A better deal for subnormals Our subnormality services are the subject of a number of current investigations, which will provide valuable information upon which a better service can be built. In this article Dr. F. M. Martin surveys
some
of the research work
now
going
on.
people who need residential care. In such experimental area, the medical, psychiatric and psychological services, as well as the educational, training and recreational needs of the patients, would be supplied by the local services (expanded where necessary) which already meet the needs of patients living at home. The relatively small numbers involved?23 places would be sufficient to provide for all those mentally subnormal children belonging to the area who need residential care?clearly indicate the possibility of using family group homes. subnormal
an
Dr. Kushlick has gone
The past few years have seen a greater recognition of the part that research can play in estimating the need for medical care services, in analysing the ways in which such services actually function, as distinct from the ways in which they are conventionally assumed to function, and in assessing their effects upon patients. Such operational studies have already done a great deal to deepen our understanding of the personal and social consequences of mental illness and of the implications of different types of psychiatric care.
More recently, operational research has extended the field of mental subnormality, and it is hoped
'nto
that
in progress will show and weaknesses ?f our existing services for the subnormal and about the lines on which they can most effectively be a
number of studies
us much more about the
now
strengths
developed in the future. Striking advantages ^luch interest has been aroused by velopments in residential care. One
two recent deof these is the
small family group home for subnormal children. the now classic 'Brooklands' experiment, Professor Jack Tizard compared the intellectual and emotional development of children in one such home with that of matched children who remained in one of the most admirable of our large institutions, and con-
eluded that the former offered striking advantages, ^e emphasised, however, that further research and e*periment were urgently required. ^r- Albert Kushlick has very recently completed an eXceedingly thorough survey of the prevalence of Cental subnormality in the area of the Wessex Regional Hospital Board, and is now using the epidemiological data as the basis for the design of a nevv experimental scheme for the evaluation of serGiven an area of any specified population, Dr. vices. kushlick shows that it is possible to make a very teliable estimate of the number of children and adults ?f varying degrees of subnormality who 'belong' to 'tat area. Taking as his model an area of 100,000 people, he that for experimental purposes, places could ^uSgests e provided within its borders for all its own severely
L
so
far
as
to
show how
a
family unit of ten, randomly selected from institutions, would be divided between age-groups, and what numbers it would contain of the bed-bound, the incontinent, and the children with major behaviour problems. As Dr. Kushlick points out, a comparison of an experimental comprehensive service for an area of 100,000 population with the traditional service in a comparable area would involve consideration of several variables in the two groups? the level of social and intellectual development attained, the frequency of signs of disturbed behaviour, the problems of management experienced by families, the administrative problems and consequences, and so on. It should not be assumed that one method will always prove to be superior, whatever the criterion chosen. In evaluative studies of this kind, we must take into account as many factors as possible, make the most detailed assessments our methods permit, and then aim at a decision based upon substantial knowledge. Research cannot eliminate value-judgments, but it can at least ensure that they are well-informed. A second type of residential care is that provided by the hostels which local health authorities are being encouraged to build for subnormal patients who are believed not to need the full facilities of a hospital, but do not have homes to return to. Dr. M. W. Susser, Dr. Joyce Leeson and Dr. Alison Campbell of Manchester University, in collaboration with Lancashire County Council, are beginning to study a sample of one hundred patients, who have been selected for transfer before they leave hospital, and then follow their progress in the hostels. The transferred patients will be compared with other patients who have similar characteristics, but who remain in hospital because there are no ho3tel places for them in their home areas. Adult subnormals
The focus here will be on adult subnormals, and much basic work has to be carried out in devising appropriate measures of performance. Studies of the social structure of the different institutions, of staff attitudes and practices and of the impact of these upon patients will form an integral part of the Manchester
enquiry.
This project differs from the Wessex proposal in taking advantage of a policy decision on the verge of
The heart of the
matter
implementation, while the latter postulates a new and deliberately experimental development of services. The final problem of evaluation, however, may still involve a complex balancing of advantages and drawbacks. What is important is that we shall know in precise terms what effects different types of and do not have. Discussion need no confined to unsupported assertions. Whatever developments there may be in the provision of hostels or of small residential units, the majority of subnormal people needing residential care are likely to be looked after in the larger institutions for many years to come. Indeed, a number of doctors believe that the more 'traditional' type of institution has important potential advantages which have been underestimated in the current wave of enthusiasm for small centres. hostel do
longer be
Kind of environment Two current projects are concerned primarily with mental subnormality hospitals. Professor Townsend and Mrs. Pauline Morris of the University of Essex, with the support of the National Society for Mentally
Handicapped Children, are carrying out a detailed survey of a sample of hospitals, voluntary and private hospitals and homes, as well as NHS institutions of different sizes. Their main interest is in the quality of the environment that these hospitals provide?the physical amenities, the degree of self-determination possible, the extent to which contacts with families and the community are fostered and the educational and occupational provisions made. Information is being collected from staff members and by direct observation in the wards. The study also includes a statistical review of the characteristics and condition of a sample of patients, supplemented by interviews and assessments of a sub-sample. An extension of this project is an intensive study of two or three hospitals, which are being described and analysed in detail as social communities. The National Association for Mental Health, supported by the Spastics Society and the National
Society at
Mentally Handicapped Children, is also in a four-part investigation, mainly on hospitals for the subnormal. The
for
present involved
centred research workers are Mrs. Margaret Bone and Miss Bernardette Spain, with the author as consultant. This project has some aims which are similar to those of the University of Essex survey; it is concerned with the kinds of patients currently in hospital and with the facilities provided for them. In addition, it will ascertain what changes are occurring in the type of patient being admitted to hospital, in duration of stay, and in the factors influencing admission and discharge.
