HL Deb 13 December 1961 vol 236 cc324-416

2.53 p.m.

LORD AMULREE rose to draw the attention of Her Majesty's Government to deficiencies in the arrangements for the care of the elderly, both sick and infirm; and to move for Papers. The noble Lord said: My Lords, once more I have put down a Motion dealing with the problems of the elderly, but before I develop what I am going to say I should like to explain what type of elderly person it is to whom I refer. Most of the people to whom I shall refer in the course of my speech will be taken from the 5 million-odd pensioners, and, there again, most of them will be among those people who are in receipt of National Assistance as well as their pension and who number about one million. A large number of elderly live quite comfortably with their families or with their friends and therefore pose no problem at all; but we find this quite big number—although it may not be very large as an actual number, it is certainly very big from the point of view of their problem—which does pose a great difficulty. Most of the elderly sick will get their treatment in hospital or in their home in just the same way as younger people do.

I do not want to claim for a moment that those services which may be called the geriatric services should take up all people of pensionable age—that is, women of over 60 and men of over 65—but the people I refer to are those people who do require some sort of geriatric service. We must not think of that as being merely a hospital service. It is a service which has to include the care of them when they leave the hospital; the care of those who have no families or homes to go to; and the care of those who want some kind of assistance in their normal life, whether that may be continued in their homes or whether they need to go to some kind of communal home. That sets out the problem I want to talk about; and, because I have set it out in that way, I should like to take the hospital side of the question first. That may be looking at it rather the wrong way round, but I think it is the most convenient from my point of view.

One finds that geriatric departments have now been set up in about one hundred hospitals. They have generally been constructed in what were the chronic sick wards of the old Poor Law infirmaries. There, I should like to make the suggestion to Her Majesty's Government that we call them geriatric departments of hospitals and not geriatric units. If you call it a geriatric unit, that rather makes it appear as if it is something by itself and separate from the normal services, whereas if you call it a department it means that it is an integral part of a general hospital, and I think that that is the conception to which we want to return. We rather have the idea that the elderly sick are something special, whereas they are something exactly the same as the younger sick but they require a better kind of treatment.

One of the troubles about the fact that they are housed in what were, for the most part, the chronic sick wards of the old Poor Law infirmaries is that, in a way, they have not made a great deal of claim. Take the question of staffing—and I dealt with this point the first time I spoke to your Lordships' House, which was, I think, in 1946. One of the troubles is that there are these large hospitals with insufficient medical staff. There are a number of these geriatric departments which have improved a great deal, but a survey was carried out recently by the British Geriatric Society, of which I have the honour to be the President, in which we inquired about the staffing of these new geriatric departments. We found that in the areas of seven of the Regional Hospital Boards there was one physician in charge of 400 beds. Now that, I maintain, makes practical, good medicine almost an impossibility, because not only does the doctor in question have such a large number of beds under his care but, in quite a number of cases, he is not of consultant status. Therefore, he cannot talk equally to his colleagues. He is of a status called senior hospital medical officer, which is a junior grade to consultant; and that, as I have said, does not make it easy for him to get full collaboration from his colleagues.

The other difficulty in most of these areas is the shortage of ancillary staff. Here, I should like to join the noble Lord, Lord Taylor (and I am sorry I was not here for his debate the other day) in paying tribute to doctors from the Commonwealth and foreign parts of the world, to whom we owe a great debt. They are people who will take jobs in these geriatric departments and who will do their work extremely well, and if they were not there I do not know what would occur. The same remark applies to the other branches of medicine which one expects to find in a general hospital. We have not the right number of people in occupational therapy, in physio-therapy, in the almoner's department and in all those other departments of the hospital which we now regard as essential for the proper treatment of patients, whether they be young or whether they be old.

Another difficulty is that these departments are, in general, in what were the old Poor Law infirmary wards, and some of the buildings are buildings which should have been pulled down and demolished many years ago. Some of your Lordships may have seen a certain amount of correspondence in the papers during the summer. when Dr. Sheldon conducted a survey in the Birmingham Region. The conditions he found and the state of the hospitals where the aged folk had to be housed were really too shocking to be believed. About a fortnight or so ago there were two very good articles in the Sunday newspaper the Observer, a London paper, in which a woman called Susan Cooper gave a rather similar account, which again showed that a large number of these elderly sick or infirm people were housed in conditions which savoured of the worst sort of buildings of the nineteenth century.

