From Our Archive: A Policy for Old Age

Is this country today, although there are many services for old people, there is no policy for old age. The result is well summed up in the Boucher Report of 1957.’

Much of this failure can be attributed to the deficiencies of the National Assistance Act, 1948, which was to “be seen as the coping stone of the structure of the social services of Great Britain.” Its main preoccupation was the abolition of the Poor Law, and so it was a backward-looking rather than a forward-looking measure. There was much to be said against the Poor Law, though less against the Poor Law Acts themselves than against the administrative glosses which had been put upon, notably those of “destitution” and “lesser eligibility.” Again, the hatred of the Poor Law, eloquently expressed in the debate, was inspired by its treatment not so much of old people who normally formed the great majority of its beneficiaries, as of the able-bodied un-employed who only bulked largely in times of depression and had been outside its scope since 1932.

It was a backward-looking measure, not only because in abolishing the Poor Law it did away with something that was potentially good as well as with what was bad, but also because the new provisions were based on past conceptions rather than on new thinking which was beginning to take shape.

The good in the Poor Law was that it could give a coordinated personal service to its clients. The duty of Poor Law authorities was “ to provide such relief as may be necessary to the lame, impotent, old,” etc., and this was performed through relieving officers in charge of limited areas. It was the relieving officer's function to see that the applicant got the help he needed, and he had power to order both hospitals and institutions to admit those who needed their services. Relief is indivisible, and in theory at least an obligation lay to meet the whole need.

In introducing the Bill Mr. Bevan said: “Where the individual is immediately concerned, where humanity and warmth is the primary consideration, then the authority which is responsible should be as near to the recipient as possible.” These words were not reflected in the measure itself, by which the local authorities have no share at all in the administration of outdoor relief (the responsibility of the National Assistance Board) and the larger authorities alone, the counties and county boroughs, have responsibility for indoor relief. The only power given to the smaller authorities is that of contributing to the funds of voluntary bodies. Doubts were expressed in the House of Lords as to the wisdom of excluding the “closer touch by subordinate authorities,” and an amendment was actually moved by Lord Addington at the committee stage “to allow County Councils and County Borough Councils to make arrangements with housing authorities for them to provide accommodation for a certain number of these elderly persons, who would thus be able to live in their normal surroundings in their own neighbourhood among their own friends and their own relations,” but this was rejected.

In fact, the Government adhered to the old Poor Law distinction between outdoor and indoor relief, making the former responsibility of the National Assistance Board and leaving institutional relief to the larger local authorities. It was made clear that it was to be a new sort of institutional relief in small establishments as different as possible from the old workhouses, but these were still to be institutional in the sense that those in them were to lead communal rather than independent lives. The part that special housing might play was not considered.

Indeed, although reference was made from time to time in the debates to the fact that by 1970 one-fifth of the population would be of pensionable age, there is little recognition in the National Assistance Act, 1948, that this implied some new conceptions as to the social provision to be made for the old.

Hospital or Institution?

The existing defects in the social provision for old people are due in part to the complications and frictions resulting from the new administrative framework in which these services operate and in part to a failure to recognise the implications of the altered age structure of the population.

The first to attract public attention resulted from the split between hospital and institution administration, which, though not anticipated in legislation, had been foreseen by Lord Amulree in the House of Lords Debate on the National Assistance Bill.

The number of chronic sick beds in hospitals was actually reduced initially and there was no longer any official like the relieving officer with the power to order hospitals to admit, with the result that some old people in need of hospital treatment were left to die in their own homes and general practitioners “sometimes sought admission of unsuitable cases to Welfare accommodation in the belief they would be transferred thence to hospital.” Welfare authorities throughout the country report that admissions are increasingly infirm, mentally and physically, and these more infirm cases are generally accommodated in the old institutions, where the large staffs allow for night attendance and more constant supervision than in the small homes. Both hospitals and institutions have long waiting lists, so that each is chary of taking cases from the other; in 1955 there were some 4,500 patients in chronic wards whom the doctors considered should be in Part III accommodation, and about 2,000 residents in institutions whom the welfare authorities considered should be in hospital. To the lay-man visiting both types of accommodation, there appears singularly little difference between the types of resident in them.

The great difference between the establishments themselves is that those who enter hospital may get the benefit of geriatric treatment, and those who enter institutions almost certainly will not.

“Geriatrics,” says the Boucher Report,” “is not a clinical specialty, but is concerned primarily with degenerative changes and long term illness and has as its object the physical and social rehabilitation of the patients of which the latter is more com-plex.... Many geriatric physicians have had remarkable results and their successful methods have attracted wide interest.

