fabian tract 435 
new deal for the elderly

chapter 
1 introduction 1 
2 the social services 3 
3 housing and the elderly 11 
4 the NHS and the elderly 15 
5 summary and conclusions 25 

this pamphlet, like all publications of the Fabian Society, 
represents not the collective view of the Society but only the 
views of the individual who prepared it. The responsibility of 
the Society is limited to approving publications it issues 
as worthy of consideration within the Labour movement. 
Fabian Society, 11 Dartmouth Street, London SW1 H 9BN. 
July 1975 ISBN 7163 0435 X 


1. introduction 
There has been some public concern with 
the sca:le of public spending on the elderly 
but n1uch less with its pattern. Now at 
last the Government is showing some will 
to make fresh decisions and to shift 
spending away from institutional care. In 
the most recent circular on local 
authority capital programmes, the 
Government imp'lied that it was unlikely 
to give loan sanctions for old peopleshomes in areas which a'lready had more 
than 20 places per 1 ,000 elderly (Department 
of Health and Social Security, 
LASSL (74) 22). 

The main theme of this pamphlet is that 
the shift away from spending on 
institutional care should go much 
further. Past government policy can be 
criticized for the extreme slowness with 
which the governments have acted. But 
the most important criticism is that we 
have put aH our eggs into very few 
baskets. Certain lines of spending such as 
the building of old people's homes have 
seen a good dea'l of effort. Others-such 
as the ·building of sheltered housing-
have been encountered by apathy.
Government after Government and local 
authority a:fter local authority have 
ignored the striking evidence about the 
current housing situation of the elderly. 

Old age can often be a period of 
emotional strain through. bereavement 
and the· loss of friends, and also of 
physical ill health. 

Yet we are expecting peop1le who are 

having difficulty in coping, to live in con


ditions which would tax the fittest. We 
, make an old lady with arthritis live in a 

house which is damp and has no heating 

and no internal we. Then we are sur


prised when she becomes depressed and 

neglects herself. 

The aim must surely be to get a 
balance of care which bears some relation 
to the evidence on what the problemreaUy are. But we have instead the 
planning of services almost completelyin isolation from each other, most 
notably as between old people's homes 
and sheltered housing. The argument has 
been too much about absolutes and too 


If ( /,.r'J 

little about priorities at a particular pointin time. Thus there can be many views 
about the merits of old peoples homes as 
against sheltered housing, but such 
arguments are not really very helpful. 

The most important point at the moment 
is that we have not even built enoughsheltered housing for people who would 
very clearly be able to live in it-for the 
most promising candidates. 

This pamphlet starts from the conviction 
that the mood of gloom about the 
elderly has been grossly exaggerated. The 
real subject for gloom is how little 
thought we have given to the ways of 
giving help. To natural problems of ill 
health and waning a'lertness have been 
added problems of poverty, poor housingand inappropriate services which have 
been largely man made. Of course there 
is a good deal of depression and 
loneliness among the elderly-a·lthough 
one survey showed that pensioners were 
much less depressed and lonely than 
young people imagined them to be (NewSociety, 24 January 1974). Of course 
there are many frail old peop'le livingalone and only just managing to cope. 

Of course there have been unfavourable 
changes in society which have made it 
more difficult for younger re•latives to 
give support. Thus people have tended to 
move out of the centres of cities to 
suburbs, leaving their elderly relatives 
behind in poor housing. But most peop'le 
who work with the elderly from day to 
day agree that the great majority of 
families do care about their elderlyrelatives and in fact make great efforts 
to help them. Natural feelings and 
loya'lties have not !been destroyed by the 
welfare state. But government action has 
done far too little to mitigate those unfavourable 
changes in society which 
cannot be avoided. Too often in the past 
government action has inadvertentlystrengthened the effects of damagingchanges that were already strong. In a 
general way government has encouraged 
a belief in institutions because so much 
of government spending goes towards 
institutional care in spite of commenda:ble 
expansion in some community services. 


This pamphlet grew out of visits made 
in many parts of the country to geriatric 
departments, social service departments,
sheltered housing developn1ents, day 
centres and luncheon clubs as weU as out 
of experience as a counciHor in a London 
borough with many old people living 
alone in poor housing conditions. The 
author was impressed by the strength of 
critical opinion to be found in manyplaces about our policies for the elderly. 
There is no doubt there is a widespread 
and deep discontent about traditional 
policies and approaches. But 'little of this 
has affected the ways in which the money 
has been spent. Many years have already 
been lost; let us not lose more time. It is 
vital that policy should reflect the best 
thinking in local authorities and the conclusions 
of research. The evidence is that 
far too often in the past it has not done 
this. The real tragedy of old age in this 
country is our unwillingness to jumpbureaucratic barriers and to make an 
effort of imagination in order to help the 
elderly to maintain their independence. 

The argument has to be conducted 
against a background of fiscal stringency. 
I have assumed that there would be at 
best limited amounts of extra moneyforthcoming and these only for well 
defined purposes. At worst the strategy 
could be adapted to a " nil growth " 
situation. There are great numbers of 
competing claims and litt•le prospect of a 
fiscal miracle; hence we really must 
spend those limited amounts which we 
have got sensrb'ly. 

At a time of stringency in public spending, 
it becomes vital to distinguish those 
changes which do most to help the disabled 
and hand'kapped elderly, from 
changes which help mainly the more 
active elderly. Some of the policies that 
have attracted most public attention 
recently, such as the short lived relative 
rise in the pension (1974), subsidized 
travel and the re'laxation of the earnings 
rule have ·been of most help to the active 
elderly. They do rather little for the very 
old or the chronically ill. In a time of 
stringency in public spending there n1ay 
have to be choice between further such 
changes and inve tment in improved 

housing, rehabilitation and communityservices which really do help the more 
disabled. Such a decision has to be made 
against a background of a growing social 
and economic division within the retired 
population. Alongside the process of 
physical ageing there is a process of 
social ageing which goes further as people 
get older. It is the over 70spredominantly 
women-who face the 
worst problems of isolation, of poorhousing and of poor health. It is the 
younger retired who are married and have 
occupational pensions and their own 
homes. There is a definite cycle of socia1 
ageing. As people get further away from 
retirement their income drops in real 
terms; the stock of possessions left over 
from their working life wears out; their 
contacts becom·e fewer. As health 
worsens so the need for extra income for 
heating and other needs increases. Support 
costs rise just as income falls. The 

need for support with domestic tasks 
and for companionship also grows. The ' 
" social " elderly are a substantial 
minority within the retired population,

who need more help. 

For the immediate future the priorityhas to be not that of more he'lp to the 
active elderly, but that of improvements 
in sheltered housing, in the services for 
rehabilitation and in community services. 

We have to concentrate much more on 
the more vulnerable among the elderly. 
We now turn to sketch out what these 
priorities might be in the social services, 
housing and health. The a'im is to 
identify a sma11 number of changes which 
could make a real difference and on 
which we could concentrate. 

The Government is introducing a new 
pension scheme which will radicallychange the economic position of the 
elderly in the long term. This is the first 
part of any new deal, but other measures 
are needed in housing, health and social 
services. The Government has made a 
start-wiJI it now follow it through ? 



2. the social services 
L egislation, the legacy of the workhouse 
and the policy of the Department of 
ealth and Social Security (DHSS) have 
.all helped to concentrate attention on the 
old people's home. The oldest and 
perhaps the key piece of legis1ation still 
is the National Assistance Act of 1948. 
Part three of this Act enables a local 
authority to provide "residential accom-
modation for persons who by reason of 
age, infirmity or any other circumstances 
are in need of care and attention which is 
not otherwise availab'le to them." Later 
legislation began to shift the balance 
towards the community services. The 
Health Services and Public Health Act 
1968 ena'bled the 'local authority to make 
arrangements for promoting the welfare 
of the eldedy and also for giving assist-
ance to voluntary organizations. The 1970 
Ohronicai'ly Sick and n ·isabled Persons 
Act encourages local authorities to pro-
vide a rather wider range of services for 
the disab'led including the elderly dis-
abled. But in practi'ce most of these are 
permissive powers. The main duty is to 
provide residentia1l accommodation. 
. The language of the 1948 Act now has a 
curiously old fashioned ring and is 
strikingly lacking in the kind of advanced 
thinking which characterized the 
children's legislation of that period. The 
who·le notion of " infirmity " has been 
somewhat overtaken by the development 
of geriatrics and rehabilitation-and also 
by the development of sheltered housing. 
Yet it is against this background of 
legislation that local authorities have been 
making decisions for more than a 
generation. 
The concentration on the old peopleshome between 1948 and 1960 did repre-
sent a practical solution to a pressingproblem-how to improve the lot of 
people living in the old workhouses. Even 
now there are perhaps 10,000 places still 
used in old workhouses in England and 
· Wales, with rather more in Scotland. The 
old workhouses were large institutions-
sometimes for hundreds of peop'le. Manyof them had come to be in a poor state 
of hea:lth. Conditions in the new homes 
are obviously a great improvement on 
the former workhouses. But the form was 
set in relation to the inheritance of the 
past rather than possibilities af the future. 
The homes have come to loom largerand larger-as things that are good in 
themselves rather than as practica'l solu-
tions to a pressing difficulty. Societyhaving so defined the choices open to an 
elderly person has taken this as evidence 
that he is capable of no more. The 
pattern of institutions has tended to 
create a certain pattern of expectationsand a certain view of the possibilities. A 
change in the pattern of service-such as 
the building of rea:l1y substantial amounts 
of sheltered housing-would tend to 
change peoples view of what the elderly 
themselves could achieve. 
The main direction of DHSs impact on 
local authorities, month by month, 
reinforces the effect of legistlation and of 
the legacy from the workhouse. Every-
thing centres round "loan sanctions " for 
capital projects, mainlly for homes for the 
elderly. In the past 'th'is had some veryimportant effects on local authoritybehaviour and thinking. It has tended to 
mean that numbers of starts and com-
pletions have been taken as the major 
measure of success in services. "Under 
our administration we built x number 
of old peoples homes " has been the 
major indicator of success. It has led to 
a divorce in peoples minds between 
capital projects and their revenue con-
sequences. The idea of a 11oan sanction 
seems an attractive one-almost costless 
except for the interest payments. Yet 
once completed the revenue effects are 
important, until an energetic local 
authority can become the victim of its 
own success-it can find that it has so 
much residential accommodation with 
such heavy runruing costs, that it has 
nothing to spare for quite small expan-
sions of the community services that 
might actually prevent peoP'le cominginto residential care. 
Apart from its power to grant or with-
hold loan sanctions, the DHss's other main 
point of impact OJl the mind of local 
government is through the " norm " for 
places per thousand population. The 
norm is currently 25 places per thousand 
population. This norm is not based on 
2. the social services 
L egislation, the legacy of the workhouse 
and the policy of the Department of 
ealth and Social Security (DHSS) have 
.all helped to concentrate attention on the 
old people's home. The oldest and 
perhaps the key piece of legis1ation still 
is the National Assistance Act of 1948. 
Part three of this Act enables a local 
authority to provide "residential accom-
modation for persons who by reason of 
age, infirmity or any other circumstances 
are in need of care and attention which is 
not otherwise availab'le to them." Later 
legislation began to shift the balance 
towards the community services. The 
Health Services and Public Health Act 
1968 ena'bled the 'local authority to make 
arrangements for promoting the welfare 
of the eldedy and also for giving assist-
ance to voluntary organizations. The 1970 
Ohronicai'ly Sick and n ·isabled Persons 
Act encourages local authorities to pro-
vide a rather wider range of services for 
the disab'led including the elderly dis-
abled. But in practi'ce most of these are 
permissive powers. The main duty is to 
provide residentia1l accommodation. 
. The language of the 1948 Act now has a 
curiously old fashioned ring and is 
strikingly lacking in the kind of advanced 
thinking which characterized the 
children's legislation of that period. The 
who·le notion of " infirmity " has been 
somewhat overtaken by the development 
of geriatrics and rehabilitation-and also 
by the development of sheltered housing. 
Yet it is against this background of 
legislation that local authorities have been 
making decisions for more than a 
generation. 
The concentration on the old peopleshome between 1948 and 1960 did repre-
sent a practical solution to a pressingproblem-how to improve the lot of 
people living in the old workhouses. Even 
now there are perhaps 10,000 places still 
used in old workhouses in England and 
· Wales, with rather more in Scotland. The 
old workhouses were large institutions-
sometimes for hundreds of peop'le. Manyof them had come to be in a poor state 
of hea:lth. Conditions in the new homes 
are obviously a great improvement on 
the former workhouses. But the form was 
set in relation to the inheritance of the 
past rather than possibilities af the future. 
The homes have come to loom largerand larger-as things that are good in 
themselves rather than as practica'l solu-
tions to a pressing difficulty. Societyhaving so defined the choices open to an 
elderly person has taken this as evidence 
that he is capable of no more. The 
pattern of institutions has tended to 
create a certain pattern of expectationsand a certain view of the possibilities. A 
change in the pattern of service-such as 
the building of rea:l1y substantial amounts 
of sheltered housing-would tend to 
change peoples view of what the elderly 
themselves could achieve. 
The main direction of DHSs impact on 
local authorities, month by month, 
reinforces the effect of legistlation and of 
the legacy from the workhouse. Every-
thing centres round "loan sanctions " for 
capital projects, mainlly for homes for the 
elderly. In the past 'th'is had some veryimportant effects on local authoritybehaviour and thinking. It has tended to 
mean that numbers of starts and com-
pletions have been taken as the major 
measure of success in services. "Under 
our administration we built x number 
of old peoples homes " has been the 
major indicator of success. It has led to 
a divorce in peoples minds between 
capital projects and their revenue con-
sequences. The idea of a 11oan sanction 
seems an attractive one-almost costless 
except for the interest payments. Yet 
once completed the revenue effects are 
important, until an energetic local 
authority can become the victim of its 
own success-it can find that it has so 
much residential accommodation with 
such heavy runruing costs, that it has 
nothing to spare for quite small expan-
sions of the community services that 
might actually prevent peoP'le cominginto residential care. 
Apart from its power to grant or with-
hold loan sanctions, the DHss's other main 
point of impact OJl the mind of local 
government is through the " norm " for 
places per thousand population. The 
norm is currently 25 places per thousand 
population. This norm is not based on 