Hospitals questioned
Four studies are now in progress. A simple review of the facilities provided by the hospitals, such as industrial contract work, occupational therapy and 18
Photo: Photo: John John Brooke Brooke cannot be looked after What's What's cooking? Where retarded children cannot at home, an attempt is made to give institutional life a a homely now recommended care is for such children. atmosphere. Community
training centres, in relation to the number ot patients housed and their distribution by age and grade, is being carried out by means of a questionnaire to all hospitals in England and Wales. A more detailed study is being carried out in three Regions, where ward staff are providing systematic information on a ten per cent sample of patients. It will be possible to examine the make-up of the in-patient population, in terms of the frequency and degree of different types of physical, emotional and behavioural handicap, and thus to estimate for planning purposes the need for different levels of nursing care and the proportions apparently capable of acquiring varying levels of skill. The other enquiries now under way at NAMH involve the employment of the cohort method to study trends in the utilisation of subnormality hospitals. Details of all first admissions to such hospitals in one Region in 1949, 1959 and 1963 have been extracted from case records, and are being analysed to find out how these admission cohorts differed in respect of age, sex, diagnosis and IQ, in the length of time they remained in hospital, in death rates and in discharge rates. Finally, a comparable study of all patients notified as subnormal to one large local health authority in the same years is nearing completion. Analyses of these data are principally designed to show what effect increases in the provision of community services have on the demand for hospital care. From these varied researches a very detailed picture will gradually emerge of the workings of our services for the mentally subnormal, and of their strengths and weaknesses. Future policy reappraisals will have unusually firm scientific foundations on which to build.
some
of the research work
now
going
on.
people who need residential care. In such experimental area, the medical, psychiatric and psychological services, as well as the educational, training and recreational needs of the patients, would be supplied by the local services (expanded where necessary) which already meet the needs of patients living at home. The relatively small numbers involved?23 places would be sufficient to provide for all those mentally subnormal children belonging to the area who need residential care?clearly indicate the possibility of using family group homes. subnormal
an
Dr. Kushlick has gone
The past few years have seen a greater recognition of the part that research can play in estimating the need for medical care services, in analysing the ways in which such services actually function, as distinct from the ways in which they are conventionally assumed to function, and in assessing their effects upon patients. Such operational studies have already done a great deal to deepen our understanding of the personal and social consequences of mental illness and of the implications of different types of psychiatric care.
More recently, operational research has extended the field of mental subnormality, and it is hoped
'nto
that
in progress will show and weaknesses ?f our existing services for the subnormal and about the lines on which they can most effectively be a
number of studies
us much more about the
now
strengths
developed in the future. Striking advantages ^luch interest has been aroused by velopments in residential care. One
two recent deof these is the
small family group home for subnormal children. the now classic 'Brooklands' experiment, Professor Jack Tizard compared the intellectual and emotional development of children in one such home with that of matched children who remained in one of the most admirable of our large institutions, and con-
eluded that the former offered striking advantages, ^e emphasised, however, that further research and e*periment were urgently required. ^r- Albert Kushlick has very recently completed an eXceedingly thorough survey of the prevalence of Cental subnormality in the area of the Wessex Regional Hospital Board, and is now using the epidemiological data as the basis for the design of a nevv experimental scheme for the evaluation of serGiven an area of any specified population, Dr. vices. kushlick shows that it is possible to make a very teliable estimate of the number of children and adults ?f varying degrees of subnormality who 'belong' to 'tat area. Taking as his model an area of 100,000 people, he that for experimental purposes, places could ^uSgests e provided within its borders for all its own severely
L
so
far
as
to
show how
a
family unit of ten, randomly selected from institutions, would be divided between age-groups, and what numbers it would contain of the bed-bound, the incontinent, and the children with major behaviour problems. As Dr. Kushlick points out, a comparison of an experimental comprehensive service for an area of 100,000 population with the traditional service in a comparable area would involve consideration of several variables in the two groups? the level of social and intellectual development attained, the frequency of signs of disturbed behaviour, the problems of management experienced by families, the administrative problems and consequences, and so on. It should not be assumed that one method will always prove to be superior, whatever the criterion chosen. In evaluative studies of this kind, we must take into account as many factors as possible, make the most detailed assessments our methods permit, and then aim at a decision based upon substantial knowledge. Research cannot eliminate value-judgments, but it can at least ensure that they are well-informed. A second type of residential care is that provided by the hostels which local health authorities are being encouraged to build for subnormal patients who are believed not to need the full facilities of a hospital, but do not have homes to return to. Dr. M. W. Susser, Dr. Joyce Leeson and Dr. Alison Campbell of Manchester University, in collaboration with Lancashire County Council, are beginning to study a sample of one hundred patients, who have been selected for transfer before they leave hospital, and then follow their progress in the hostels. The transferred patients will be compared with other patients who have similar characteristics, but who remain in hospital because there are no ho3tel places for them in their home areas. Adult subnormals
The focus here will be on adult subnormals, and much basic work has to be carried out in devising appropriate measures of performance. Studies of the social structure of the different institutions, of staff attitudes and practices and of the impact of these upon patients will form an integral part of the Manchester
enquiry.