There is no doubt that in future years the modern geriatric approach will be the normal practice in hospitals. If in hospitals, why not in institutions, to which the residents normally come also because of a physical or social breakdown, and where those residents, because generally caught at an earlier stage, are more likely to benefit from treatment? By this split between hospital and welfare administration the infirm old in institutions have for the most part been shut out from the benefits of the development of geriatrics. The Ministry has indeed recommended the appointment of Joint Geriatric consultants, but only in one or two instances has this recommendation been adopted.

Providing Accommodation

An even greater defect of the National Assistance Act which has become more gradually apparent, is its implicit assumption that the natural solution to offer to those old people who for any reason cannot remain in their existing homes is communal accommodation. That such an assumption was false was recognised even by the Minister who introduced the Bill, who in doing so used these words:

There are many reasons why old people cannot continue to live in their existing dwellings. They may have notice to quit, and be unable to find any other suitable accommodation within their means. They may have given up their homes impulsively following the desolation of the loss of a life-long partner. They may be living with children the growth of whose families in age and in number may leave no room for a grandparent. On the other hand, the daughter may be in employment, leaving the old person lonely and neglected in working hours. The existing dwelling may be so unsuitable as to be virtually uninhabitable by an old person. This is especially likely to happen in large cities, where the younger generation has opportunities of moving to new accommodation on the outskirts while the old people remain behind, and, because of their economic position, generally have to take the worst of what is left. Survey after of old people " has shown this to be the case. A similar situation exists in rural areas also, and in the Thingoe (Suffolk) Rural District Council area “reports which the Council received from its health officers at the commencement of the slum clearance survey under the Housing Repairs and Rents Act, 1954, showed that the majority of unfit cottages were occupied by old people living alone. Finally, they may have reached such a state of physical or mental infirmity that they are no longer capable of living an independent existence.

It is only with this last category that the obvious solution is admission to Part III accommodation, or indeed to a chronic sick hospital where geriatric treatment can be given. What is required for the others is suitable housing, suitable not only in providing compact, convenient, and easily run accommodation, but also where necessary in providing some degree of oversight and a sense of security.

But, save in county boroughs and London County, welfare authorities are not housing authorities, and so long as welfare authorities exist, so long as they are confronted with waiting lists for admission, they have a vested interest in providing more and better Part III accommodation, whether or not this meets the real need. Moreover, even when welfare authorities and housing authorities are one and the same, housing and welfare are always separate departments, with one exception. What this may mean is illustrated by the remark of a welfare officer in a large county borough, who on being asked if there was good co-operation with the housing department replied: “You wouldn't know we belonged to the same firm.” The one exception is Barnsley, where housing and welfare are under one committee and one administrative officer; Barnsley has the biggest old people's housing pro-gramme for its size in the country, and is almost the only welfare authority which has no waiting list for Part III accommodation.

Special provision for the aged has been a part of the programmes of housing authorities since the Housing Act of 1936. According to the latest statistics, 72,529 old people's bungalows had been built by the end of March 1958, but eight county boroughs, twenty metropolitan boroughs, fifty-seven non-county boroughs, 106 urban district councils, and ninety-five rural district councils had built none. One-bedroom flats may also be suitable accommodation for the old, though frequently occupied by younger individuals, but thirteen non-county boroughs, fifty-six urban, and seventy rural district councils had provided neither old people's bungalows nor one-bedroom flats.

Elderly people require special accommodation for two distinct reasons: first, because in the normal family cycle the household is reduced to two when the children have left home and the parents are aged from 56-60: secondly (and this happens perhaps twenty years later), because most old people become subject to increasing infirmity and isolation.

Old people's bungalows and one-bedroom flats take care of the first category, though it is to be noted that tenancy of the bunga-lows is generally restricted to those of pensionable age, while there are five million people in the country aged 50—59.

The infirm and the isolated require something more, perhaps most comprehensively described as a sense of security, and here little has been done until comparatively recently. The pioneer in this special type of provision was Sturminster R. D. C., Dorset, which in 1948 built a group of thirteen dwellings with a warden and a bell communication system and certain other amenities, and subsequently put up similar groups in the other villages in the district, receiving subsidy from the county council for all four schemes.Other counties began to follow suit, and while up to the end of 1556 only eleven had done so, by the end of 1958 the total was thirty (including Dorset), the number of schemes involved being 152 comprising 3,640 dwellings, while a further sixty-four schemes with 1,376 dwellings were under consideration.

This sudden activity was due to insistent promptings by the Ministry of Housing culminating in Circular 18 of 1957, which gave powers to county councils to grant-aid this type of accommodation without the ministerial consent which had previously been necessary, coupled with the fact that Government housing grants were discontinued save in respect of one-bedroom dwellings and slum clearance. The county grants of £20 to £30 per annum, plus the Government grant of £10, offered a considerable financial inducement to housing authorities to get on with this type of dwelling.

Now for the first time there is widespread and elective co-operation between some welfare and housing authorities in securing that old people shall get the sort of accommodation they want. But at the beginning of 1959 there were still twenty-seven county councils in England and Wales that were making no grants, and a further fifteen in which only one scheme was in existence.

The position in the county boroughs is less encouraging. Here there is no financial inducement: welfare departments do not make grants to housing departments, both generally being in competition to get such shares of the Votes as they can. It is doubtless for this reason that grouped old people's housing of the kind described is to be found in only twenty-nine of the eighty-three county boroughs, and where found is generally less fully developed—only six schemes, for example, had communicating bell systems. An illustration of the prevailing attitude was given in a conversation with the welfare officer of one county borough who claimed with pride that his authority was making the very high provision of 3-9 beds in Part III accommodation per 1,000 population and contrasted unfavourably the 1-2 and 1-8 of the two neighbouring counties. Asked if there was any grouped housing for old people in the borough he replied there was not, and on learning that in the two counties there were 124 and 106 such dwellings respectively, with twenty-six and 121 under construction, he agreed their lower proportion of Part III places might not be against the interests of the old people.

The lessons of the foregoing paragraphs appear to be that the chief obstacle to old people getting the homes they want are departmentalism and apathy, and the chief incentive a solid financial inducement.

Guarding Against impersonality

In 1939 the London County Council published a 250-page hand-book for its relieving officers, divided into two parts, the first entitled “The Relieving Officer as a Statutory Officer,” the second “The Relieving Officer as a Focus of the Social Services.” Today there is no relieving officer and no focus of the social services and this is the third great deficiency in the present set-up of the social services, especially in so far as they affect old people.

In the days of the Poor Law, the old person would apply for assistance, obtain medical attention and draw his relief all at one and the same office, generally not far from his home, and the relief staff could keep an eye on him, since his relief was paid to him weekly in person at his own home, if necessary. Today he makes his application for financial help at a National Assistance Board office (and because there are fewer of these they are, therefore, on the average more distant), goes to a general practitioner for medical aid, draws his allowance from an impersonal post office, and if he wants residential care has to go to a welfare office, these again being fewer and more scattered than they used to be. There is no one official who has an overall responsibility for his welfare, and those officials with whom he has to deal are scattered over a wide area. It is as easy to overrate as to underrate the merits of the Poor Law administration, but the present system assumes that an old person knows what he needs, and knows where to go for it.

That a gap had been left was recognised in Ministry of Health Circular 11 of 1950 which said: “The experience gained since the [National Assistance] Act came into force has shown an urgent need for further services of a more personal kind which are not covered by the existing statutory provision,” and went on to urge that this should be provided by voluntary effort with the support of local authorities. Voluntary effort under the inspiration of the National Old People's Welfare Council has made a great response, and there are now over 1,4000 local old people's welfare committees in the country providing visitation, clubs, meals on wheels, chiropody, and other services. No one would question the value of these committees, but they vary greatly in function, in effectiveness, and in their relations with their local authorities. Some, for instance, in Birmingham and Plymouth, may be virtually independent of their local councils, though working in close co-operation with them, and even undertaking what are normally regarded as local authority services—the home help service in Plymouth, chiropody in Birmingham, a laundry service in Bristol. In others, as in Manchester, there is friction. In others again, such as Salford and Nelson, the Old People's Welfare Committee is virtually an organ of local government, though much voluntary service may be given. Under section 31 of the National Assistance Act, 1948, A local authority ” (and local authority here includes county districts and metropolitan boroughs) “ may make contributions to the funds of any voluntary organisation whose activities consist in or include the provision of recreation or meals for old people. Provided that the local old people's committee includes one or other of these services in its activities, there is no limit to the financial aid the council can give. In the smaller and less wealthy areas where such committees are active the main financial support comes from public funds and this generally means that the local council is strongly represented on the committee and has a deter-mining voice in its policy.

There are two other noteworthy points in connection with the functions of old people's welfare committees. First, where they are independent of the local authorities there is yet another local office concerned with the needs of the old. Secondly, it is in the areas of the smaller local authorities, i.e., the housing authorities, that the greatest number of them functions, because it is in them that the community sense most readily finds expression.

Simplifying Administration

The administrative framework within which the services to old people function is now set in this country, and the time has passed when it would be possible to devise a fully co-ordinated scheme such as exists in Denmark. There, at the centre, there is no Ministry of National Insurance, no Ministry of Health, no Ministry of Housing and Local Government, no National Assistance Board, but one Ministry of Labour and Social Affairs. The local authorities (of which there are only two types, the county and the commune, which may range in population from a few hundred to Copenhagen with a million) act as the agents for central government as well as having local government responsibilities. Thus, those reaching pensionable age make application for their pensions to the commune, which is also responsible for granting any residual assistance required. The communes are both welfare and housing authorities, their responsibilities in respect of the latter being smaller because there are no housing subsidies except in respect of old people's housing. The counties are responsible for hospitals, but in the larger communes the welfare departments provide for the accommodation both of the chronic sick and of the aged. Thus, if an old person is in any sort of need in Denmark, he goes to the welfare office of his commune.

It would be impossible to introduce such a simple and coherent pattern of administration into this country today. But the old fall quite naturally into two main categories—those who on account of infirmity are incapable of living independent lives, and those who are capable, with or without assistance, of continuing to live in homes of their own. Both these categories arc now the responsibility of more than one authority. Is it possible to concentrate this responsibility?

The existing definitions of chronic sick and infirm, laid down by the Ministry of Health to determine which were properly in care in hospitals or Part III accommodation, are generally recognised to be unrealistic, largely because old people frequently pass from one category to the other and back while physical transfer is often impossible, even if desirable on human considerations. If an old person is to remain indefinitely in institutional care, it is far kinder that he should be able to regard the establishment to which he goes as his permanent home than that he should be liable at any time to move from one place to another, away from his friends and familiar surroundings. Moreover, as has already been mentioned, the present set-ug means that residents are virtually deprived of the benefits which geriatric treatment might bring them.

For this reason, if the two services were to be combined, it would seem desirable that infirm accommodation in welfare establishments should be taken over by the hospitals rather than the reverse.

With regard to old people living in their own homes, the great need is that some authority should be responsible for their welfare, and because the individual is concerned and humanity and warmth are the primary consideration, in the words of Mr. Bevan in 1947, that authority should be as near to the recipient as possible, that is to say, it should be the borough, urban or rural district council. This is not to denigrate the work of the existing old people's welfare committees, nor to suggest that they may not have an ever-increasing value. The mere fact that they have come into existence in so many of the smaller authority areas is an indication of what and where the need is. But there are still areas, even county boroughs, without these committees, and a complete coverage is needed which can only be ensured and perpetuated by the existence of a statutory responsibility.

These smaller authorities are also the country's housing authorities, and their constitution as welfare authorities would give formal recognition to the close relationship which exists between old people's welfare and their housing. It would also be desirable that the home help service should be transferred to these authorities. At present this service is the responsibility of the public health authorities (counties and county boroughs). As a result, and because there is a general shortage of home helps, complaints are constantly heard from those concerned with old people that when an emergency medical need arises (childbirth or severe illness) the aged are liable to lose the service which they so greatly need. To meet this situation, more than one authority has already transferred its home help service to the welfare department (Coventry is a notable example), and this is in fact the normal practice in Northern Ireland.

If housing authorities in general were welfare authorities, the situation which now exists in county boroughs would be reproduced, and there would no longer exist the stimulus of county council grants which has played so large a part in encouraging the provision of special housing for old people. It would be desirable that this should be replaced by an inducement from central government, and that the existing £10 subsidy for single bedroom dwellings should be supplemented by an additional subsidy of say £30 a dwelling for accommodation with welfare services provided specifically for old people.

Conclusion

This article has been primarily devoted to a consideration of the need for change in administration of the social services for old people. It may not be out of place to conclude with a word on the conceptions which lie behind these services. There exists in some of them an unconscious patronage of the old. Much thought is given today to what the community should do for them; much less to what they can and should do for the community. The greatest need of many of the older generation is better opportunities and better facilities to look after themselves and one another.

More consideration of this respect is needed at a time when, on the one hand, it is becoming customary to dismiss all people of pensionable age, women of sixty and men of sixty-five, as non-contributors, and on the other hand there are more of them with better health and more leisure than there have ever been.

The provision of more suitable accommodation, the government's proposal to relax the earnings rule in relation to old age pensions and the efforts of some industrial undertakings like Rubery Owen and Rolls-Royce to find a continued use for the services of their older workpeople, are all steps in this direction, but a great deal still remains to be done, and perhaps the best rallying cry for action in this field can be found in Mr. Ben Gurion’s “Old age is bad. It's not an achievement but a defeat. It should be fought like any other enemy.” Old people want help in that battle, and more support should be available to those who have not surrendered.

Originally published in the Political Quarterly, Volume 31, Issue 2 (April 1960), pp. 120-131

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