend Lord Auckland also knows, the Epsom area contains too much hospital provision for the mentally handicapped. His own hospital has some 600 beds, and the Manor Hospital 994 beds. In these circumstances, it really is difficult to justify the provision of further accommodation, albeit a hostel, within the hospital. At present, as I am sure he will agree, St. Ebba's has a very large catchment area—far too large—and the Regional Hospital Board are planning to rationalise this catchment area and to provide a hostel within the community, though operationally linked to St. Ebba's. This, in my opinion, is the right way forward, and I hope that my noble friend will feel able to direct his considerable energies in helping to promote such a plan. I hope that perhaps he may be able to get some help, too, from the King's Fund on such a venture.

There are a number of other points in my noble friend's speech to which I wanted to reply, but time is short, and I hope he will forgive me if I write to him, because there are a number of matters in other speeches that I should like to try to answer. In answer to the noble and learned Lord, Lord Gardiner, who spoke about the provision of a special after-care hostel for ex-Broadmoor patients—and I think he also included other patients from hospitals for the mentally ill—I should like to say, first of all, that we take the greatest care in arranging proper facilities for patients who are discharged from Broadmoor. There are social workers at Broadmoor who work in close collaboration with the social services department in the local authorities where the patients may find their homes. I should have thought that in certain ways there were advantages in treating patients discharged from Broad-moor in the same way as those going from other hospitals all over the country. One advantage, perhaps, would be that they would escape from the label of "Broad-moor" which the noble and learned Lord mentioned as a disadvantage. I think there might be a disadvantage if there were one single hostel known to be catering for Broadmoor ex-patients, and it would get an unfortunate label. I would only say that certainly this question is still under discussion, and I know that what the noble and learned Lord has said this afternoon will be carefully considered.

The noble Baroness, Lady Masham of Ilton, asked me a number of questions. I listened with great care to all that the noble Baroness said. As she knows, I am extremely interested in the problems of tetraplegics and, as she mentioned, I have been to see at first hand some of the difficulties. I shall study the noble Baroness's remarks with great interest. She made a point about the care of the younger chronic sick. We allocated funds in November, 1970, for the provision of extra facilities for the younger chronic sick, and this is going ahead. I have visited several hospitals where units are being built, and some of them, I think she will agree, are very pleasant buildings. As she said, there is an obligation under Section 17 of the Chronically Sick and Disabled Persons Act to publish the number of younger people in geriatric wards. At the most recent date for which figures are available, just under 2,500 chronic sick adult patients under pensionable age were accommodated in hospital wards principally for elderly patients; but only a small proportion of these were under 25 years of age—in fact, there were 43 under 25. I listened to what the noble Baroness had to say about the question of rehabilitation, which I think is a subject that would require a debate of its own. But my right honourable friend and I are extremely interested in this problem, covering again a wide field. I would only beg her not to press her suggestion of incorporating the word "rehabilitation" in the title of the Department, which is already too long.

The noble Lord, Lord Donaldson of Kingsbridge, spoke about the socially handicapped and the difficulty of crossing the frontier, as it were, between the Home Office and the Department of Health and Social Security. Both I and my colleagues in the Home Office are deeply concerned about the problem of the homeless inadequate. The whole emphasis of the Criminal Justice Bill, as the noble Lord knows, lies in the direction of providing community services for men in this group who have no real need of a prison sentence. My Department is anxious to foster experiment in the long-term support of the inadequate, often the very men of whom the Supplementary Benefits Commission have so much experience through their reception centre service. We work closely with the Home Office in this field, and we are represented on a Home Office Working Party which is reviewing the residential facilities needed for offenders under court order or on licence. This is one way in which we hope to overcome some of the difficulties to which the noble Lord referred.

The noble Lord asked me a question about sheltered workshops for the socially handicapped. I have a feeling that the socially handicapped are not at the moment catered for by sheltered workshops, but, as he probably realises, this is a matter for the Department of Employment, which is another frontier between Departments.

I was grateful to my noble friend Lady Elliot of Harwood, and a great many other of your Lordships, including my noble friend Lady Brooke and the noble Lord, Lord Maybray-King, who referred to the problems of autistic children. I should like to say how grateful I am to the noble Lord, Lord Maybray-King for quoting from my speech when I was on the other side of the House. I do not retract a single word of it; I am very happy to think that I was so wise even then. We readily agree that there is a gap in the provision of residential care outside the hospital service for this group of young people after leaving school. Local social service authorities are aware of their responsibilities, and if possible they place autistic adults in their hostels or arrange for them to stay in a home or community run by a voluntary organisation. But there is certainly a great deal to be done in this field. I am grateful to my noble friend for mentioning the circular from the Department of Education and Science. This recommends in paragraph 20 that the Education Department should make proper arrangements with ether Departments on the questions of employment, and on the provision of residential accommodation for those who may need it after leaving school. She asked me specifically about paragraph 19 and about the comparative study. Dr. Rutter has been conducting a comparative survey over the last six years. Data has been analysed and a report is due any time now. He has been examining two questions: he has been looking at the different approaches to special education of autistic children in three places, and relating this to the progress achieved. He has also been looking at the nature of the handicap and of the educational implications.

My noble friend Lord Davidson, whose great interest and first-hand experience in this matter I willingly acknowledge, made an interesting suggestion about the use of hospital land. I should be grateful if he would give me specific details about this. He suggested that he was bowling me a googly on the question of the provision of a special service for the mentally handicapped outside the National Health Service; but it was no googly to me. I am an avid reader of the Daily Telegraph and have already read his views on the subject: in fact, I rather expected him to mention it. I know that he will not expect me to comment now on that particular suggestion. It was certainly no googly, either, that I received from the noble Lord, Lord Soper. I had expected him to speak about the problem of alcoholics, for whom he has done such a great deal. He, as always, made a fascinating speech and I was extremely interested in his analysis of the three stages of hostel treatment required for alcoholics. I had understood—indeed I had inquired specifically about this point when I knew that he was going to speak—that when he came to see my right honourable friend the Secretary of State for Social Services he had expressed himself as not needing further financial support, and that this was not one of his problems; but now that he has told me he is in the field for further support—

LORD SOPER

My Lords, after some prayer on the matter I became convinced that we did need some finance. May I interrupt for one moment?

LORD ABERDARE

Certainly.

LORD SOPER

It is because of a development which now appears to be necessary in the actual work that our outlook has changed somewhat, and we shall be very glad to get any money that may be going.

LORD ABERDARE

My Lords, I will have to see that the second thoughts are taken account of, although I do not know the amount of money which by now has been committed. Seriously, I think it would be useful if the noble Lord would let us know what he has in mind.

The noble Lord, Lord Platt, also spoke about the socially inadequate. We have for some time been deeply concerned about the effects the shrinking pool of cheap lodging accommodation in London has on those people who have to use such accommodation. The noble Lord mentioned the forthcoming closure of Butter-wick House, and this provides a striking example of the problem. We are in close touch with the London Borough of Hammersmith in which the social services department is making strenuous efforts to meet the needs of all those of its visitors who require not just a new roof but also some form of care. The Borough has helped two voluntary bodies, both of which are receiving help from my Department, to set up a series of small hostels for these socially handicapped or inadequate men. My Department has also been planning with the local authorities and hopes to issue guidance to them on the need to experiment with providing long-term care and, if possible, rehabilitation for inadequates such as those who form the population of Butterwick House. My Lords, I have rather rushed through the comments of those noble Lords who have spoken. I will certainly study the report of their speeches later, and if there are any points which I have not had time to deal with this evening I will do so in writing.

8.5 p.m.

LORD GRENFELL

My Lords, my right of reply gives me the chance not only to congratulate but to thank my noble friend Lady Young for her first speech from the Despatch Box. It was a memorable speech and I know that we shall look forward to many more from her. I must say that I feel a little disappointed in the fact that I did not hear more about my village community idea, but I feel sure that the Ministry will study this subject and write to me in the near future. I am deeply grateful that we have had this debate. I think it has been a great debate, because not only have we had many speakers but it is of great importance, in my mind, that handicapped people all over England should know that we care. This debate has shown that we do, and that we shall do everything possible to help them in the future. With that feeling in my mind and with gratitude in my heart, I beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.