4 
careful research or scientific study. It is 
simply an arbitrary number set a little 
ahead of the current average number of 
places in local authorities. But by some 
local authorities this is taken almost as 
hdly writ. The new Hampshire Social 
Services department inherited ten yearplans from the three old authorities of 
Portsmouth, Hampshire and Southamp-
ton. All three ten year plans had laid 
great stress on the DHSS norm-in fact 
Portsmouth had even decided to increase 
it: that plan had " adopted a ratio of 
28 : 1,000 places as compared to DHSS 
critical figure of 25 per 1 ,000 places " 
(Hampshire Social Services 10 Year 
Development Plans, appendix 3). 
Of the three authorities, Portsmouth 
and Southampton were already quitewell stocked with homes, afthough this 
did not stop them from planning to build 
a few more. Hampshire, on the other 
hand, had one of the lowest levels in 
the country, with a!bout 12 places per1,000 elderly in 1974. The old Hampshire 
authority had suggested a rea:lly large 
building programme. T-he new social 
services department inherited p'lans to 
build more than a thousand places in 
homes. Much of this may in fact have 
been delayed by the cuts in publicspending, but the reasoning process in 
the original Ten Yea·r Plan remains 
signlificant. Hampshire's commitment did 
not arise from any independent study of 
the needs of the elderly in that county;
it was simply a reaction to the DHSS 
norm, such reflexes appearing to be 
common. 
"The norm" involves a perfect circle. It 
is in fact simply an average of local 
authorities' own record. But loca'l 
authorities take it as a " critical figure ", 
which is presuma!bly based on intensive 
study. There are shocked, hushed tones 
in com·mittee meetings when social 
service committee members discover that 
their authority is "below" the number. 
One rfina'l irony is that the DHSS tends to 
revise the number every so often as the 
number of places increases. Thus the 
number used to 'be 20; since the average 
number rose above 20 it has been 
revised upwards. There are some other 
norms for other services but these are · 
set in a similar ad hoc way, and anyauthority which managed to get itseif 
positioned on all these norms would not 
therefore have a perfectly balanced 
serv1ce. 
Thus the system has worked so that there · 
have been two vital questions for each 
authority: how many " loan sanctions it 
is going to get " and where its num'bers 
of residentia!l places stand in relation to 
the DHSS norm. There have been some 
bold authorities that have broken away. 
Liverpool, in spite of being rather below 
the DHSS norm (with 18 places perthousand elderly) has decided once a very 
small number of current projects have 
been completed not to build any more 
old people's homes but to build onlysheltered housing instead (LiverpoolSocial Services, 10 Year DevelopmentPlan, 1974-84). It has taken this decision : 
in spite of having far worse problems of 
housing and isolation among the elderly 
than most county authorities. But few 
authorities have done as much as this. 
Most have stuck within the perfect circle 
of norm setting and norm hunting. Few 
authorities have looked at the 
adequacy of assessment. Many years ago, 
Peter Townsend condemned the inade-
quacy of interviews lasting sometimes 
only 15 minutes on which people could 
be uprooted from their homes and sent 
off to institutions till they died. How 
much has really changed in the quality o 
initial assessment ? 
With their eyes fixed on the distant and 
ever moving grail of the norm, local 
authorities have not looked at the experi-
ence of old people as they go into the 
homes and once they get there. There 
is little wrong with the materia'l con-
ditions-food and comforts are reason-
ably well provided. But there is much 
else to be criticized. The process in which 
people get admitted to the homes is often 
rather haphazard still. There may be one 
or two visits from a social worker and 
then people are put on the waiting list 
Even within one London Borough there 
are extraordinary differences in the 
propensity of social workers in different 
4 
careful research or scientific study. It is 
simply an arbitrary number set a little 
ahead of the current average number of 
places in local authorities. But by some 
local authorities this is taken almost as 
hdly writ. The new Hampshire Social 
Services department inherited ten yearplans from the three old authorities of 
Portsmouth, Hampshire and Southamp-
ton. All three ten year plans had laid 
great stress on the DHSS norm-in fact 
Portsmouth had even decided to increase 
it: that plan had " adopted a ratio of 
28 : 1,000 places as compared to DHSS 
critical figure of 25 per 1 ,000 places " 
(Hampshire Social Services 10 Year 
Development Plans, appendix 3). 
Of the three authorities, Portsmouth 
and Southampton were already quitewell stocked with homes, afthough this 
did not stop them from planning to build 
a few more. Hampshire, on the other 
hand, had one of the lowest levels in 
the country, with a!bout 12 places per1,000 elderly in 1974. The old Hampshire 
authority had suggested a rea:lly large 
building programme. T-he new social 
services department inherited p'lans to 
build more than a thousand places in 
homes. Much of this may in fact have 
been delayed by the cuts in publicspending, but the reasoning process in 
the original Ten Yea·r Plan remains 
signlificant. Hampshire's commitment did 
not arise from any independent study of 
the needs of the elderly in that county;
it was simply a reaction to the DHSS 
norm, such reflexes appearing to be 
common. 
"The norm" involves a perfect circle. It 
is in fact simply an average of local 
authorities' own record. But loca'l 
authorities take it as a " critical figure ", 
which is presuma!bly based on intensive 
study. There are shocked, hushed tones 
in com·mittee meetings when social 
service committee members discover that 
their authority is "below" the number. 
One rfina'l irony is that the DHSS tends to 
revise the number every so often as the 
number of places increases. Thus the 
number used to 'be 20; since the average 
number rose above 20 it has been 
revised upwards. There are some other 
norms for other services but these are · 
set in a similar ad hoc way, and anyauthority which managed to get itseif 
positioned on all these norms would not 
therefore have a perfectly balanced 
serv1ce. 
Thus the system has worked so that there · 
have been two vital questions for each 
authority: how many " loan sanctions it 
is going to get " and where its num'bers 
of residentia!l places stand in relation to 
the DHSS norm. There have been some 
bold authorities that have broken away. 
Liverpool, in spite of being rather below 
the DHSS norm (with 18 places perthousand elderly) has decided once a very 
small number of current projects have 
been completed not to build any more 
old people's homes but to build onlysheltered housing instead (LiverpoolSocial Services, 10 Year DevelopmentPlan, 1974-84). It has taken this decision : 
in spite of having far worse problems of 
housing and isolation among the elderly 
than most county authorities. But few 
authorities have done as much as this. 
Most have stuck within the perfect circle 
of norm setting and norm hunting. Few 
authorities have looked at the 
adequacy of assessment. Many years ago, 
Peter Townsend condemned the inade-
quacy of interviews lasting sometimes 
only 15 minutes on which people could 
be uprooted from their homes and sent 
off to institutions till they died. How 
much has really changed in the quality o 
initial assessment ? 
With their eyes fixed on the distant and 
ever moving grail of the norm, local 
authorities have not looked at the experi-
ence of old people as they go into the 
homes and once they get there. There 
is little wrong with the materia'l con-
ditions-food and comforts are reason-
ably well provided. But there is much 
else to be criticized. The process in which 
people get admitted to the homes is often 
rather haphazard still. There may be one 
or two visits from a social worker and 
then people are put on the waiting list 
Even within one London Borough there 
are extraordinary differences in the 
propensity of social workers in different 

' 
1 
' 
1 
social service areas to put people on the 
waiting list. The decision is a:lso coloured 
by the sympathy for and knowledge of 
the social work profession for the 
elderly, which is highly varialJle. People 
can then be sent to a home without 
having had a chance of a preliminaryvisit. But then after this rather cursory 
attempt to help, people are stripped of 
an their belongings, including their 
furniture, and there is very lit~le chance 
of their ever getting back into the community, 
o'f active rehabilitation or even 
of going out to a luncheon dub. It is in 
any case a strange and old fashioned idea 
that people should go " into " a home 
and there stay without any chance of 
there ever coming out again. Once in the 
home the experience is one of boredom 
and dependence, sitting around the walls 
waiting for meals. There are tfew peoplewho would wish the experience of goinginto a home onto their own friends or 

relatives. Nor are the homes very good at 
coping with either physical ill hea!lth or 
mental confusion. Staff are dedicated 
enough but for the most part they are 
simply not trained, and they are working 
with overlarge numbers. 

To the evidence of impression, there is the 
evidence of academic research-not least 
the work of Peter Townsend in The Last 
Refuge-work which has proved againthat admission to a home leads not only 
to boredom but even to i'llness and death. 
One of the darker and least documented 
aspects of life ;in the homes 
is the frequency of quite serious 
epidemics. Certainly some of the worst 
features of the home can be improved by 
redesigning them so that people have 
much more chance of an independentlife. But such redesigned homes reailymerge gradually into sheltered housing. 

One pa;rticularly striking example of the 
bias towards institutions has been in the 
care of the mentally infirm elderly. The 
1959 Mental Health Act encouraged local 
authorities to do more. The majority in 
fact did very little. But the first reaction 
in most others was to start specia11 homes. 
Very few started special day centres and 
social clubs. A survey showed in 1968 
that only one in eight of local authorities 

had started any form of day care for the 
mentaHy infirm elderly, whHe one 
quarter of them had started specialwelfare homes (M. Meacher, Taken For 
a Ride, Longman, 1972). 

There have been many doubts about 
these homes for other reasons. They tend 
to be more remote from the communities 
which they •serve and it is often treated 
as a disgrace and a disa ter by relatives 
and their friends to be sent there. It has 
been argued that confusion i as much 
created by segregation and by beingdeprived of a:ll power over their own 
lives, as it is a definable clinical state. 
But these are separate issues. The pointhere is the reaction of local authorities 
and for that matter of central government 
-which was towards building yet more 
institutions. In this case there was a 
similar concentration of institutional care 
within the NHS and a 'lack of active 
assessment. 

the community services 

~bout the role of the old person's home 
there has been considerable disagreement. 
There has been much less about the role 
of the community services. Both central 
and local governments have been in 
favour of a rapid expansion in these 
services. Now government's support for 
the objective of community care and for 
an expansion of the community social 
services can be applauded-but has it 
really been effective in practice ? In 
spite of the general supp·ort received from 
all quarters, the record of expansion in 
the home help service-perhaps the most 
important of the community social 
services-has been rather smaller than is 
often imagined. Between 1959 and 1973 
the number of home helps (in whole time 
equivalents) rose from a!bout 20,000 in 
England to about 33,000. It is fair to 
assume that most of the time of home 
helps was taken up with the elderly. The 
rise is substantial but hardiy specta·cular · 
and prospects for expansion in the 
immedia:te future do not seem bright. 

The "need" for the home help service 
is rather less a matter of opinion than 


residential care. It has been shown that 
there are many people living alone without 
anyone to do the household chores 
and who are getting little help from the 
home help service. Thus Amelia Harris 
showed that in Great Britain there are 
2,000 very severely handicapped and 
90,000 handicapped living alone and 
having no welfare services (A. Harris, 

Handicapped and Impaired in Great 
Britain, volume 1, HMSO, 1971). She 
shows that 7 per cent of the impaired 
have a home help, the proportion being16 per cent for the very severely handicapped 
and 11 per cent for those 
appreciably handicapped. Other studies 
have shown that only a smaH minority of 
those demonstrably in need get home 
helps. 

Rapid growth in the home help service 
would certainly pose increasing problems 
of supervision-of using people's time 
effectively. But it would also give opportunities 
to use the home help service in 
imaginative ways so that this kind of 
care could genuinely help to keep people 
in the community who might not otherwise 
have been ab'le to continue living at 
home. For example, Liverpool is planning 
a special home care programme for 
elderly people at risk who are aJbout to 
leave hospital. About one in five elderly 
people immediately after discharge from 
hospital wil11 get a home help and meals 
on wheels for a four week periodafterwards. 