This project differs from the Wessex proposal in taking advantage of a policy decision on the verge of
The heart of the
matter
implementation, while the latter postulates a new and deliberately experimental development of services. The final problem of evaluation, however, may still involve a complex balancing of advantages and drawbacks. What is important is that we shall know in precise terms what effects different types of and do not have. Discussion need no confined to unsupported assertions. Whatever developments there may be in the provision of hostels or of small residential units, the majority of subnormal people needing residential care are likely to be looked after in the larger institutions for many years to come. Indeed, a number of doctors believe that the more 'traditional' type of institution has important potential advantages which have been underestimated in the current wave of enthusiasm for small centres. hostel do
longer be
Kind of environment Two current projects are concerned primarily with mental subnormality hospitals. Professor Townsend and Mrs. Pauline Morris of the University of Essex, with the support of the National Society for Mentally
Handicapped Children, are carrying out a detailed survey of a sample of hospitals, voluntary and private hospitals and homes, as well as NHS institutions of different sizes. Their main interest is in the quality of the environment that these hospitals provide?the physical amenities, the degree of self-determination possible, the extent to which contacts with families and the community are fostered and the educational and occupational provisions made. Information is being collected from staff members and by direct observation in the wards. The study also includes a statistical review of the characteristics and condition of a sample of patients, supplemented by interviews and assessments of a sub-sample. An extension of this project is an intensive study of two or three hospitals, which are being described and analysed in detail as social communities. The National Association for Mental Health, supported by the Spastics Society and the National
Society at
Mentally Handicapped Children, is also in a four-part investigation, mainly on hospitals for the subnormal. The
for
present involved
centred research workers are Mrs. Margaret Bone and Miss Bernardette Spain, with the author as consultant. This project has some aims which are similar to those of the University of Essex survey; it is concerned with the kinds of patients currently in hospital and with the facilities provided for them. In addition, it will ascertain what changes are occurring in the type of patient being admitted to hospital, in duration of stay, and in the factors influencing admission and discharge.
Hospitals questioned
Four studies are now in progress. A simple review of the facilities provided by the hospitals, such as industrial contract work, occupational therapy and 18
Photo: Photo: John John Brooke Brooke cannot be looked after What's What's cooking? Where retarded children cannot at home, an attempt is made to give institutional life a a homely now recommended care is for such children. atmosphere. Community
training centres, in relation to the number ot patients housed and their distribution by age and grade, is being carried out by means of a questionnaire to all hospitals in England and Wales. A more detailed study is being carried out in three Regions, where ward staff are providing systematic information on a ten per cent sample of patients. It will be possible to examine the make-up of the in-patient population, in terms of the frequency and degree of different types of physical, emotional and behavioural handicap, and thus to estimate for planning purposes the need for different levels of nursing care and the proportions apparently capable of acquiring varying levels of skill. The other enquiries now under way at NAMH involve the employment of the cohort method to study trends in the utilisation of subnormality hospitals. Details of all first admissions to such hospitals in one Region in 1949, 1959 and 1963 have been extracted from case records, and are being analysed to find out how these admission cohorts differed in respect of age, sex, diagnosis and IQ, in the length of time they remained in hospital, in death rates and in discharge rates. Finally, a comparable study of all patients notified as subnormal to one large local health authority in the same years is nearing completion. Analyses of these data are principally designed to show what effect increases in the provision of community services have on the demand for hospital care. From these varied researches a very detailed picture will gradually emerge of the workings of our services for the mentally subnormal, and of their strengths and weaknesses. Future policy reappraisals will have unusually firm scientific foundations on which to build.