I will not say that there has not been a certain amount of improvement, because the idea is spreading around that elderly people can be properly treated and must not just be firmly tucked up in bed the whole time. But although I will not say that there has not been some improvement, there is still a very great deal of improvement to come. What is rather sad about what has occurred with the new departments is that we have lost one of the good things of the Poor Law. Although there were not many good things about it, there were one or two and one of them was that a person in need of a bed was entitled to a bed. Whether that was a good or bad bed, I am not going to argue to-day; but a person was entitled to a bed, whereas nowadays people in need of a bed often cannot get into hospital. That just shows what some of these buildings are like.

Then, if some of these elderly folk fall sick and need to go into hospital, there is very great difficulty in finding a bed for them because of a shortage of beds. May I quote one or two figures to your Lordships? I have some figures which apply to the London area. They are supplied by the Emergency Bed Service, which is an organisation set up by the King Edward's Hospital Fund. If a patient is between nil and 50 years of age he has a 98 per cent. chance of being admitted to hospital. If he is between 70 and 80 years of age then his chance has fallen from 98 to 92 per cent. If he is over 80, the figure is down to 89 per cent. That shows that people who really need hospital accommodation find it increasingly difficult to obtain it as they grow older. Again, I think that is something which is rather to be deplored.

What has been found during the past few years is that if these elderly patients go into hospital they can be treated and cured. Of course, a large number of them will die because they are old, and they have gone into hospital to die. But, again, a very large number will eventually be fit for discharge. There we come up against another really big difficulty. It is not so bad if they have families or friends to take care of them, or have somewhere to go; in that case it does not really pose any particular problem. But what one finds—and, here again, I am talking about the big built-up area in and around London, because that is the sort of area where I myself work, and about which I have most knowledge—is that a very large number of people live by themselves, and when I say "live by themselves", I really mean by themselves.

In some parts of London as much as up to one-fifth of the people of pensionable age live by themselves. In the country areas, the figures are nowhere near as large as those for London, but so far as London itself is concerned that is certainly the case. There are various reasons for that. Because London is a great big sprawling area, members of a family may go to work in different parts of London. The family itself does not want to move—there is a very great housing problem in London, to which I shall refer in a moment. Therefore, a large number of people do live by themselves, and do not live in very satisfactory conditions.

One of the things which make it even more difficult is this. I have been going over some of the figures of aged patients admitted to my wards during the past five or six years, and I find a really rather frightening thing. In 1956, 60 per cent. of the people admitted to my wards were at least 75 year of age. In the first half of 1961, the figure had gone up from 60 to 70 per cent. That means that you have a very large number of elderly people coming into hospital, and more elderly people being eventually discharged. Supposing they live by themselves and are unable to cope that creates a very serious problem.

There are two alternatives to deal with that. The first alternative is provided under the National Assistance Act, 1948. If I may just read a brief sentence from Section 21, subsection (1), that Act provides: It shall be the duty of every local authority to provides— (a) residential accommodation for persons who by reason of age, infirmity or any other circumstances are in need of care and attention which is not otherwise available to them: For the London areas the local authority is the London County Council and the Middlesex Council. In those areas we find that the amount of accommodation available under that section is extremely limited; in fact, it is nowhere near enough. The accommodation they provide at present consists of two types. Quite a large number of extremely good, new, modern homes have been built, which are comfortable, pleasant to look at, and, I should think, comfortable to live in. But at the same time, several of the old workhouses still exist. There is one in Marylebone; there is one in Islington; and there is one in North London and one in South London. These are great big nineteenth century barracks of places, containing about 1,000 or 1,200 people, and although they have been considerably improved, they are not what you would call very good accommodation now.

The trouble about there not being enough accommodation available in these homes is that a large number of patients—or, rather, let us call them persons who have been patients and have recovered from the acute illness which sent them to hospital—have recovered enough to be able to lead a semi-normal, independent life but cannot do so by themselves, and therefore have to be kept in hospital at the present time. I have ninety beds, and in those beds I have fourteen persons who have been accepted by the L.C.C. as being entitled to have accommodation but who have been waiting for it for between four to eleven months. The longest wait has been eleven months; the shortest, four. That is a very serious state of affairs, because it gives rise to waste of medical staff and nursing and ancillary staff; and people who are sick in their homes and who should be admitted to hospital cannot come in because we cannot get the other persons transferred to other accommodation.

To come to a rather more mundane matter, this, in turn, costs more money, because in a hospital like the one where I work the average cost of a bed is about £41 to £42 a week, whereas if one goes to one of these homes the cost is about £7 a week. I do not want to stress that side of it, but I think it is a point to be taken into consideration; we are being rather extravagant about it. I have talked to officials of the L.C.C. They are extremely kind; I do not say a single word against them. They try their best in a very difficult situation indeed and try to do all they possibly can, but they are confronted with this grave difficulty. I think that for the complete L.C.C. area there is a waiting list of about 500 persons, of whom about half are in hospitals and half are in their own homes. Quite naturally, the L.C.C. first take people who are in their own homes, because they are in need of some kind of care, whereas those in hospital are certainly being taken care of already. Therefore, it means that if there is a long waiting list the future is a little difficult. I suppose that to accommodate 500 persons would require five or six new homes, because the new ones they are building take between eighty and ninety people.

Things are going to be worse than that in future, because one of these big workhouses, which is now called Luxborough Lodge, is going to be pulled down. I think that everybody would agree that that is a very good thing. Although it has been improved a lot during the last 12 or 15 years, it is still not an attractive place in which to spend the rest of one's days. It contains from 1,000 to 1,200 people and they have to be rehoused somewhere else. It is not a very difficult sum, if you know that the new places are going to have 90 beds, to get the result that some 10 or 12 new homes will have to be built over the next few years, and then Luxborough Lodge can be pulled down. But that means that there is going to be no increase in the number of beds. The type of bed will improve, but the number will remain the same, and the problem I am talking about will continue.

I do not want to criticise the L.C.C. at all violently, but this raises a point in one's mind when they are talking about building a National Theatre and the like. Although I am greatly in favour of building a National Theatre, and by the L.C.C., I think we have to get our priorities right somehow. Surely, building to deal with a great social problem like this is a greater priority than a National Theatre.

I am bound to say that things are not so bad in the country. In Scotland, for instance, as the noble and learned Viscount on the Woolsack will appreciate, things are very much better. The average waiting time is about two weeks, and if old people have to wait longer the doctors are very surprised and shocked. They do things better there than they do down in England.

One of the great problems we are up against is what to do with people who have recovered, who have been rehabilitated in hospital, and who yet cannot go back to their homes, particularly when they have no home to go to. This is the third problem, the question of housing. Again I must refer to London entirely. A lot of people could go home if they had some reasonable house to which they could go, but we have the old story in London of tenement houses which were built in the middle of the nineteenth century as family dwellings and, because a change of population has occurred, have been cut up into single rooms and small flats, but not improved inside. They are often four-storeyed houses, with maybe another storey in the basement, and one finds even now that in these houses there is only one w.c. on the ground floor or frequently across a little courtyard. The old folk generally go to live in the basement or on the top floor, because the rooms there are cheaper, and that does not make it very simple for them, if they have to come down several flights of stairs and cross the courtyard every time they want to go to the w.c. It is quite common for old people not to be so continent with their urine as younger people and they need to visit the w.c. more frequently.

One would have thought that, if a person was well enough to be discharged, it would be easy to find a house for him, because a great deal of building is going on now in London; but during the last 18 months I have managed to get only three people rehoused out of quite a number who needed rehousing. Sometimes I do not even think it worth trying, because I know there is absolutely no chance of getting a new house for them. They have to go on living in these most uncomfortable conditions, which lead to their health breaking down again and to the recurrence of long-term degenerative diseases, and they need to come back into hospital again for treatment, which is both expensive to the country and uncomfortable to the person concerned. The principle was enunciated by Edwin Chadwick, the great social reformer in the nineteenth century that if we get proper houses, proper mains, proper drains and good environmental condition, we are going a longer way to stopping infectious sickness than we think possible. If we want to prevent old people from becoming sick and causing a lot of difficulty, we should press on with getting more and more houses for old people. I know that I shall be told that a lot has been done. I agree; but it is not nearly enough. When one sees housing accommodation being torn down to make way for the building of new blocks of offices, when there is this crying need for all sorts of people to be housed, it makes one wonder whether there is not something wrong somewhere.

There is one question I should like to ask the noble Lord, Lord Newton, who is going to reply, of which I have given him prior notice. I would ask whether the Government can tell me the number of people who are at present bedfast in their own homes and the number who are permanently housebound. This is information which is difficult to find, but perhaps figures have come in from regional boards from which it might be possible to give some idea of what the total may be.

Supposing old people do go back home, many can cope perfectly well by themselves, but a certain number cannot. There are a certain number of domiciliary services available. The first, and most important, is the home help service, which consists of somebody going to the homes of old ladies, old gentlemen or old couples, to keep the place clean, cook meals and do the shopping. There is also the home visitor, who is very important. These services should be expanded, but that is not so easy, because the home helps are volunteers and obviously volunteers are the most suitable people for this kind of work. It is a service which, I think, can never cover all needs, but I think it can be extended, if more propaganda were done and more encouragement were given to people to take on this extremely valuable job.

The home help service was started from the maternity and child welfare service. I see the noble Baroness, Lady Swanborough, shaking her head. I am sorry if I am wrong, but I think that that was one of the important aspects of health visitation which produced the home help service. It happens sometimes that home helps are taken away from old people to visit younger persons who are ill and the old people are left by themselves. Another valuable service is the district nursing service, which does an enormous amount of excellent work and keeps a large number of sick people comfortable in their homes. What we should do without it, I simply do not know. I should like to see it encouraged and increased, if possible.

The next important question is the supply of a midday meal. I do not want to go into this in detail because we had a long debate on this during the summer, but I should like once more to stress the importance of the midday meal. A great deal is being done by voluntary service, which is doing a fine job of work. They are serving more meals now than they were a year ago, but we cannot say that the country is properly covered until it is possible for everybody who needs a meal to get one five days a week. I do not say that all will want this, but a five-day-a-week service of meals should be possible so that old people and the sick can really stay at home and be properly fed. A six-day week, with the weekend, can be difficult, but a five-day week service is perfectly possible. At the same time, one would like it if some of these meals could be given in the form of rather simple diets—I do not mean an elaborate form of dietetic service—so that it would be possible for people who need special feeding to have the food provided. That is why, if you are going to have the big meal services going, you must have some kind of medical advice attached to it so that the diet question can be solved. However, there is a Private Member's Bill in another place dealing with this matter and I will not go into it further.

There is one other point on which I should like to touch, and that is the question of the health services and the welfare services. One of the difficulties which occurred when the National Health Service Act and the National Assistance Act came into force was that they ran on parallel lines and there was little point of contact between the two. It appeared to be all right on paper, and the Government of the day told me during the debate on the National Assistance Bill that they were fully conscious of the need for a close liaison between the health and welfare services, because otherwise matters would not be satisfactory. Things were not satisfactory for quite a long time, but I am pleased to say that they have improved now, because the Local Government Act, 1958, made it possible for county councils to delegate their powers to authorities with more than 60,000 members; and most of them have taken advantage of this and have put the medical officer in charge of the welfare and health departments. I am sure that will make for simpler and easier running and for a far better service not only for the old but for younger people as well.

At the same time, some eleven of the county councils have put their medical officers in charge of the welfare committees; and some of the county boroughs—21 out of a very large number—have done this, too. Once again I am afraid I must say that things were done better in Scotland, where the large burghs, which cover a very large part of Scotland, combined the services under the health authority. That is two occasions to-day on which I have said that they do things better in Scotland.

LORD TAYLOR

They have a higher infant mortality rate.

LORD AMULREE

Never mind. To continue, that again was one of the great advantages of the old Poor Law. I said that there were two; I have quoted one, and now I will quote the second. It is that if you got people in the old workhouse they had an infirmary attached and it was possible in winter for the sick and frail people to be transferred to the infirmary, with no question of administrative difficulty, and in the spring they went back again to the house. I am not wanting to get that system back, but it was important that there was no trouble in getting sick people into hospital and fit people into some other kind of accommodation.

Finally, I want to put to the Government that what we have never really known is the total number of beds required for the elderly population who are unable to live in their homes. We have some idea of the number of hospital beds required; but there is an enormous number of different kinds of beds wanted, some with a good deal of care and attention and others with not so much. But for people who cannot live alone, we just do not know what number is wanted. That is something I should like to put to the Government, to see whether we can get some figures out of the total number of beds required in any one part of the country; and it will not be the same all over, because parts of the country differ widely in their social structure. It would be a good thing if we could get some figure as to that, because we could then really begin to think about a proper co-ordinated service for those old people who require it. As I said before, housing is the crux of the whole matter. If you have your population well housed in appropriate housing you will not require so much institutional and hospital accommodation and your people will be much more comfortable and happier. We are going to have more old people, and I hope that what I have said to-day may help them in the future. I beg to move for Papers.

3.26 p.m.

LORD TAYLOR

My Lords, any of your Lordships who wish to see the Welfare State at its best cannot do better than go and visit the geriatric department at the University College Hospital which is looked after by my noble friend Lord Amulree. It is housed in what was one of those terrible old workhouse buildings, and any of your Lordships who knew St. Pancras Infirmary as it used to be in the Poor Law days, overlooking the coroner's court, and not the most cheerful of spots, between St. Pancras and King's Cross stations, would hardly believe your eyes if you went there and saw what beautiful geriatric wards have been created out of those old wards by spending public money really sensibly and intelligently. I think there is a lesson there for all of us when we look at old buildings and wonder whether they ought to be pulled down or converted. It is surprising what can be done by conversion, and very often conversion is cheaper.

I agree with almost everything that the noble Lord has said—perhaps not everything about Scotland, and I would make one or two other provisos which I shall come to in a moment. I am sure, however, that we are all grateful to him for drawing our attention to the problems and difficulties and deficiencies in the services for old people. I count it my good fortune that I have spent a good deal of my life with people who are much younger or much older than myself. It is very nice to be with young people, because they are so full of vigour and enthusiasm; but I almost enjoy the company of older people more, because one learns so much from their experience and wisdom. There comes the point when one's young friends suddenly start calling one "Sir" and one realises that one is getting old. That is the time, of course, to enter your Lordships' House, because all of a sudden you become "My boy" again. That was one of the most delightful things that happened to me when I arrived here.

In the fifth chapter of the first book of Aristotle's Rhetoric he describes what he calls Eugeria, which is the art and science of growing old healthily and sensibly, and I think that is nowhere better exemplified than in your Lordships' House. I am sure that this process has to start when one is young. You cannot start to grow old when you are getting old; you must learn about it when you are young. It involves having the capacity to amuse and occupy oneself, by oneself it may be, because old people have to spend a good deal of time by themselves in their own homes. They do not mind this, but it is a great help if when they were young they learned to do things for themselves and to enjoy doing things for themselves. For it cannot all be done by other people, however much they may try.

Inevitably very old people live in some measure in the past, when they remember with advantage the feats they performed in other days. I feel that the B.B.C. could do more for them by having perhaps a special programme once or twice a week for the very old, enabling them to live again the days of the 'nineties, hearing the old songs and old stories again and the old music they like. The B.B.C. do many good things for the blind and other special groups. The very old, with an exceptional point to which I am coming in a moment, merit their special consideration.

When I was thinking about this debate, I went to visit one of the old buildings to which my noble friend Lord Amulree was referring. It is a building called "Hillside", and is at the bottom of Highgate Hill. I am sure the noble Lord knows it well. It was an old workhouse, and it is now one of the large L.C.C. homes for old people. While I was in there I met a dear old lady of 105 who had broken her femur, which is the large bone of the thigh, when she was 102, and had had a satisfactory operation. There she was, not perhaps hail, but not too had. When I got back home my children said, "Did you ask her the 64 000 dollar question?" I said, "No, I forgot." It was just a sign that one was getting old. The 64,000 dollar question was, "Do you get a telegram from Her Majesty The Queen on your 101st, 102nd, 103rd and subsequent birthdays?" I subsequently found out that you do not; you get it only on your 100th birthday; therefore, if you whack up a good score you do not get another one. It is not usual, and one can perhaps understand the difficulties that might arise.

This old lady is in one of several wards for bedridden people, the great majority of whom are incontinent. There is no smell, and no bedsores. It is a very nice ward, although it is a very old building. There are four-hourly changes of linen by the nursing staff, and in the laundry of that home 16,000 articles have to be washed every week. The average age of people admitted to that department—it is not an institution; it is a home—is 72 to 85; some are 95. The average age of death is 79 for men and 86 for old ladies. They live for years and years, up and about, most of them, although some are in bed. They live a very simple, sheltered existence. They are warm, clean, and well fed. There is a gradual closing in of interests as they get older. There are plenty of games, cards and handicrafts that they can do. There are books in the library, but as time goes on they do not want these things. They just gradually close in. The very old ones do not altogether like the radio, partly because they are deaf and it muddles them up if they have a deaf aid. So their lives become simpler and simpler. They just sit and think, or perhaps sometimes just sit and watch the television. As long as they can watch the television, that is a very good thing.

This sort of cabbage life of some of the old is not necessarily an unhappy one, for with the blunting of the senses there appears to go a blunting of sensibilities, which is a good thing. They have no reason to die. They do not very often become ill. They appreciate their food very greatly, and at "Hillside" one of the nice things that have recently been done is that they have a trolley from which the patients—they are not really patients, but old folk—can buy things. They have 11s. 6d. a week pocket money after they have paid for their accommodation. Three months ago they started having Guinness on the trolley, and I am pleased to say they are taking 80 dozen bottles of Guinness a week off the trolley, which is a very good thing indeed.

BARONESS SUMMERSKILL

That is advertising.

LORD TAYLOR

This is not the B.B.C., my Lords. I still think it is a very good thing indeed. If these old folk cannot organise their money, if they are too confused to hand it out, it is kept for them. An account is kept, and if they want any little things they just ask for them and get them. I think we should all agree with what the noble Lord, Lord Amulree, said: that old people should be able, with help if necessary, to look after themselves in their own homes. I know my noble friend Lady Summerskill is going to say something about those homes in a few minutes. But in the attainment of this ideal everything depends on those services which my noble friend Lord Amulree was mentioning. There is the home itself. It should be small enough, and within the capacity of the old person to cope with. There is nothing sadder than to see old people landed with houses too big for them, and yet, because it is their home they do not and will not move out of it. Yet they cannot cope, and you see a gradual deterioration. It is much better if they can move into accommodation within their capacity.

Secondly, relatives and friends should be near at hand. I entirely agree with what my noble friend Lord Amulree was saying about the tragedy of the lonely old people in London and other great conurbations, where loneliness can be far more real and terrible than in the smaller towns and in the countryside. Then there are the home social services to which my noble friend referred. To the first line of detection, which very often is the general practitioner, one would add the parish priest. I hope the right reverend Prelate, the Lord Bishop of Sheffield, will say something about the work of the parish priest and the old people, because I think the parish priest has a very important part to play, not only in knowing where they are—because that is one of the problems—but in this simple act of being a friend to them.

I would join with my noble friend Lord Amulree in paying tribute to the district nurses. They do the most remarkable and wonderful jobs with these old folk. They nurse them at home with never a mark on their backs, and it is quite remarkable how they do it. The Lambeth Borough Council run a special laundry service for those old folk who are incontinent in bed at home. That is another wonderful service, and a very good thing. I am sure many other borough councils do the same, but it just happened that I came across that instance to-day. Now the home helps. Again I endorse all my noble friend has said. With regard to "meals on wheels" we cannot say enough for them but, alas! there are many areas where they are not yet available. When my friends say that, I always reply, You write to Baroness Swanborough, and all will be well we hope"—and often it is.

There are other folk who ought to be available in a home. There are the chiropodists. Old people need a chiropodist very much indeed. More and more local authorities are providing chiropody clinics for old people, cheap or free, but not necessarily a mobile service. I do not know of any, but I believe there are one or two services where there is a mobile chiropody service to go to the old people who cannot go to the clinic. Then there is home physiotherapy. There is a great shortage of physiotherapists, and the hospitals have said that they must concentrate these physiotherapists in the hospitals. I am not sure that that is right. I think there is a great deal to be said for bringing a physiotherapist to the old people in their homes, particularly those people who are not necessarily bed-bound or room-bound.

As my noble friend Lord Amulree has said, some of them are stuck at the top of a house for life. It is an awful thing. There they are, at the top of these high blocks in St. Pancras and Islington, unable to get down. One of the great jobs is to keep old people mobile. It is all too easy to let them take to their beds and stay there—because they want to, very often—and of course it makes the care of them easier in the home. It makes them easier to look after if they are in bed. One of the dangers is the danger of mental apathy because by being in bed and doing nothing there follows circulatory enfeeblement due to muscular disuse, difficulty with the bowels and all sorts of other difficulties which may make the job of the geriatrician not difficult, but sometimes impossible.

We are all agreed about the value of holiday homes and holiday periods for these old people, either in a hospital in a geriatric department, or in a welfare place where they can go for two or three weeks just to give the relatives a break. Very often by doing that it is possible for the family to carry on with their home care. May I express my own personal gratitude to the noble Lord, Lord Amulree?—because he, in his unit, gives just that kind of help, and my family have actually had experience of it. But there comes a time when home care becomes impossible. Often a widow carries on for a year or so after the death of her husband but, being a very old person, she finds she cannot cope. Or an old man is without a wife or relations. They, in the words of the circular which the noble Lord, Lord Amulree, quoted: … are in need of care and attention which is not otherwise available, and are not sick. Then they become eligible for Part Three accommodation—and what a horrible phrase "Part Three accommodation" is. But there it is; that is what it is always called. But 'Part Three accommodation is not as bad as it used to be. It is getting better all the time, but I quite agree with my noble friend when he says we have still a lot to do.

He put the number of places on the L.C.C.'s waiting list for Part Three accommodation (that is, for old people who are not ill but in need of care and help) at 500, although I spoke to the Chief Welfare Officer a little while ago and learnt that it is actually 1,000. His breakdown was not inaccurate, because 400 of them are waiting for selective vacancies; that is to say, people who only want to go to vacancies in small homes, and it is not absolutely urgent that they should go in. That 300, as he said, are in hospital. Again, exactly as he said, the welfare officers are inclined to say, "Those old people are being looked after all right; we will not worry too much about them," but by not worrying too much about them, they are blocking the way for other old people. Again, precisely as he said, there are 300 urgent cases in the L.C.C. area.

The L.C.C. has 8,000 places for these old people; 4,000 in the large homes, which are being upgraded to small home standards; 2,000 in the small homes, mostly of the excellent new variety which my noble friend is talking about; and 2,000 in voluntary homes, which are paid for in part or wholly by the welfare authority and which are making a very real contribution. To each of these there are as a result of the natural course of events—that is to say, because of death—about 100 vacancies a month, although the figure varies with the time of year, and that is what the L.C.C. in the County of London area can accommodate. In 1948 they had 6,600 places for old people, mostly in very unsuitable condition. Now they have 8,000 places, and there are another 700 in the pipeline—that is to say, up to 1965. But I agree that I do not know what the answer to the closing of Luxborough Lodge is, because this will knock out 1,000-odd places and will produce a very serious and difficult situation. Again, I agree so much with my noble friend that it would be very valuable if we could have a real estimate of the whole problem. Nobody knows how many more old people's places are required to meet the need. It cannot be an enormous number because, with a waiting list of 500, not a tremendous number of places would be required to get rid of that waiting list.

A word about conversion or new building. Each new place in a new home costs £1,500; in hospital it costs say £3,000 to £6,000 per place, so it is obviously much more economical to provide such places in welfare authority homes where a smaller measure of nursing care is given than in hospitals. But if we take the conversions, the upgrading of old workhouse buildings, some is very good indeed and the L.C.C. have done a remarkable job. For example, the frightful old corridors and great high rooms have artificial ceilings fitted across them. They all have Parker Knowle chairs, delightful modern furniture, modern little coffee tables, and so on, and they are very homely and nice, even though outside the old building remains an awful old building. Most expensive of all, of course, they have to fit in an entirely new heating system. That sort of thing costs about £900 per place, usually with small dormitories or rooms for couples. There are increasingly places for one old person by his self or herself, but many old people like to sleep two together, just in case something happens in the night and there is somebody to lend a hand. For these the maximum charge is £7 a week. The great majority of the people, however, are getting N.A.B. pensions of £2 17s. 6d., of which they pay in £2 6s., and all must have, as I said earlier, 11s. 6d. a week for spending and pocket money after they have done that.

L.C.C. places have gone up by 25 per cent. in twelve years, and the quality has gone up very greatly, but as the noble Lord, Lord Amulree, said So much has been done, so much remains to be done," and they are my sentiments, too. What has been done is a tremendous achievement. When one looks back to before the war and how we did not look after our old people, one realises that it is a wonderful thing that has been done since the war. We ought to be proud of what we have done, though we still have to do a great deal more. However, matters are moving in the right direction, especially in geriatrics. The subject is new. If we take the country as a whole, the figure has gone up to 84,500 places, an 82 per cent. increase since 1949, since the Health Service came in. But that is not all old people, for one must knock off 11,000 of these places for other welfare cases, such as the blind, deaf, epileptic, physically handicapped, and so on.

As my noble friend said, there is the problem of the margin where the line is drawn between the hospital and the welfare home, though the position is much better than it was. The difficulty is that there are too few beds for both, and so we get the hospital's beds blocked up. The noble Lord quoted his own department. Your Lordships may have seen a letter in the Guardian from Dr. James Andrews, Geriatric Consultant to the South-West Middlesex Group: it is the same situation, only worse. In this hospital his geriatric unit alone has 38 patients, accepted by the Middlesex County Council Welfare Authority, whom they are unable to take. Some of these patients have been waiting over two years—two years in a hospital bed at probably three times the cost of a welfare bed. This, in turn, stops the admission of sick and elderly people who are in urgent need of care in hospitals.

One of the things which strike one when one goes round these beds for the care of the medically sick, whether in hospital or in welfare home, is that of the people who are looking after them half come from the Republic of Eire and the other half come from our Commonwealth. They are coloured folk from the Commonwealth, not only from the West Indies. I met a very nice boy who was a young male attendant and who came from British Honduras. I do know how much we owe to the patience and kindness and the good nature of these people, and the supervisory nursing and lay staff who train them and help them to give of their best, and get so much out of them in terms of efficient and good service. It is incalculable. Are we sure that the position will not be prejudiced by the legislation which is now before another place? We have to be very sure, when that legislation comes to us.

Another piece of impending legislation which will affect this subject is the Government plan for Greater London. I am going to say one thing only; in the distribution of these homes for old people, the L.C.C. has built them where there were sites available. The result is that if you take Wandsworth it will have a very good supply indeed of old people's homes when they all go back to borough status, but other boroughs will not have one home at all. I think we shall have to do some adjusting there; there will have to be a great deal of interplay if we are to get by with it.

I have three more points. The first is the presence of ill-health in the elderly and the importance of dealing with it early. One of my friends who is a general practitioner makes it his business to go round his old patients in the summer when he is not too busy and have a look at them, and give them a general checkover to make sure things are not going on that he will miss in the winter. That is a very sensible thing to do. One of the things which easily gets missed is a condition called chronic glaucoma, which is a gradual increase in tension in the eyeball, which comes slowly and which results in blindness; and yet if it is detected early it can be dealt with. There are a number of conditions where early detection in the old can save a mint of misery and really put off the process of ageing.

Perhaps I may say one word about private nursing homes. These make a contribution, but I am not sure that it is altogether a very good contribution. Certainly the women who run them—and they are mostly nurses; some are run by doctors—are doing a service, but it is not altogether satisfactory. Some of your Lordships will have read the National Corporation for the Care of Old People's Report on Nursing Homes in England and Wales. A great many of them are looking after old people. One defect is lack of sitting rooms. Although 62 per cent. of the elderly patients seen in this survey in private homes were not bedfast, few proprietors seemed to provide sitting or dining rooms. They had single rooms but no sort of social mixing. Ten to twelve guineas a week was the average charge, though many were more expensive and there was no clear relationship between the price paid and the quality of care received. I know that many of the old folk who go into Part III accommodation, having been in private care, say it is better in the new circumstances. One cannot blame the excellent folk who try to run these nursing homes. These homes have grown up because of the demand and because we are not meeting it properly, but it is not really a suitable form of private enterprise, because one cannot do this sort of thing really well and make a profit; the better you do it, the less money there is to spare.

I would say one word about the role of charitable bodies. I am delighted to see that immediately after me the right reverend Prelate the Lord Bishop of London is to make his maiden speech. I used to be the Member of Parliament for the Barnet constituency and he used to be the vicar of High Barnet. He went up and I went out; he was promoted and the Barnet electorate rejected me. It is very nice indeed to see him again after all these years, and we are delighted that he should have chosen this occasion to make his maiden speech. I want to say one word about the valuable work which the churches can do and in some cases are doing for the care of those who are slowly dying. The Roman Catholic Church has done most in this sphere; they do a very remarkable and wonderful job, not necessarily for old people though often for old people.

Some of your Lordships may know a very remarkable lady called Dr. