Homes for Old A. N.
People Exton-Smith, M.D.,
m.r.c.p.
By 1975 it is envisaged that the number of beds in mental hospitals will be reduced from the present level of 3.3 per thousand of population to about 1.8 per thousand1. It is uncertain whether this considerable reduction will be achieved mainly by a diminution in the numbers of elderly or of younger patients who must remain in mental hospitals. It is, however, clear that it will be practicable only if the community health services are greatly expanded. The chief medical officer of the Ministry of Health in his annual report for 1957 estimated that of all the patients over the age of 65 in psychiatric hospitals during 1954, some 12} per cent could be cared for in old people's homes. An important function of local authorities now is to provide residential accommodation under Part II of the Mental Health Act of 1959. But by the end of 1961 only four hostels for ambulant elderly confused people had been established by local authorities. 234
A
dynamic policy
With the ten year hospital programme, a dynamic policy regarding welfare accommodation is required. Such a policy is proposed by Mr. Peter Townsend in "The Last Refuge"2 and it is based on the results of his comprehensive survey of 173 residential institutions and homes for the aged in England and Wales. The four main types of institution studied are the former workhouses, the small local authority homes of up to 60 people, voluntary homes and homes for the aged run privately. Of the estimated 100,000 old people in these institutions 47 per cent are still accommodated in former workhouses and the vivid account of the life these old people lead, the effects upon them of the institutional environment and how they came to leave their own homes, makes a dismal and pathetic story. The sad heritage of a state of affairs determined by social policies of the days of the Poor Law makes reform an urgent necessity, but hardly an encouraging basis for future planning. To quote the words of a warden: "Our greatest problem is the mixture of mental, sick, confused and infirm. This makes it very hard for the patients. We have tried forms of segregation but it's not possible." Owing to lack of adequate diagnosis Mr. Townsend found difficulty in estimating the incidence of mental disorder among the residents, but he considered 17 per cent to be mentally impaired, and 5 per cent severely so. Some of the disturbances such as depression, aggressiveness and other behaviour disorders he attributed to institutional environment and routine?on which little research has been done. He complains of the indiscriminate use of terms such as mentally confused, senile, forgetful, senile dement,
mentally incapable,
Purpose
etc.
of residential homes
He expects more such people to be transferred to welfare homes and he discusses the purpose of the residential home and argues that they should have the same "therapeutic philosophy" as geriatric units. The facts that at the time of his survey 40 per cent of new residents had not been seen by a doctor since admission, that many needed dentures, spectacles and hearing aids, and that in only three or four of the 173 homes was physiotherapy available are indications of the magnitude of present neglect. What is true for the physical disabilities of old age applies equally in the field of mental health. A report of the World Health Organisation3 points out that a high proportion of mental illnesses in old age are curable if treated early. Mr. Townsend's suggestion that Hospital Management Committees should take over residential accommodation might attain a higher standard of medical care in the homes, and simplify administrative responsibility. A comprehensive policy for the health and welfare of the aged must be based on clearer definitions of the responsibilities of psychiatric, geriatric and welfare services.
Psycho-geriatric
units
Few field studies of the needs of mentally confused old people have been conducted, but from a small survey in Wales, Andrews and Insley4 conclude that the number of old people who require special residential accommodation is not large, but they emphasise that these people should live in an environment suited to their special needs and capabilities, out of competition with their mentally fitter comrades on the one hand, and unassociated with gross mental illness on the other. Although obviously there are difficulties in segregation in welfare homes, the success and ease of working of one such special home in North London has been demonstrated during its nine years of existence5. The development of psycho-geriatric 235
units accommodated either in geriatric departments early assessment and treatment and would suitable homes or long-stay nursing annexes. ensure
1 2
3
4 5
or
in psychiatric hospitals would that patients are placed in
see
A Hospital Plan for England and Wales. H.M. Stationery Office, 1962. Townsend, P. "The Last Refuge: A Survey of Residential Institutions and Homes for the Aged in England and Wales". London, 1962. (Routledge and Kegan Paul, 60s.). World Health Organisation Expert Committee on Mental Health "Mental Health Problems of Ageing and the Aged". Technical Report Series No. 171, Geneva, 1959. Andrews, J. D. B. and Insley, M. L. Geront. clin., Basle, 1962, 4, 94. Hill, M. N. "An Approach to Old Age and its Problems". London, 1961.
People Exton-Smith, M.D.,
m.r.c.p.
By 1975 it is envisaged that the number of beds in mental hospitals will be reduced from the present level of 3.3 per thousand of population to about 1.8 per thousand1. It is uncertain whether this considerable reduction will be achieved mainly by a diminution in the numbers of elderly or of younger patients who must remain in mental hospitals. It is, however, clear that it will be practicable only if the community health services are greatly expanded. The chief medical officer of the Ministry of Health in his annual report for 1957 estimated that of all the patients over the age of 65 in psychiatric hospitals during 1954, some 12} per cent could be cared for in old people's homes. An important function of local authorities now is to provide residential accommodation under Part II of the Mental Health Act of 1959. But by the end of 1961 only four hostels for ambulant elderly confused people had been established by local authorities. 234
A
dynamic policy
With the ten year hospital programme, a dynamic policy regarding welfare accommodation is required. Such a policy is proposed by Mr. Peter Townsend in "The Last Refuge"2 and it is based on the results of his comprehensive survey of 173 residential institutions and homes for the aged in England and Wales. The four main types of institution studied are the former workhouses, the small local authority homes of up to 60 people, voluntary homes and homes for the aged run privately. Of the estimated 100,000 old people in these institutions 47 per cent are still accommodated in former workhouses and the vivid account of the life these old people lead, the effects upon them of the institutional environment and how they came to leave their own homes, makes a dismal and pathetic story. The sad heritage of a state of affairs determined by social policies of the days of the Poor Law makes reform an urgent necessity, but hardly an encouraging basis for future planning. To quote the words of a warden: "Our greatest problem is the mixture of mental, sick, confused and infirm. This makes it very hard for the patients. We have tried forms of segregation but it's not possible." Owing to lack of adequate diagnosis Mr. Townsend found difficulty in estimating the incidence of mental disorder among the residents, but he considered 17 per cent to be mentally impaired, and 5 per cent severely so. Some of the disturbances such as depression, aggressiveness and other behaviour disorders he attributed to institutional environment and routine?on which little research has been done. He complains of the indiscriminate use of terms such as mentally confused, senile, forgetful, senile dement,
mentally incapable,
Purpose
etc.
of residential homes
He expects more such people to be transferred to welfare homes and he discusses the purpose of the residential home and argues that they should have the same "therapeutic philosophy" as geriatric units. The facts that at the time of his survey 40 per cent of new residents had not been seen by a doctor since admission, that many needed dentures, spectacles and hearing aids, and that in only three or four of the 173 homes was physiotherapy available are indications of the magnitude of present neglect. What is true for the physical disabilities of old age applies equally in the field of mental health. A report of the World Health Organisation3 points out that a high proportion of mental illnesses in old age are curable if treated early. Mr. Townsend's suggestion that Hospital Management Committees should take over residential accommodation might attain a higher standard of medical care in the homes, and simplify administrative responsibility. A comprehensive policy for the health and welfare of the aged must be based on clearer definitions of the responsibilities of psychiatric, geriatric and welfare services.
Psycho-geriatric
units
Few field studies of the needs of mentally confused old people have been conducted, but from a small survey in Wales, Andrews and Insley4 conclude that the number of old people who require special residential accommodation is not large, but they emphasise that these people should live in an environment suited to their special needs and capabilities, out of competition with their mentally fitter comrades on the one hand, and unassociated with gross mental illness on the other. Although obviously there are difficulties in segregation in welfare homes, the success and ease of working of one such special home in North London has been demonstrated during its nine years of existence5. The development of psycho-geriatric 235
units accommodated either in geriatric departments early assessment and treatment and would suitable homes or long-stay nursing annexes. ensure
1 2
3
4 5
or
in psychiatric hospitals would that patients are placed in
see
A Hospital Plan for England and Wales. H.M. Stationery Office, 1962. Townsend, P. "The Last Refuge: A Survey of Residential Institutions and Homes for the Aged in England and Wales". London, 1962. (Routledge and Kegan Paul, 60s.). World Health Organisation Expert Committee on Mental Health "Mental Health Problems of Ageing and the Aged". Technical Report Series No. 171, Geneva, 1959. Andrews, J. D. B. and Insley, M. L. Geront. clin., Basle, 1962, 4, 94. Hill, M. N. "An Approach to Old Age and its Problems". London, 1961.