The most serious trouble has not, however, 
been with the overall expansion of 
the home help service-but with its distribution. 
In some generous authorities 
10 to 15 per cent a£ the elderly are 
getting the home help service in a year. 
Elsewhere-particularly in the counties 
and seaside towns-5 per cent or less 
(CIPA, Local Health and Social Services 
Statistics, 1972-3). There is three times 
the chance that an old person in the 
Borough of Greenwich will get some 
home help, than an old person in Kent 
(CIPFA Statistics). In some places no 
reasonable request is turned away; jnothers it is very hard to get a home help 
for any length of time at all. Again and 
again the suggestion has been made that 

m1mmum standards should be set-

nothing has been done. 

The second important communityservice is the meals service. This can be 
of two kinds: mea'ls on wheels in the 
home or meals served at luncheon clubs. 
Overall the number of meals has been 
expanding very rapidly. The main 
problem here is again one of distribution. 
Within the London area there were, on 
the most recently available figures-
those for 1972-3-sixfold differences 
between authorities in the nun1bers of 
meals served. Kingston on Thames and 
Brent serve about 3,500 mea!ls perthousand population; Southwark and 
Tower Hamlets about 20,000 (ciPFA 
Statistics). E~sewhere Manchester serves 
about 14,000 meals a year per thousand 
population and Halifax 2,000 (ibid). 

There have been many doubts and 
queries raised about the value of meals 
on wheels. Research has shed some doubt 
both on their nutritional value and their 
palatability. Certainly this is not a service 
which could or should be expanded indefinitely; 
nor is it always a good idea 
for every client to have the service five 
days a week. One study in Portsmouth 
has suggested that peop'le may even 
prefer to have the meals only two or three 
times a week (L. Davies et al, 
"Meals on Wheels Deliveries," Modern 
Geriatrics, November 1974). 

One well off authority -Greenwich 
reckons that it is " close to satisfying the 
total need for meals " (l)omiciliaryServices for the Elderly in Greenwich, 

Key Issue Report Programme, Planning 
Staffs). This recent enquiry carried out 
by the programme planning staff suggested 
that after 1975-6 there should be 
no further expansion of the meals on 
wheels service. Here there m~ay well be 
a question a£ maximum levels, but it is 
clear that many authorities are waybelow these levels. 

Many authorities are coming to put more 
emphasis on luncheon clubs, which provide 
company as we11 as food. There is 
a great danger of this relatively small 
scale effort being somewhat neglected, at 


a time of stringency in public spending. 
Here again there is a need for minimum 
levels of provision. 

So far we have been discussing services 
which are well known and of which the 
pattern of service is relatively well 
defined. There is also some level of 
service in all parts of the country. We 
turn now to other services-good neighbour 
schemes and day care which are not 
so widely established. 

One effect of concentration on largescale capital projects has been that such 
a relatively small idea as a good neighbour 
scheme has been somewhat 
neglected. But these schemes can draw 
on the good-will which is there in the 
community. 

By this service, peopie are paid a smaH 
amount to take an interest in a particular 
elderly person or group of people. This 
system has been widely used in 
Manchester and in the London Boroughof Camden. It is not a commitment to 
look after, to give nursing care and to 
act as a cut price home help. It is a 
commitment to keep in touch and to 
spend some time with. It is a commitment 
to take shopping every so often, 
to visit and to chat and to share a cup

of tea. It is a commitment to be a friend 
and someone who is on ca'll in an 
emergency. It is just an extension of 
what happens anyway-so much help is 
given on a completely unpaid basis byneighbours. It should be most usefu1 for 
people who have no neighbours and on 
their own. It a!lso gets around a most 
undesirable feature of the services at 
present; it is possible for an old person 
in difficulties to be the target of the 
attentions of so many statutory services, 
and yet for them all to be a vague blur 
of half-recognized faces. Under a Good 
Neighbour scheme at least the goodneighbour gets to know a particular old 
person. 

Liverpool have had a good neighbour 
s·cheme for some time. As of March 
1974, if had covered three areas of the 
city with about 150 helpers who are 
looking after about 700-800 old peo'(Yle. 

The organizers recruit fit elderly or 
retired people to the service. This idea 
grew up originaily because they were 
never going to be able to expand the 
home help service enough to cover all 
the need. The good neighbours al_"e paidabout £3.50 a week plus SOp expenses to 
do this. It is run by Age Concern. It 
needed care in selecting clients and in 
selecting good neighbours. Not a!ll the 
clients who were first seen proved to be 
in need of help. It has also allowed the 
ordinary home help service to concentrate 
more on people in great need. 
They are planning to cover the whole 
city. The social services then expect to 
have something like 5,500 old peoplecovered by this service. (I am grateful to 
Dr B. Meredith Davies, Director of 
Social Services, Liverpool, for this 
information.) A report for three Liverpool 
postal areas showed how the 
service developed in a particular area. 
The initial publicity for the scheme came 
through churches, and the referrals 
through pensioners luncheon clubs, 
through social workers and also from 
hospitaJs for people who were about to 
be discharged. The report writes of the 
scheme: " It is noticeable that a bond 
quickly develops between a Good 
Neighbour and client. The success of the 
scheme is dependent ·on the qualities of 
the Good Neighbours who must have a 
real concern for the people in their care. 
This is frequently shown in the range of 
help which they give. Lighting fires on 
Saturday and Sunday m·ornings when 
home helps are not available, sewing for 
the man who lives alone, providing a 
Sunday dinner when Meals on Wheels 
are not avai•lalJle, visiting in the late 
evening and settling the old person f.or 

the night, are some orf the examples of 
the work they do beyond their general 
duties " (Liverpool Report on Good 
Neighbour Scheme, Age Concern, 
January 1974). 

Other schemes have a somewhat different 
emphasis. A scheme in Kirkcaldy aims 
that a street warden should be in touch 
with every single elderly person in the 
borough. In practice each warden is looking 
after about 23 old people. Obviously 
here the degree of personal relationship 


must be fairly limited and the ma1n 
purpose of the scheme seems to be to 
make sure that people have somewhere 
to go in emergency ( J. W. Knox, " Street 
Warden Scheme," Health and Social 
Service Journal, 21 July 1973). It is supplemented 
by a home visiting scheme. 

At present we are spending about 
£3 million a year in capital expenditure 
on day centres, but there are manyauthorities which have none at all. The 
day centres seem to be serving two 
rather different purposes: the need for 
recreation, warmth and companionshipand the need for more active ·care and 
rehabilitation. A study of a day centre 
in Buckinghamshire (Des borough Hall, 
Buckinghamshire County Council Social 
Service Department, June 1974) has 
shown that of peop!le who come to the 
day centre on their own initiative, m·ost 
are younger and fitter than those who 
are referred by social workers. As a 
result df transport diffi:culties day centres 
are not likely to be accessible to the frail 
as much as would be desircrble. Nor does 
the centre offer much potential for 
rehabilitation. 

To build day centres on the presentmodel so that they would be accessi:ble to 
most old peo.P'].e would take a massive 
amount of public spending-which is 
hardly likely to materialise at present.
Because of transport difficulties even if 
many more centres were built they might 
not be fully used. A survey for AgeConcern showed that only a small 
number <Yf centres could offer adequate 
transport; most had to make their own 
way to the centre. Yet day care has so 
much to offer-in enjoyment and in 
reducing loneliness (I. D. Horley, DayCare, Age Concern, 1974). 

proposals for the future 

The general objective has been clear: to 
give as many people as possible a chance 
of a normal life in the community. Can 
we relate the pattern of spending to this 
objective ? The table in the next column 
sets out how the money is being spent. 
Excluding the very doub~ful figures for 

LOCAL AUTHORITY 
EXPENDITURE, ENGLAND, 1972-3 
revenue spending £m 

home heips 40.07 
day centre care 2.86 
meals-on-wheels 

& luncheon clubs 4.80 1 
residential homes (net) 71.26 
(social work visits 19.29) 

capital spending 
residential homes 
(loan approvals) 35.68 
day centres for the 
elderly (loan approvals) 2.42 
Source: DHSS. The figure for expenditure 
on social work time is extremelydoubtful. It is based on General Household 
Survey data on the number of visits 
made to the elderly. 

expenditure on social worker time, we 
are spending more on the running costs 
of homes than we are on all the community 
services put together. We are 
spending far more on keeping 106,000 · 
residents of homes than we are on the 
elderly in the community in face of 
evidence tha:t the great majority even of 
the severely handicapped and housebound 
live in the community. Nor is the 
scale of spending on the communityservices impressive compared with spending 
in many other parts of the public 
sector. It is really rather difficult to relate 
this pattern of spending to the objective 1 
of policy which has seemed so clear and 
agreed. 

Of course there are people who will no 
longer be able to cope and who wiU have 
to 1eave their own homes. This will 
require a heavy investment, to give support 
particularly to those who are in need 
of nursing care. But at present we are 
making this investment in the wrongplace-in the social servkes which are m 
equipped to provide nursing care rather 
than in the NHS. As i discussed in the 
chapter on the NHS, there is possibly a 
need for more places which could provide 
nursing care and which would be more 
like nursing homes than old people's 
homes. The social services on the other 
hand should attempt to carry through the 
task which they are upposed to be doing 


· but have never in fact fuHy done-that 
of providing a much higher level of support 
in the community. 


The DHss has already taken the first 
steps by limiting approvals for homes for 
local authorities with more than 20 
places per thousand. What further steps 
could the government take to 'bringabout a higher and more even pa:t:tern of 
community care and to draw on the 
community's own resources? 

We should stop the building of any more 
old people's homes except as replacements 
for former workhouses. The home 
in its present form does little to help two 
groups : the very frail who need nursing 
care and who form increasing proportions 
of residents and the more independentwho could live in sheltered housing if it 
were available. It is being asked to play 
a role for disparate groups which it was 
never really equipped to play. Many of 
the authorities with the lowest numbers 
of homes and most likely to be building 
are anyway county authorities where old 
people's homes are least suitable. 

Th'is decision would require heavier 
investment in two directions-with the 
NHS and for sheltered housing. If funds 
can be diverted across departmentalboundaries, it would be better to divert 
some of the money that is now beingspent on homes to sheltered housing. But 
it should be recognized that this has 
impiications for the community services. 
As residents in sheltered housing get 
more frail they will need a good deal 
o'f support from community services. 

The decision here cannot be made in the 
a:bs·dlute: it is a matter of priorities at a 
particular pdint in time. At this pointthe revenue consequences of building 
more homes are likely to threaten the 
money required for the communityservices. There is direct competitionwithin the social services departmentbudget. There are already authorities 
who have actually been cutting back on 
the home help service. There is currently 
a very uneven standard in the community 
services between different parts of the 
country. And there are many authorities 

with no sheltered housing at all and we 
are not even giving the chance to people 
Who could o'bviously use it. 

The government should set minimum 
standards for the home help and the 
meals service. This has been suggested 
again and again, but so far nothing has 
been done. But how can the presentsituation be defended ? Why should a 
pensioner who lives in Kent get so much 
less good a service than one who lives 
close by in the Borough of Greenwich ? 
As more local spending is financed out of 
central taxation, such great differences in 
the standards of service 'become even 
more inequita!ble. It is sometimes argued 
that recruitment difficulties are the main 
cause of the inequalities but this hardly 
fits with the experience of those 
authorities in active labour markets who 
have recruited heavily and successfully. 
The DHss really must act to set standards 
for the home help and meals service. 

We need more day care, but few people 
are going to get it so long as we concentrate 
on l'arge capital schemes. 
It would produce better results to build 
sma:H centres either in existing premises 
or in smaller purpose built premises.
These prem'ises could be the centre for a 
luncheon clu1b and for social activities. 
They could have a much strongerrelationship to a particular neighbourhood 
than the larger centres could have. 
They could be the focus for a genuineneighbourhood effort. The DHSS should 
draw up a blueprint for a model centre 
of this smaUer type__,which would of 
course be used by other groups as well 
as by the elderly, even though it would 
principally belong to the elderly. It 
would not be a!ble to provide the range 
of services which other centres wouid 
provide-hut it would be much better 
than n6thing. Instead of concentrating 
our main effort on day centres costingperhaps £200,000 it would be better to 
go for a much sm'aller and more local 
type o'f centre costing perhaps £50,000. 
Such a centre would raise far fewer 
prdblems with the availability of sites. 
The provision would be fairly basic-
perhaps a hall, a dining area and kitchen. 
But it could provide a companionable 


setting, one which did not raise massive 
transport problems. They could also be 
meeting places for special clubs for the 
blind and the deaf. Eventually there 
might be one of these neighbourhood 
centres for each 25,000 people in urban 
areas. Such centres would provide a 
better result for spending even the present 
£3 million than day centres on the current 
pattern. 

Day centres on the current pattern often 
aim to provide some element of 
reha:bil'itation. But they cannot providethe full range of medical and sociai help 
which a person in serious difficulties 
ought to be getting. It would be better 
to concentrate here on extending the role 
of the day hospital so tha:t it could also 
serve as an assessment centre run jointlyby the health and social services. At 
present people can be sent into homes 
without any proper assessment or 
sustained attempt to help them in the 
community. For ten years we have been 
struggling to get joint planning between 
the health and s·ocial services. In 1965 
the HM (65) 77 circular recommended 
joint planning groups. Ten years later 
we are still struggling to set up such 
groups renamed "health care planningteams." Let us make a practical start 
on co-operation with jointly run assessment 
centres. If they were entirelyseparate from day hospitals they would 
be yet another competitor for extremely 
scarce resources, while the day hospitalwould ·continue to play the more strictly 
medical role it has in the past, it could 
also take on this new task. 

The DHSS should give strong official 
encouragement to the growth of goodneighbour schemes. These can draw on 
great reserves of care and interest in the 
community. 


3. housing and the elderly 
The evidence on the poor housing conditions 
of the elderly is clear: we are 
asking people who are least able to 
cope to live in conditions which would 
tax the most resilient. Overall 39 per cent 
of heads of households aged over 65 in 
1971 lived in houses built before 1919 
compared to 24 per cent of people under 

44. Their houses lacked amenities-20 
per cent of households over 65 were 
living in houses without internal wcs 
compared to 9 per cent of youngerhouseholds (D. C. C. Wroe, "The 
Elderly," Social Trends, 1974). Housing 
tends to get worse as people get older 
and the worst conditions of all were 
found with the over 80s. Many elderly 
people are living in housing which has 
been little repaired for forty years and 
which inevitably suffers from poorwiring, damp and even from serious 
structural faults -conditions whi(jh 
cause anxiety and which aggravatechronic illness. These facts on the housing 
conditions of the elderly are well known 
but have had remarkably little influence 
on spending. 
There are many aspects of housingpolicy which affect the elderly. For 
example it would be possible for the 
elderly to apply for improvement grants 
alVbough in practice few have. But the 
most important question is whether we 
have made a consistent effort over a 
period ·of years to provide more 
sheltered housing. 

The idea of sheltered housing is an old 
one. It began with the almshouse and 
even in the Royal Commission on the 
Poor Law Report of 1909 there are 
approving mentions af special housing 
for the elderly, particularly in Woolwich 

(Royal Commission Majority Report,

1909). Between the wars a few specialdwellings for old people were built


•28,000 out of 1.16 million. Directly after 
the war there was some degree of interest; 
a discussion in the Rowntree Reportsuggested that perhaps 5 per cent of the 
dwellings in any community should be 
for the elderly. But these dwellings were 
ma:inly distinguished by being small. "In 
general old people's dwellings need few 
special fittings" (J. Seebohm Rowntree, 
Old People). These were ordinary small 
houses, bungalow~ or flats. From 1945 to 
the early 1970s, considerable numbers of 
small flats were built: from 1945 to 1960 
in England and Wales-202,384 or 10 
per cent of the total; and from 1966 to 
1971-379,761 or 27.3 per cent of fue 
total (H. Mellor, Housing in Retirement). 
But not all these small flats are 
occupied by the elderly. The occupancyoverall is not known although three-
quarters are probably used by the 
elderly. Again there have been greatdifferences between authorities in the 
numbers of flats built. A great many have 
done virtually nothing. Most of these 
units do not have the special design 
features advocated in a ministry· circular 
in 1969. Currently we are building about 
23,000 small flats a year. 

A1ongside the older concept of the small 
flat or bungalow has grown up the idea 
of the sheltered housing development. 
This usually has a resident warden, and 
a call system for residents, together with 

pecial design features which make them 
suitable for the disa:bled and frail. They 
may also have some element of communal 
provision. Progress with such 
grouped schemes was slow in the 1950s 
and 1960s. By 1958 not more than 4,300 
dwel'lings had been built, as a special 
survey showed. Townsend in The Last 
Refuge suggested that a target of 50 
grouped sheltered housing places perthousand elderly should be set. But little 
notice was taken of this in practice. This 
would now mean about 350,000 units 
for the United Kingdom in 1981. There 
are at most 50,000 units in existence. 
Perhaps 6,000 of the 23,000 small flats 
being built each year are sheltered. 

Any figures have to be tentative because 
no proper survey has yet been done. The 
figure for 50,000 units of purpose built 
accommodation for the elderly or handicapped 
may well be an over estimate. 
Certainly the official survey of the 
housing of the handicapped by Judith 
Buckle showed that only 5 per cent of 
aU handicapped and at most 7 per cent 
df those most severely handicapped were 
living in sheltered housing in 1968 ·69 

(J. Buckle, Work and Housing of 

Impaired Persons in Great Britain, 

OPes, 1971). In spite of many years of 
vague encouragement and support, little 
sheltered housing has been built. One 
study looked at what happened in 
Scot:land in the 1960s (J. Williamson, 
"Facilities for the Care of the Elderly 
in Scotland; 'Progress ' in the Interval 
1962 to 1969," Health Bulletin, April1971). In 1962 Scotland had no sheltered 
housing. 

As Prdfessor Williamson wrote: " The 
iinplication of this is that when an 
elderly person gets to the stage 'Of not 
being ·a!ble to manage in an ordinarysmall ·house ... then she must perforce 
in almost all parts of Scotland accept 
institutional care and virtual total 
dependency ... " (J. Williamson, Zoe Cit).
Increases by 1969 in the amount of 
sheltered housing in Scotiand had been 
trivial. The annual Rep·ort of the 
Scottish Health Council for 1969 states 
that no new houses of this type were 
being provided. 

Many surveys have presented evidence 
that a substantial proportion df peoplewho at present go into homes could live 
in sheltered housing if it were available. 
Carstairs for Scotland has argued that 
two thirds of people who are at presentin homes could live in sheltered housing 

(V. Carstairs and M. Morrison, The 
Elderly in Residential Care, SHHD, 1971). 
The estimates made by social workers ·of 
this proportion tend to be lower. Thus 
Wager (R. Wager, Care of the Elderly; a 
Cost Benefit Analysis, Essex CountyCouncil, 1972) asked welfare officers in 
Essex to say whether people on the waiting 
list for residential care could in fact 
live with intensive support in the community, 
possibly including sheltered 
housing. A·bout one quarter o!f these 
elderly were thought to be capa'ble of 
continuing in the community with more 
support. All such estimates are made in 
a certain ·context which may have 
influenced attitudes about what the 
elderly can achieve. As more sheltered 
housing 'becomes available so people'sexpectations would change. It should be 
recognised, however, that increased 

numbers of people in sheltered housing 
will put an increased demand on the 
community services. 

The building of sheltered housing serves 
the interests of groups other than the 
elderly. It releases under occupiedhousing for use by others. There are 
n1any elderly people living in accommodation 
which is too large for them 
and for which they cannot afford 
repairs or maintenance. Sheltered housing 
not only gives the elderly greater 
independence. It also he}ps other groups 
who are in need of housing. 

Some local authorities have been taking 
much greater interest in sheltered 
housing. Perhaps the best study is that 
by Greenwich (Key Issue Report : Old 
People's Homes and Sheltered Housing in 
Greenwich, November 1972). This works 
out the demand for sheltered housingfrom a great dea:l of carefuUy collected 
information on whether people were . 
living alone and on their physical and 
mental state. It argu·es that even in terms 
of a " tight " definition of need, Greenwich 
has a deficit of about 1,150 units 
of sheltered housing. Similar calculations 
have been made in Camden, where the 
defi·cit is reckoned at a!bout 2, 700 units. 

This has 1been one among manyauthorities which until very recently had 
built almost no grouped supportedhousing at aH. Manchester has carried 
out a study df its elderly population and 
now plans to ·build many units of 
sheltered housing. Liverpool has decided 
to build no more homes but to concentrate 
entirely on shettered housing.
Through active use df housing associations, 
Liverpool is already well towards 
its aim of several thousand more units. 

Thus a new initiative from central 
government would be weH in line with 
the actions of the more progressive local 
authorities. 

Local studies and surveys have againand again put the priority as sheltered 
housing. One such study is that byRosemary Gruer in the Scottish Border 
counties-the Lothians. She reports that 


" In numerical terms, the greatest need 
is in sheltered accommodation. If the 
· local authorities adopt a policy of 
· admitting to residential homes only frail 
. persons who could not live independently 


t 

in sheltered houses, the present pro1 
vision of residential pl'aces is adequate " 
(R. Gruer, The Needs of the Elderly in 
f the Scottish Boarder Counties). Going to 
the other end of the country-to the Isle 
of Thanet-we find a young nursingsister writing of the shortages of sheltered 
accommodation: " Within the Thanet 
area there are eight warden-assisted 
flatlets schemes with an average of 32-36 
flatlets in each community. To get an old 
person into one of these one has to 
. apply to the housing manager, but there 
is a long waiting list" (Lorraine Roberts. 
"The Care df Psycho-geriatric Patients," 
· Nursing Times, 20 March 1975). It is 
alm'ost fifteen years since Townsend in 
The Last Refuge recommended the build. 
ing of m·ore sheltered housing as the 

major priority. But still there are local 
, authorities which have no sheltered 
· housing at a]J. 

In central government the strongest lead 
· has been given to Scotland. In 1972 the 
Scottish Home and Health Department 
set a targ~t of 25 places per 1 ,000 elderly 
populati'on. Th.is is on the low side as 
, targets go-understandably enough in 
view of the complete absence of sheltered 
housing in Scotland. Manchester has set 
a target of 32 places rer 1 ,000; Greenwich 
is aiming at about 40 places per1,000, and Townsend's target of 50 per1,000 still has many supporters. Some 
authorities are trying to provide more 
sheltered housing through the introduction 
of a system 'by which people can call 
wardens in existing housing, but this 
although useful does not serve the same 
purpose as grouped supported housing. 

The Department of the Environment has 
limited itself to descriptive circulars on 
design and philosophy. The first was the 
1969 circular on design standards for the 
~lderly (Ministry of Housing Circular 
82/69). More recently jt has issued a 
circular on mobility housing and a 
general serm·on on housing the single. But 
it has not set any kind of target for local 

authorities to aim at or any mmrmum 
standard. A general circular on housingfor the elderly has been promised since 
1973. So far nothing has 'happened . 

Meanwhile housing associations relative 
to their size and resources have been 
more active than government. Housing 
Associations of which the most importantare Help the Aged and the Hanover have 
been building about 3,000 units a year.
kll local authorities put together have 
been managing only 6,000. 

To reach the modest target of 25 places 
per 1,000 by the early 1980s, we would 
have to at least double the current rate 
of building. Assuming construction and 
land costs of aibout £8,000 per unit (a 
reasonable extrapolation from the figures 
coJlected by Wager for 1969-70 (R.
Wag·er, Zoe cit), this would involve an 
annual expenditure commitment df about 
£50 million. There would be effects on 
the community services too as the building 
of m·ore sheltered houses is bound to 
create more work for them. To move 
towards any more ambitious level of provision 
would be helpful but probablyunattainable in current fiscal circumstances. 
The sum at stake is then 
a!bout £50 million a year over initiallyfive years, although even then we would 
be well below the target. 

Part of this spending could be transferred 
over from the capital programme for ·old 
people's homes. At the most modest 
estimate, 20 per cent of the places in 
homes are taken by people who could 
live in sheltered housing if it were available. 
While it would be unrealistic to 
expect an exact match of res·ources to 
individual need, the views of social 
workers and others on the need for places 
in homes should surely change a little 
as an aHernative becon1es more widelyavailable. The current state of things is 
that we are not even offering the chance 
to people who could definitely live in 
sheltered housing. 

Particular attention should be paid to 
getting a fair geographical distribution of 
sheltered housing-otherwise it will be 
the same old story over again of some 


places having a great deal and others 
virtually nothing. 

After such a critical account of the norm 
for residential home places, it may seem 
paradoxical to suggest another norm. But 
the argument was against having an 
unbalanced norm which applied to one 
service only rather than against norms 
as such. The evidence suggests that local 
authorities have taken notice of the 
norm for residential places, but there 
has been no comparable pressure for the 
expansion of sheltered housing. The 
argument is not about sharp alternatives 
but about balance. Our current 
unbalanced services reflect differingdegrees of energy by governmentdepartments and local authorities-
rather than any approach to the optimal. 

Grouped sheltered housing is the highest 
priority for the elderly. But there is 
another change on the housing side which 
would help. At present, people who wish 
to move in order to be close to elderly 
relatives get no priority at all for transfers; 
nor are the elderly themselves able 
to transfer. In areas of great housing 
stress such as Central London it may be 
difficult to arrange this-but in most of 
the country the desire to help elderly 
relatives should surely become legitimate 
grounds for seeking a transfer. Families 
often , do want to give more help to their 
elderly relatives, but they are not able 
to do this unless they can live close to 
them. 

The story of governments and sheltered 
housing is a rather discreditable one for 
successive ministers in housing departments. 
For many years, it has been rather 
widely recognized that grouped sheltered 
housing could be of great assistance to 
the elderly. But what actively has been 
done by central government to encourage 
m·ore building ? There is rather strange 
a!bsence of mind, verging on negligence. 


4. the NHS and the elderly 
lli health in the elderly is often a complicated 
affair. It often involves several 
illnesses at once and it usually has social 
as well as medical aspects. It can also 
involve both mental and physica:Itroubles. Both initial assessment and care 
aimed at a return to the community are 
extremely skilled jobs. But many geriatricdepartments are showing what can be 
done. They have greatly increased 
therapeutic optimism. 

There has recently been more disquietabout the so-called " psycho-geriatric 
patient.". Prevalence surveys disagreeabout exactly how much mental illness 
there is among the elderly, ·but there is 
clearly a great deal, and very little of it 
is treated. There is a certain amount of 
psychiatric illness. There are patients who 
are suffering fr·om dementia. But there 
are a rather larger group of patients who 
are " confused "-a state of depressionand disorientation to which bereavement, 
loneliness and constant struggles with 
difficulties in daily living aU contribute. 

There are people who are not going to 
be able to cope in the community again. 
Work 'by Dr Bernard Isaacs and his 
colleagues suggests that death is often 
preceded by a period of " pre death " in 
which people begin to wane in their 
faculties and eventually become bedbound 

(B. Isaacs et al, " The Concept of Pre 
Death," The Lancet, 24 May 1971).
Help must be given to the growing numbers 
of people who are suffering from 
chronic iHness and in need of nursing 
care. 
The great majority even of .severely disabled 
patients are being looked after in 
the community. The burden of lookingafter incontinent and bedfast patients is 
being borne mainly by overtaxed 
relatives. 

What do these considerations suggest for 
the NHS ? They suggest as first priority 
a high standard of assessment and 
rehabilitation for people with mental as 
well as physical troubles. They suggest 
that the numbers of people in need of 
long stay care are possibly growing. They 
suggest that the community b~sed 

services are of great importance to the ill 
elderly. How sens.i'ble are the dispositions 
of governments seen from these starting 
points ? Are we in fact providing or 
likely foreseeably to provide a highstandard of rehabilitation and assessment? 
Are we looking after long stay 
patients with care ? Are we building up 
the community services ? 

The care of the elderly affects many 
parts of the NHS. Patients above retirement 
age make up a third or more of 
patients in medical and surgical wards. 
They are getting much more active treatment 
than even a few years ago. To 
mention only one example: advances in 
orthopaedic surgery have been a greatblessing for the elderly. But there are 
often increasing difficulties in dischargingelderly patients Where an effective service 
of rehabilitation does not exist. 
Significantly the numbers of in patients 
treated in the NHS fell in 1973 for the 
first time in many years. Unless we can 
offer the elderly a better standard of 
care, the NHS will become overall a less 
effective service. 

There has been a great deal of discussion 
about the effects of the elderly 
on the hospitals. Less often discussed is 
the role of medical education and of 
medical research. But the care of the 
elderly should not be just a matter with 
which people on the wards are left to 
struggle. It should have the help of those 
who are leaders in the medical and 
nursing profession and it should have a 
reasonable share of the effort devoted to 
medical research. 

What has been the pattern of spending 
on services for the elderly in the NHS ? 
It is impossible to disentangle spending 
which takes place on general wards, but 
there are figures for spending on those 
parts of the service , which are labelled 
services for the elderly. These figures are 
set out in the ta!ble on page 16. 

Within the hospital service most of the 
expenditure has gone on long stay care. 
The spending on services which contribute 
directly to rehabilitation and on the 
community services has been small. 


EXPENDIITURE ON THE ELDERLY, 
ENGLAND & WALES, 1972-3 
revenue spending: £m 

geriatric in patientsgeriatric out patientsgeriatric day patients 
dementia in, patientshome nurses 
health visitors 
chiropody 
116.40 
0.54 
2.91 
33.42 
15.93 
2.15 
5.09 
capital expenditure 
Source : DHSS. N ote : 
Practitioner Services. 
excludes 
23.24 
Family 

What have been the policies of governments 
and what have they been attempting 
to do ? How far has it been a 
question of the DHSS wanting to do the 
right thing and not being able to do it ? 
Part of the basic strategy has been to 
support the development of geriatrics as 
a speciality by trying to win for it acute 
assessment beds in the district generalhospital and to achieve improved staffing 
in geriatrics. We first of all examine the 
record for those questions on which 
governments have t a k e n majorinitiatives. But the strategy seems to have 
been a rather hospital based one. How 
far has encouragement been given to the 
growth of the community services? 

Where have been the achievements o'f 
the last twenty years ? What are the 
strong points on which policy ·could 
build ? Perhaps ·one of the strongest has 
been the growth of the speciality of 
geriatrics. This gives us a very important 
base compared with that of many other 
countries. "In the beginning was 
Marjorie Warren." She was a pioneer of 
the active treatment and rehabilitation of 
chronic sick patients in the West 
Middlesex Hospital of the 1930s. She 
wrote of the " deplorable results oif lack 
of initiative in chronic wards " and took 
the view that " there is much to 
recommend geriatrics as a specialitycomparable to pediatrics. The creation of 
such a speciality would stimulate those 
with a leaning to this type of work and 
raise the standard of work done " (M.
Warren, The Lancet. 8 June 1946). But 
at the beginning of the Heath Service, 
there were still many thousands of 

patients who were almost imprisoned byinfirmity in long stay wards. Two 
registrars in the Lancet in 1949 described 
the situation in St Pancras Hospital, the 
old municipa'l hospital which became 
part of the NHS in 1948 (A. N. Exton 
Smith and G. S. Crockett, " The Chronic 
Sick under New Management ", The , 
Lancet. 11 June 1949). "The hospitalhad three 36 bed wards for men and 
three 45 bed wards for women, the latter 
being full to capacity. Most of the 
patients were 65 to 85 years of age, but 
some were under 50 ". 

The diagnoses on the case sheets were 
o'ften in such vague terms as " senility " 
and " myocardial degeneration "; hyper-

H 

tension " was frequently used for want 
of a better la!bel. · 

The patients were weH nourished, clean 
and without bedsores. But almost all had 
painful, stiff and in some cases fixed 
joints in their lower limbs, which were 
usually held in the position found most 
comfortable. It is these stiff and painfuljoints-resulting from long continued 
immobilization in tightly made beds-
that !form the greatest problem in 
getting these patients walking again.
The mental state tended to be one of 
apathy and depression. Over the yearthe better geriatric units (at University 
College Hospital, Ipswich and Hastings 
-to give only three examples) have come 
to set new standards in rehabilitation 
and to bring about a revolution in our 
expectations of what an elderly person 
can achieve. These better geriatric units 
are the most hopeful achievements on 
which to build for the future. Each one 
has had to esta!blish itself in the teeth 
of hostility or at 1best apathy-lfromgeneral physicians, from general practitioners 
and from the administration. 
They had first to show that they could 
treat patients actively-that they could 
do something. The position of geriatricstill shows a great variation locally. Jn 
some places it treats many more acute 
cases than in others. Its degree df access 
to the district general hospital also varies. 
Albove aU there are variations in attitude 
to the elderly, which have been 
frequently commented on in the Hospital 


Advisory Service Reports. But the best 
geriatric departments have lit the flame 
of " therapeutic optimism." 

They have done thi in most adverse 
.conditions. There i evidence to how 
that geriatric departments get many more 
df the older and sicker patients coming 
from worse home conditions and living in 
greater social isolation. A study byIsaacs examined whether geriatricpatients over 65 had a higher proportionof dependent people -whether theyshowed one or more of five symptoms:
stroke, falls, immobility, incontinence and 
mental abnormality (B. I aacs et al, 
Studies of the Illness and Death of the 
Elderly bi Glasgow, SHHD, 1972). 

" The results showed that the two groups 
of old people differed sharply. Two 
thirds of the medical patients had none 
of the five chosen presenting symptoms. 
Two thirds of the geriatric patients had 
two or more and one sixth had four or 
five. A state of dependency was defined 
as the period in which one or more of 
the last three symptoms-immobility, 
incontinence and mental abnormality-
was continuously present. A state of 
dependency be'fore admission was absent 
in aH Jbut 18 per cent of medical 
patients, and in half of these the state of 
dependency lasted for less than one week, 
while in only 8 per cent did it exceed one 
month. By ·contrast three quarters of the 
geriatric patients were dependent for 
more than one week at home before 
referral; three fifths for more than one 
month, and one quarter for more than 
one year. Nearly all the medical 

patients were discharged within three 
months. By contrast less than one third 
of the patients admitted from home to 
the geriatric unit were discharged within 
three months of admission; one third 
died in that time; and the rest remained 
in hospital" (B. Isaacs, op cit). There 
was one group among the geriatricpatients who hardly figured at all among 
the medica!l patients. These were people 
who were admitted because of 
" insufficient basic care " who made up26 per cent of the geriatric group.
Num'bers of these isolated patients had 
in fact been kept at home mainly through 

the devoted efforts of the 'home helpservice. But the service was able to give 
rather little help to relatives lookingafter the bedfast. Only a minority of 
people were using any community 
services. Only 31 per cent of incontinent 
patients had had any help from the district 
nursing service and " no use was made 
of the incontinent laundry ervice." 
Glasgow may be a somewhat extreme 
case and other studies in the London 
area suggest that geriatric departments 
are taking s-lightly more of the curable 
cases. But from the basic picture it is 
clear that geriatric departments are taking 
a very high proportion of the more 
difficult cases. 

Another success has been the clearing 
away of some of the worst of the old 
buildings that were inherited from the 
Poor Law. There are still far too manyworkhouses in use : but the more 
extreme situations which Sheldon found 
in his report on geriatric services in the 
West M'idlands have mainly disappeared. 
(I am grateful to the librarian of the 
Birmingham RHA for lending me one of 
the few surviving copies of this report). 

Sheldon's report in 1961 was iHustrated 
with vivid photographs of bags df fouled 
linen waiting collection in a main 
corridor. "The odour may permeate a 
building" of acutely angled tairs in a 
hospital, of 1ong teep stairs to a 
dmmitory for Part Three patients, of a 
small ward kitchen in the basement with 
the two floors above and of bed pans 
being stored for the night (under Dettol). 
Other photographs showed a buildingconstn1cted on the lines of a prison with 
tiers of inner balconies overlooking a 
central walL of an outside bath house 
for 84 men an'd of an outside entrance 
to an upstairs ward. Wards were 
severely overcrowded and generally without 
day rooms. At the end there was a 
photograph at a ho pital of the 
"mortuary and the pig sty in the same 
building." At least some of the most 
extreme cases have gone-although it 
was still possrble for a committee of 
geriatricians to write in the South East 
Metropolitan Board Area that: "No one 
will envy the Regional Hospital Board's 


inheritance of ancient monuments and 
general Dickensiana. Nearly all the 
hospitals used by geriatric departments 
are old buildings which were out of date 
and unsuitable for the treatment of the 
sick b~fore the turn of the century. Theylong ago reached the limit of their usefulness 
and demand replacement at the 
earliest possible moment " (South East 
Metropolitan Rim, Development of 
Services for the Elderly and ElderlyConfused, 1971). 

We turn now to the DHss's policies for 
the hospitals. The DHSS has intervened 
in four main ways through circulars,
through setting norms and guidelines,
through control of capital expenditure 
and through attempts to improve medical 
and nurse staffing in geriatrics. 

circulars 

One major theme has been the need to 
set up proper geriatrk departments. This 
was first enunciated in 1957, in a circular 
which like so many was a sound enough 
statement of doctrine. " The Minister 
considers that hospital authorities should 
give high priority in the allocation of 
resources to the establishment in every 
hospital centre of a geriatric department 
under the charge of a specialistphysician" (Geriatric Services and the 
Care of the Chronic Sick, Ministry of 
Health, HM (57)86). It was emphasizedthat these should have assessment beds in 
general hospita-ls. It also urged the va-lue 
of day hospitals. The Department's views 
were based on a special survey carried 
out by one of its medical officers, Dr 
Boucher. Much later in 1970 the 
Department issued another circular 
setting out in much more detail where 
hospital geriatric departments should be, 
and urging that 50 per cent of the beds 
should be in general hospitals (DHSS,
ns(329) 71). 

The most authoritative judgment on 
the effects of this policy comes from the 
Hospital Advisory Service (HAS) which 
has visited most geriatric departments 
in the country. In its 1969-1970 Report, 
the Director wrote that " The team has 

noticed how little change there has been 
in many hospitals compared with the 
situation described some fifteen years ago 
in the Summary Report prepared by Dr C. 

A. Boucher (HAS Annual Report, 196970, 
HMSO, 1971). The Report went on to 
say that " although the Department of 
Health has advised on the need for day 
hospitals for the elderly, there are still 
far too few in the areas we have visited, 
often have a limited function and even 
new ones have been built incomplete." 
In its Report for 1971, the HAS commented 
with surprise a!bout geriatrics that 
" so little priority is being given to 
developing this branch of medicine " 
(HAS Annual Report 1971, HMSO, 1972).
Even in planning for future generalhospitals it is conunon to find that far 
too few beds are being allocated to a 
geriatric service and in existing hosp'itals 
it is almost always the case that the 
geriatrician is given the worst accommodation 
and the rejects from other 
specialities. Some new district generalhospHals and teaching hospitals have been ' 
built without any geriatric provision. 

There are cases of new blocks beinghastily designed and stuck on the back of 
new buildings, to fill the gaps. At 'best it 
has been a desperately hard struggle to 
win a place for geriatrics-at worst a 
losing b a t t I e against intolerable 
conditions. 

norms 

The second main initiative of the DHSS 
has been in setting norms. The 1957 
circular was sceptic;al about whether it 
was possi'ble to set such norms 
(HM I57 (86) ). But by the time of the Hospital 
plan of 1962, the Ministry was less 
agnostic. They came down for a norm of 
10 beds per 1,000 over 65. Their advocacy 
of this was somewhat cautious. " It 
appears . . . from studies conducted bythe Ministry of Health that in areas 
where the whole range of serv'ices outside 
hospital is well developed, the necessary 
hospital provision is being achieved with 
about 10 beds per 1,000 population " 

(NHS: A Hospital Plan for England and 


Wales, Cmnd 1604, HMSO, 1962). As 
: ervices for rehabilitation improved, it 
might even be possible to reduce the 
number of beds. The bas1is of research 
for this judgment was not at all explicit. 
But nearly fifteen years later this number 
was still being taken as writ. There was 
official concern that the ratio was in 
Eact only 8.8 rather than 10 and some 
people spoke worriedly about a shortfall 
in bed provision of 12 per cent. 
he bed norm had a mixed reception.
here were two main lines of criticism 
which the norm attracted. There was the 
complaint of the HAS that " the 
exaggerated importance attached byhospital authorities to bed numbers con-
tinued to plague the service . . . A large 
number of beds does not necessarily 
mean an active and effective service . . . 
It is clear that the success of a depart-
ment does not depend on the number of 
beds but on the way those beds are 
used" (HAs Annual Report, 1973). This 
seen1s to reflect the experience of some 
of the better departments of geriatrks. 
For example two geriatricians and an 
·administrator from Oldham write of their 
experience over a 16 year period: " The 
increase in turnover is accompanied by 
an increase in the number of vacant beds 
and a decrease in the average length of 
stay. The virtual absence of any wa~iting 
list, the reduction in the number of 
· available beds, and the consistent increase 
in discharges and deaths indicated that 
the proportion of ' chronic ' iongstaybeds to ' acute ' short stay beds has fallen 
over the years. In January 1955 for 
instance, 66 per cent of the beds were 
occupied by patients in hospital for more 
than one year ... but in October 1972 
'only 23 per cent of the beds in the unit 
~ere so occupied." They conclude that 
" higher turnover can be achieved bybetter use of existing beds rather than by 
an increase in the number of beds " 
•cT. D. O'Brien, D. M. Joshi and E. W. 
Warren, "No Apology for Geriatrics,"
British Medical Journal, 3 November 
1973). Their hospital is in a district with 
9.2 beds per 1,000 population-that is,
less than the current " norm " of 10. 
Another major point of criticism is that 
the norm does not take enough account 
of the special needs of the over 75s. One 
unpublished study has shown that the 
use of hospital beds is six times higher 
for the over 74 age group as it is for the 
65-74 age group. Use of tltis adjusted 
norm would mean some increase in the 
number of geriatric beds in some areas 
particularly along the South Coast. This 
has in fact been suggested by a working 
party of the Wessex Regional Health 
Authority. It would however mean a 
decrease in the number of geriatric beds 
elsewhere where there are smaller 
numbers of over 75s. 
capital allocations 
A third way in which the DHss has inter-
vened is through special allocations of 
capital. Sir Keith Joseph allocated some 
extra finance for spending on geriatricand psychiatric hospitals. This of course 
came at the end in most regions of a 
long period of low spending as the 
Report on the South East shows. " Out 
of a total of £34 million allocated to the 
Board for capital works between 1948 
and March 1971 about £2 million has 
been spent on new and upgraded geriatric 
accommodation. In this Region at least 
there was a substanital improvement and 
over the period 1972-73 the Board was 
planning to spend some £1.8 million. 
It was by no means certain that there 
would generally be a net increase in the 
amount of money being spent on 
geriatrics as a result of the government's 
move. It may well be that RegionalBoards eliminated plans for spending of 
their own, in face of the department's 
special allocation. There was some 
quantitative evidence of low response in 
regions where the geriatric problem was 
at its worst. For instance, the capital 
programmes for 1972-3 in the Wessex 
and South Metropolitan Regions showed 
for 1972-3 less than 5 per cent allocated 
to the geriatric services compared with 
ove_r 16 per cent in the highest spending 
regiOns. 
Thus there is some evidence that 
the Department's drive has met with less 
Wales, Cmnd 1604, HMSO, 1962). As 
: ervices for rehabilitation improved, it 
might even be possible to reduce the 
number of beds. The bas1is of research 
for this judgment was not at all explicit. 
But nearly fifteen years later this number 
was still being taken as writ. There was 
official concern that the ratio was in 
Eact only 8.8 rather than 10 and some 
people spoke worriedly about a shortfall 
in bed provision of 12 per cent. 
he bed norm had a mixed reception.
here were two main lines of criticism 
which the norm attracted. There was the 
complaint of the HAS that " the 
exaggerated importance attached byhospital authorities to bed numbers con-
tinued to plague the service . . . A large 
number of beds does not necessarily 
mean an active and effective service . . . 
It is clear that the success of a depart-
ment does not depend on the number of 
beds but on the way those beds are 
used" (HAs Annual Report, 1973). This 
seen1s to reflect the experience of some 
of the better departments of geriatrks. 
For example two geriatricians and an 
·administrator from Oldham write of their 
experience over a 16 year period: " The 
increase in turnover is accompanied by 
an increase in the number of vacant beds 
and a decrease in the average length of 
stay. The virtual absence of any wa~iting 
list, the reduction in the number of 
· available beds, and the consistent increase 
in discharges and deaths indicated that 
the proportion of ' chronic ' iongstaybeds to ' acute ' short stay beds has fallen 
over the years. In January 1955 for 
instance, 66 per cent of the beds were 
occupied by patients in hospital for more 
than one year ... but in October 1972 
'only 23 per cent of the beds in the unit 
~ere so occupied." They conclude that 
" higher turnover can be achieved bybetter use of existing beds rather than by 
an increase in the number of beds " 
•cT. D. O'Brien, D. M. Joshi and E. W. 
Warren, "No Apology for Geriatrics,"
British Medical Journal, 3 November 
1973). Their hospital is in a district with 
9.2 beds per 1,000 population-that is,
less than the current " norm " of 10. 
Another major point of criticism is that 
the norm does not take enough account 
of the special needs of the over 75s. One 
unpublished study has shown that the 
use of hospital beds is six times higher 
for the over 74 age group as it is for the 
65-74 age group. Use of tltis adjusted 
norm would mean some increase in the 
number of geriatric beds in some areas 
particularly along the South Coast. This 
has in fact been suggested by a working 
party of the Wessex Regional Health 
Authority. It would however mean a 
decrease in the number of geriatric beds 
elsewhere where there are smaller 
numbers of over 75s. 
capital allocations 
A third way in which the DHss has inter-
vened is through special allocations of 
capital. Sir Keith Joseph allocated some 
extra finance for spending on geriatricand psychiatric hospitals. This of course 
came at the end in most regions of a 
long period of low spending as the 
Report on the South East shows. " Out 
of a total of £34 million allocated to the 
Board for capital works between 1948 
and March 1971 about £2 million has 
been spent on new and upgraded geriatric 
accommodation. In this Region at least 
there was a substanital improvement and 
over the period 1972-73 the Board was 
planning to spend some £1.8 million. 
It was by no means certain that there 
would generally be a net increase in the 
amount of money being spent on 
geriatrics as a result of the government's 
move. It may well be that RegionalBoards eliminated plans for spending of 
their own, in face of the department's 
special allocation. There was some 
quantitative evidence of low response in 
regions where the geriatric problem was 
at its worst. For instance, the capital 
programmes for 1972-3 in the Wessex 
and South Metropolitan Regions showed 
for 1972-3 less than 5 per cent allocated 
to the geriatric services compared with 
ove_r 16 per cent in the highest spending 
regiOns. 
Thus there is some evidence that 
the Department's drive has met with less 

than full success. However it is likelythat even less would have happened if 
there had not been such strong pressure, 
from the DHSS. 

staffing 

FinaHy the DHSS has attempted to 
improve staffing 'in geriatrics. It has tried 
to create more consultant posts and more 
of the training posts leading towards 
them. But it has proved most difficult to 
fill these posts. There are now 40 consultant 
vacancies in geriatrics and there 
were recently a!bout 40 District General 
Hospitals without a geriatrics department. 
There is no doubt that this reflects the 
unpopularity of geriatrics as a field for 
doctors to work in. There has been 
sympathy and support from the Royal 
College of Physicians. This recommended 
in a Report more chairs in geriatrics,
dealing with staff shortages and improved 
contact with general physicians (Reportof the College Committee on Geriatric 
Medicine, Royal College of Physicians, 
1972). But studies of the attitudes of 
young doctors showed that they tended 
to become a good deal less favountble to 
geriatrics in their first years in practice 
(J. Gale and B. Livesey, Age and Ageing, 
1974). They seemed to be more favour·
a:ble to geria:trics as students than they 
became as young doctors. It also seems 
to be the case that attempts bygeriatricians to set up rotating postsinvolving some experience of geriatricsand some in general medicine have met 
with great opposition from manygeneral physicians. The HAS has also 
criticized very strongly this n1atter of 
m e d i c a 1 attitudes. " Unfortunately 
hostility to geriatrics and to geriatricstaff can be found at all levels in the 
hospital service, and I am sorry to saythat prejudice and lack of understanding 
can occur among the most eminent in a 
teaching hospital as well as in the most 
isolated rural group. For example a 
professor of a well known teachinghospital was heard to say that ' medical 
students should not be contaminated by 
contact with geriatric patients ' and Dr 
Baker goes on to write in heavy type 
that ' I am emphasizng this matter of 

attitudes because there is little doubt that 
it underlies many of the difficulties now 
being experienced'" (HAS Annual 
Report, 1972, HMSO, 1973). These medical 
attitudes no doubt explain the verypessimistic projecbions made by the 
DHSS for the numbers of consultants in 
the geriatric service, from aJbout 400 
today to 495 in 1978 and to 720 in 1984. 

The Ministry has set minimum standards . r 
for nurse staffing which has had some 
good effects though there has been worry 
a!bout whether they would be taken as 
the norm rather than the minima. Nurse 
staffing remains a great need. As the 
report in the South East has argued:
" Women in their late seventies, eighties 
and nineties generally get up during the 
night to empty their bladders at least 
once and often two, three or more times. 
When admjtted to a hospital ward with! 
only one nurse at night in charge of 30 
or more patients, there is no chance of 
the elderly disabled patients beingassisted out of bed during the night for 
this purpose. Inevitably they must allow 
their bladders to empty in the bed and 
become incontinent. This not only creates 
more work for the nurse (and expense 
for the hospital) but is quite inhuman 
and demoralising for the patient."
Generally however there has ·been rather 
little attention to geriatric nurs1ing. The 
Briggs Report hardly mentions the subject. 
There has been some attempt to 
include geriatric nursing tnodules in 
nurse training: but apart from this there 
has been virtually no time or money 
spent on training for geriatric nursing. 

Another kind of care on which governments 
have taken initiatives is on the care 
df the mentally infirm elderly. This need 
seems to have become apparent quite early 
on in the NHS. Thus on 1 April 1950, the 
Ministry of Health issued a terselywritten C'ircular on the "care of the Aged 
Suffering from Mental Infirmity." This 
recommended short stay psychiatricunits " within geriatric departments." " It 
is contemplated that geriatric departn1ents 
will be developed in at least the 
larger hospital centres in the future and 
that such a department will normally be 
established in a general hospital. The 

r 
c 
c 

purpose of the short stay v1s1t is to 
diagnose, to provide short stay treatment 
and to ort these elderly mental cases " 
(Ministry of Health HMC/50 25). A little 
short of twenty years later the Ministry 
(or Department of Health) re-issued 
almost exactly the same circular. By this 
time the short stay units had been 
renamed "psycho-geriatric assessment 
units", but the gist of the document 
was the same. " The function 
of such a unit is to enable a precisediagnosis to be made, to initiate treatment 
and to make uitable arrangements 
for further care when necessary " and 
the document said that " normally the 
psycho-geriatric unit should 'be situated 
in the geriatric department of the district 
general hospital" (DHSS, HM 70 (11).
Since then little has happened. 

For the community services there have 
also been general injunctions, but little 
pra:ctical guidance on how to build them 
up. From the celebrated survey of 
Williamson et al, onwards (J. Williamson 
et al, " Old People at Home: their 
unreported needs," The Lancet, 23 May1964), it has been well known that many 
old people are suffering from manycompletely unreported and untreated 
disabilities. A high proportion, even of 
severely handicapped and housebound 
patients have not been recently helped by 
their GP or by a district nurse. One 
particularly important time is that 
directly after discharge from hospital:
Brocklehurst has studied the rfate of 
people in Kent immediately after discharge 
(J. Brocklehurst and M. Shergold, 
The Lancet, 23 November 1968) and 
the Age Concern Report, Care is Rare, 
(June 1973) has looked at discharge in 
Liverpool; both with worrying results. 

As with the local authority social services 
there are great geographical disparitiein the community health services: there 
is a clearer division between North and 
South than in the case with the social 
services {J. Noyes et al, The Lancet, 30 
March 1974). Studies have brought out 
again the value of the district nursingservice to the elderly-when they can get 
hold of it. T'he contfilbution of health 
visitors seems to be much more sketchy. 

A few places such as Camden have 
trained geriatric visitors but health 
visitors are mainly interested in youngchildren and their families. The attitude 
of GPs has been strongly criticized by 
some family doctors such as Dr 
Thompson of Croydon and Dr Pike of 
Handsworth who have taken a specialinterest in the elderly. There have been 
from the early 1950s many attempts to 
start screening programmes for the 
elderly but these have not caught on. 
Generally the picture is of many brightideas but little carried through to help 
large numbers of people. 

There are now 6 professors of geriatricsin English medical schools, 4 df them 
very new. They represent one df the 
most hopeful developments of the last 
few years, but they face grave difficulties 
at a time when all universityfunds are being restricted. Such restriction 
is particularly affecting new and 
struggling departments which need more 
staff. Nor are we likely to see more new 
departments in such a climate. Some 
other medi,cal schools have perhaps one 
or two staff teaching geriatrics, but without 
the resources of a fuH department.
Those departments of geriatrics are 
centres of undergraduate teaching and 
where they exist they have been successful 
in interesting medical students. They 
are centres for post-graduate training of 
future specialists and again they are 
having success in attracting applicants of 
good quality. They are also centres of 
re. earch, and they are carrying out some 
1nost important work. For example one 
new department is carrying out the first 
study of the effects of sleeping tablets and 
other drugs on the elderly. 

It is ironic that at a time of such rapid 
expansion in medical education as we 
have seen in the last few years, so little 
of it should have been concerned with 
the health problems of the elderly. It is 
particularly ironic because so much of 
the work of the NHS is concerned with the 
elderly. The DHSS has little direct voice 
in decisions on the medical curriculum, 
and on the balance between universitydepartments. These are the province of 
the Department of Education, of the 


University Grants Committee and of 
the General Medica:! Council. But it is 
surely time for the DHSS to take a 
stronger stand, in favour df a larger share 
of resources for geriatric departments. 
They need much more help to build up 
their teaching and research and we need 
more new departments in the manymedical schools where they do not 
exist. The balance between academic 
freedom and requirements for particularkinds of skilled manpower is a delicate 
matter. But 'this is one case in which 
laissez faire is not likely to produce the 
right answer. 

An even more delicate issue is that of 
direction in medicai research. Since the 
Rothschild Report, there have been three 
main groups of people concerned with 
medical research (apart from the drugcompanies). There is the DHSS itself 
which carries out research directed to 
service need. There is the Medical 
Research Council, which sponsors units 
and particular research projects. There 
are also university departments. The 
Medical Research Council has designated 
certain priority areas on which it is keen 
to sponsor m·ore work. It also givesfellowships for training in these areas to 
encourage more research workers. The 
problems of aging are not one of its 
priority areas. Of course some of the 
general research being sponsored mayproduce results which are important for 
the elderly. But the MRC Annual Reportsdo make it clear that very little direct 
work is being done on those problems 
which are of greatest importance for the 
elderly. There is no work being done on 
incontinence among the elderly or on the 
causes of dementia, to give only two 
examples. Now obviously useful research 
cannot be produced quickly any more 
than . results can be guaranteed. But 
certain steps could be taken to remedy 
the known shortage of interested 
research workers. The DHss could set an 
exampie by using some of its own 
money for training fellowships, and by 
~ommissioning more work. It could also 

negotiate with the MRC. 

The picture for long stay patients is also 
pretty gloomy. We are asking inadequate 

numbers of staff to do an impossible job 
in antiquated buildings. Within the social 
services, staff are ill equipped to look 
after increasing numbers of frail residents 
who are in need of nursing care. At 
present the DHSS is aiming to get long 
stay patients looked after in community , 
hospitals, but it is far from certain, 
whatever the merits of the idea in principle, 
that health authorities with all the 
other claims on their resources are goingto get these going in the near future. 

proposals for the future 

What ·can be done ? We need to define 
a small number of changes which could 
make a real difference and to state quite 
clearly how these are to be broughta!bout. There has been no shortage of 
s~ound doctrine and of meritorious 
circulars_jbut little has been done in : 
practice. The one great strength and greatgain of the last few years is the growth 
of geriatrics as a speciality. Governments , 
have to represent the public interest. 
This becomes difficult when, as here, 
there is a considerable gulf in attitude 
between successive governments and 
most of the medical profession. It is also 
difficult when intentions have to be 
expressed through an administrative 
machine which has become rather famous 
for inaction. Nevertheless in spite of all 
the difficulties, some attempt has been 
made to ensure that the interests of 
elderly patients and of those staff who do 
work with them are not further 
neglected. We have to recogn.ize that the 
timeta!ble for change may well have to 
be a lengthy one. If there was a real 
differ~nce within five years, this would 
be a considerable achievement. What 
changes might be useful ? 


We should give immediate additional 
help to departments of geriatric medicine 
within universities. There is evidence that 
these as new and struggling departments 
are being particularly affected by the 
current stringency in university 'budgets. 
But where they have got started they are 
having remarka:ble success in attracting 
new talent into geriatric medicine. The 
DHss should intervene with the Depart



ment of Education and the UniversityGrants Committee over this. This would 
be the single most important step in 
improving medical recruitment into a 
speciality which has had constant diffi-
:ulty in recruiting good people. Looking 
orward five to ten years, the most 
mportant change for the elderly would 
e a change in medical attitudes. We 
ihould build on those points of 
)trength which exist-the new geriatricepartments certainly are these. 
[n conjunction with geriatric departments 
Jf universities, the Medical Research 
: ouncil should be urged to sponsor a 
'll.uch larger programme df research into 
:he medical problems of old age. The 
\.1edical Research Council is rightly 
m autonomous body which makes it 
)Wn decisions. But it does seem strange 
.hat it is doing so little work on the 
1ealth problems of the elderly, which are 
1aving such a major effect on the NHS 
ts a whole. The DHSS has research funds 
)f its own, but it should also make 
•pedal representations on thi point to 
he Medical Research Council. 
.Vithin the hospital service the major.mphasis for the next five years should 
'e on staff recruitment and on staff 
tuality rather than on number of beds. 
~ven in 1973 there were only 275 
,eriatricians in England and forty vacant 
10sts. The total number of geriatricians 
; rather less than the increment in the 
tumbers of anaesthetists and pathologists1ver the last ten years. The only sure 
ay to improve recruitment in the longer 
~rm is to give scope to centres of pro-
essional excellence-hence the recom-
endation for additional money for 
eriatric departments. But in the short 
~rm we should have a special recruit-
llent effort and special training arrange-
ents to attract a small number of 
eople who are already established in 
ther specialities including generalractice into geriatrics. This would also 
equire special provision to allow previous . 
ay to be maintained during the training.
'he recruitment advertising should set 
ut the imperative reasons for this special 
ppeal. The selection of at most 50 
eople would be carried out nationally 
23 
by a panel mainly nominated by the 
British Geriatrics Society. At present it 
is very difficult for a person once 
established in a particular field of 
medicine to make a transfer; it is likelythat a fair number of good applicants 
would be attracted. The selected 
candidates would be attached to univer-
sity departments of geriatrics and would 
then apply for posts in the service. 
At present we are spending virtuallynothing on the training of nurses to work 
with elderly patients. Here again the 
longer term answer is to arouse pro-
fessional interest and to change training. 
But it would be worth starting some 
special post-qualification courses to give 
people a chance to find out about work-
ing with the elderly. 
The DHSS should use some of its develop-
ment monies for financing special work 
with long stay patients-to give some 
idea of what could be achieved. At 
present there are very few places in the 
country aJbout which people are proud. 
Why not centres of excellence here too 
and not just in clinical specialities ? 
So far we have been looking at changeswhich are brought about by new commit-
ments of money and by a new emphasis 
on staff training and quality. But there 
are other questions which are even less 
amenable. These are the questions on 
which the DHSS has had little success in 
getting the service to follow it. One 
prime example is that of geriatric 
assessment beds in District General 
Hospitals. These have often been 
recommended but stm new hospitals can 
open without geriatric departments. Nor 
has the DHSS had much success in 
getting hospitals to provide a service for 
psycho-geriatric patients. On both these 
points the government should take a 
more executive stance than has been 
customary in the NHS. It should be 
mandatory within two years for geriatricassessment beds to be within the generalhospital. 
For the psycho-geriatric service a 
special financial incentive is needed. 
Health authorities should be asked to 
ment of Education and the UniversityGrants Committee over this. This would 
be the single most important step in 
improving medical recruitment into a 
speciality which has had constant diffi-
:ulty in recruiting good people. Looking 
orward five to ten years, the most 
mportant change for the elderly would 
e a change in medical attitudes. We 
ihould build on those points of 
)trength which exist-the new geriatricepartments certainly are these. 
[n conjunction with geriatric departments 
Jf universities, the Medical Research 
: ouncil should be urged to sponsor a 
'll.uch larger programme df research into 
:he medical problems of old age. The 
\.1edical Research Council is rightly 
m autonomous body which makes it 
)Wn decisions. But it does seem strange 
.hat it is doing so little work on the 
1ealth problems of the elderly, which are 
1aving such a major effect on the NHS 
ts a whole. The DHSS has research funds 
)f its own, but it should also make 
•pedal representations on thi point to 
he Medical Research Council. 
.Vithin the hospital service the major.mphasis for the next five years should 
'e on staff recruitment and on staff 
tuality rather than on number of beds. 
~ven in 1973 there were only 275 
,eriatricians in England and forty vacant 
10sts. The total number of geriatricians 
; rather less than the increment in the 
tumbers of anaesthetists and pathologists1ver the last ten years. The only sure 
ay to improve recruitment in the longer 
~rm is to give scope to centres of pro-
essional excellence-hence the recom-
endation for additional money for 
eriatric departments. But in the short 
~rm we should have a special recruit-
llent effort and special training arrange-
ents to attract a small number of 
eople who are already established in 
ther specialities including generalractice into geriatrics. This would also 
equire special provision to allow previous . 
ay to be maintained during the training.
'he recruitment advertising should set 
ut the imperative reasons for this special 
ppeal. The selection of at most 50 
eople would be carried out nationally 
23 
by a panel mainly nominated by the 
British Geriatrics Society. At present it 
is very difficult for a person once 
established in a particular field of 
medicine to make a transfer; it is likelythat a fair number of good applicants 
would be attracted. The selected 
candidates would be attached to univer-
sity departments of geriatrics and would 
then apply for posts in the service. 
At present we are spending virtuallynothing on the training of nurses to work 
with elderly patients. Here again the 
longer term answer is to arouse pro-
fessional interest and to change training. 
But it would be worth starting some 
special post-qualification courses to give 
people a chance to find out about work-
ing with the elderly. 
The DHSS should use some of its develop-
ment monies for financing special work 
with long stay patients-to give some 
idea of what could be achieved. At 
present there are very few places in the 
country aJbout which people are proud. 
Why not centres of excellence here too 
and not just in clinical specialities ? 
So far we have been looking at changeswhich are brought about by new commit-
ments of money and by a new emphasis 
on staff training and quality. But there 
are other questions which are even less 
amenable. These are the questions on 
which the DHSS has had little success in 
getting the service to follow it. One 
prime example is that of geriatric 
assessment beds in District General 
Hospitals. These have often been 
recommended but stm new hospitals can 
open without geriatric departments. Nor 
has the DHSS had much success in 
getting hospitals to provide a service for 
psycho-geriatric patients. On both these 
points the government should take a 
more executive stance than has been 
customary in the NHS. It should be 
mandatory within two years for geriatricassessment beds to be within the generalhospital. 
For the psycho-geriatric service a 
special financial incentive is needed. 
Health authorities should be asked to 

submit plans and they should be financed 
by a special earmarked allocation of 
funds. Otherwise the DHSS will veryproba!bly be re-issuing the same document 
in 1991 as it issued in 1959 and 1971. 

Within the community health services 
there is exactly the same case for settingminimum standards as in the social 
services. This is particularly so for the 
district nursing service which plays such 
a vital role in the case of the elderly. 
Could not, too, the interest of more 
health visitors be won for the care of the 
elderly? The "geriatric visitor" experiment 
has been a success and could be 
repeated more widely. 

We need more good purpose-built homes 
for long stay patients. Perhaps one or 
two for the present homes for the 
elderly in each community should concentrate 
on the more frail and should be 
administered jointly by the health and 
social services. We need NHS NursingHomes. This is the right aim-a 
substitute for home for people who 
cannot return fully to the communityand who need nursing care. We have to 
get away from our heritage of the large 
"long stay hospital," which at the best 
of times is a rather strange idea. 

Our present arrangements for people with 
chrorric illness are becoming irrcreasingly 
unsatisfactory. We have reduced the 
numbers of long stay places in the NHS. 

At the same time we are looking after 
more people who are frail and in need of 
nursing care in the setting of old people's 
homes, as surveys of residents in Buckinghamshire 
and Coventry have shown. 
The homes are not really equipped to 
give such care. In these circumstances 
the idea of an NHS nursing home has a 
good deal to offer. It can provide nursing 
care but in a home rather than a hospital 
setting. 

These proposals together would contribute 
to the immediate aims of the 
service as we defined them-a highstandard of assessment and rehabilitation, 
better care for psychiatric and for long 
stay patients and stronger community 

services. Under present dispositions Wf 
are not likely to see these aims achieveo 
in the present century. 


5. summary and conclusions 
e fhe story of governments and the elderly 
j 1as a wider significance for our 
emocracy and for our parliamentary 
;ystem. It shows the extreme difficulty of 
mbjecting to informed scrutiny the 
<1.ctions of the executive on those matters 
hich are generally thought to be 
ncontroversial. Much of our politics has 
:;orne to be about the economy and about 
:hose few issues which have come to be 
:lighly controversial. The attentions of 
oarliament tend to be on these issues and 
~n the routine of economic management. 

·Debates on other matters tend to be 
infrequent and perfunctory. This leaves 
government departments in a position of 
immense and virtually unchecked power. 
This is a great paradox for democratic 
wcialists. Here, in the heart of government 
we have fhe complete absence of 
any form of regular democratic scrutiny. 
Information is hard to come by and there 
is a virtual a!bsence of public or 
parliamentary debate. 

'Socialists have always wanted to see 
increases in public spending, but the 
moral here is that we have to be more 
·concerned with the distribution of such 
spending and its pattern-not just with 

·its aggregate rate of increase. Of course 
this concern with patterns becomes even 
more important at a time of financial 
stringency. 

There has been remarkably little public 
debate about the different ways in which 
governments might help the elderly. Yet 
there are alternatives. There is a greatdeal of opposition among many people 
to our present policies, but it is verydifficult within our present framework 
of government for these different 
approaches to get a fair hearing. This 
pamphlet has set out one set of 
alternatives. 

The aims of policy have been to enable 
the elderly where ever possible to lead a 
full life in the community, but the 
actual pattern of spending is in manyways strangely unrelated to this aim. The 
services as we have them do not reflect 
an " optimal " pattern. Principally they 
reflect differing degrees of lethargy or 
energy among government departments. 

The issues which are seen officially as 
important and as requiring action have 
not changed very much over the last 
fifteen years. There has been a curious 
absence of mind on a number of points.
There has been no effort to set minimum 
standards for the community services 
such as the home help service. There has 
been little attention to the housingpreiblems of the elderly. Within the NHS 
the focus has been on the bed norm and 
much less on the question of quality and 
training among staff. Some things have 
been done but equally important issues 

have been neglected. 

Our effort to help the elderly is now 
distinctly unbalanced. We really cannot 
continue to make decisions about one 
kind of help in isolation from others. The 
aim of this pamphlet is to arouse some 
questioning and some debate about 
alternatives-a:bout ways in which the 
actions of governments n:light serve more 
human ends. 

Our lives are increasingly influenced by 
giant bureaucracies. Is it possible for this 
kind of society to avoid a slow ebbing of 
humanity and fellow feeling ? Is it 
possible for governments to move awayfrom the lowest common denominator of 
official caution ? As far as the elderly 
are concerned these are still unanswered 
questions. The aims of our policies 
are fairly well agreed. We now look at 
these different ways of achieving them in 
the social services, housing and the NHS. 

the social services 

A large part of the concentration here-and 
most of the spending-has been on 
old people's homes. The communityservices have expanded althoughpatchily. There has been far too little 
effort to tap the resources of good will 
and neigblbourliness that are there in the 
community. Our services have been too 
institutional and too coloniS'ed by professionals. 
We need a more communitybased service which is more evenlyspread across the country. We also need 
a mudh greater priority to sheltered 
housing. The government should (a) stop 


26 
building more homes for the elderlyexcept as replacements for former work-
houses. The spending should be carried 
over to the building of sheltered housing, 
recognising the implications that this will 
have in terms of extra demands on the 
community services. At present we are 
not even providing enough places in 
sheltered housing to serve the needs of 
the most promising candidates. (b) set 
minimum standards for the communityservices in order to remedy the present 
grossly uneven distribution. (c) con-
centrate on a new type of small neigh-
bourhood centre. (d) encourage goodneighlbour schemes. (e) start joint ass·ess-
ment units as between the health and 
social services. 
housing 
Governments have managed to ignore the 
rather shocking evidence about the 
housing conditions of the elderly. The 
facts are well known-but they have had 
remarkably little influence on spending.
We have done little to provide more 
sheltered hous·ing. We are expectingpeople who may well be suffering from 
chronic illness to cope in circumstances 
which would tax the fittest. Central 
government in England and Wales has 
been very lethargic-but some local 
authorities such as Greenwich, Liverpool 
and Manchester have begun to take an 
interest. In fact housing associations have 
a rather better record than central 
govermnent. 
It is time for a new initiative to get more 
grouped sheltered hous-ing built. The oase 
is argued for a norm and for additional 
spending df about £50 mil'lion a year. We 
also need changes in the local authority 
transfer system to make it more possiblefor people to give support to their 
elderly relatives. 
the NHS 
The pattern of illness found among the 
elderly suggests the need for a highquality of assessment and rehabilitation 
and for better community serv1ces. 
Governments have had some of the right 
ideas-but they have had great difficulty 
in getting them put into practice. The 
time scale for change has to be a long 
one and has to concentrate on changeswhich have som·e realistic chance of 
coming off. 
We also need to broaden our focus. We 
have been concerned with numbers of 
beds-but not with the quality and train-
ing of staff. We have been concerned with 
care on the wards but not with the com-
manding heights in the medical schools 
and the Medical Research Council. We 
need to back heavily the new geriatricdepartments in medical schools and to 
spend much more on medical research, 
where little is spent at present. The most 
important change which we can make in 
the longer term is to build up centres of 
excellence in the care of the elderly. Bu 
we also need new short term initiatives 
in staffing and tra'ining to meet a; 
desperate situation. 
On s·ome points such as the placing of 
assessm·ent 1beds in D·istrict General 
Hospitals and the care of psycho-
geriatric patients, the government is 
simply going to have to take much 
firmer executive aotion than has been 
customary in the NHS. Finally we need 
new help to long stay patients and the 
case is argued for introducing the 
concept of an NHS nursing home. 
The plans suggested here are financially 
realistic. Many of them involve not new 
resources but a re-allocation· of existing 
ones. The total sum of new resources 
required is less than £100 million a yea 
-which is a good deal less than the cost 
of the travel concessions to the elderlynationally. The plans suggested here 
would really concentrate effort on those 
services which are of greatest help to 
those least able to cope. They would 
add up to a " new deal " for the elderly. 
26 
building more homes for the elderlyexcept as replacements for former work-
houses. The spending should be carried 
over to the building of sheltered housing, 
recognising the implications that this will 
have in terms of extra demands on the 
community services. At present we are 
not even providing enough places in 
sheltered housing to serve the needs of 
the most promising candidates. (b) set 
minimum standards for the communityservices in order to remedy the present 
grossly uneven distribution. (c) con-
centrate on a new type of small neigh-
bourhood centre. (d) encourage goodneighlbour schemes. (e) start joint ass·ess-
ment units as between the health and 
social services. 
housing 
Governments have managed to ignore the 
rather shocking evidence about the 
housing conditions of the elderly. The 
facts are well known-but they have had 
remarkably little influence on spending.
We have done little to provide more 
sheltered hous·ing. We are expectingpeople who may well be suffering from 
chronic illness to cope in circumstances 
which would tax the fittest. Central 
government in England and Wales has 
been very lethargic-but some local 
authorities such as Greenwich, Liverpool 
and Manchester have begun to take an 
interest. In fact housing associations have 
a rather better record than central 
govermnent. 
It is time for a new initiative to get more 
grouped sheltered hous-ing built. The oase 
is argued for a norm and for additional 
spending df about £50 mil'lion a year. We 
also need changes in the local authority 
transfer system to make it more possiblefor people to give support to their 
elderly relatives. 
the NHS 
The pattern of illness found among the 
elderly suggests the need for a highquality of assessment and rehabilitation 
and for better community serv1ces. 
Governments have had some of the right 
ideas-but they have had great difficulty 
in getting them put into practice. The 
time scale for change has to be a long 
one and has to concentrate on changeswhich have som·e realistic chance of 
coming off. 
We also need to broaden our focus. We 
have been concerned with numbers of 
beds-but not with the quality and train-
ing of staff. We have been concerned with 
care on the wards but not with the com-
manding heights in the medical schools 
and the Medical Research Council. We 
need to back heavily the new geriatricdepartments in medical schools and to 
spend much more on medical research, 
where little is spent at present. The most 
important change which we can make in 
the longer term is to build up centres of 
excellence in the care of the elderly. Bu 
we also need new short term initiatives 
in staffing and tra'ining to meet a; 
desperate situation. 
On s·ome points such as the placing of 
assessm·ent 1beds in D·istrict General 
Hospitals and the care of psycho-
geriatric patients, the government is 
simply going to have to take much 
firmer executive aotion than has been 
customary in the NHS. Finally we need 
new help to long stay patients and the 
case is argued for introducing the 
concept of an NHS nursing home. 
The plans suggested here are financially 
realistic. Many of them involve not new 
resources but a re-allocation· of existing 
ones. The total sum of new resources 
required is less than £100 million a yea 
-which is a good deal less than the cost 
of the travel concessions to the elderlynationally. The plans suggested here 
would really concentrate effort on those 
services which are of greatest help to 
those least able to cope. They would 
add up to a " new deal " for the elderly. 

fabian society 


The Fabian Society exists to further 
socialist education and research. It is 
affiliated to the Labour Party, both nationally 
and locally, and embraces all shades 
of Socialist opinion within its ranks-left, 
right and centre. 

Since 1884 the Fabian Society has enrolled 
thoughtful socialists who are prepared to 
discuss the essential questions of democratic 
socialism and relate them to practical 
plans for building socialism in a 
changing world. 

Beyond this the Society has no collective 
policy. It puts forward no resolutions of 
a political character, but it is not an organisation 
of armchair socialists. Its members 
are active in their Labour Parties, Trade 
Unions and Co-operatives. They are representative 
of the labour movement, practical 
people concerned to study and discuss 
problems that matter. 

The Society is organised nationally and 
locally. The national Society, directed by 
an elected Executive Committee, publishes 
pamphlets, and holds schools and conferences 
of many kinds. Local Societies


. 
there are one hundred of them-are self 
governing and are lively centres of discussion 
and also undertake research. 

Enquiries about membership should be 
sent to the General Secretary, Fabian 
Society, 11 Dartmouth Street, London, 
SWIH 9BN; telephone 01-930 3077. 

the author 

Nicholas Bosanquet is an economi t who 
has written exten ively about the NH 
and about low pay including the Young 
Fabian pamphlet Pay, Prices and Labour 
in Power and Labour and Inequality with 
Peter Town end. He was formerly in 
charge of research for the Briggs Committee 
on Nursing, an advisor at the 
Prices and Incomes Board and a lecturer 
in health economics at King's Fund 
College. He is now a director of a firm 
of economic con ultant . A parliamentary 
candidate in 1969, Nicholas Bo anquet is 
now a Councillor in Camden and vice 
chairman of their ocial services 
committee. He i also the Chairman of 
the Fabian Society, having been on the 

Fabian executive since 1968. 

Cover design by Dick Leadbetter. Printed 
by Civic Press Limited (Tu), Civic Street, 
Glasgow, G4 9RH. 

I 
BN 7163 0435)( 


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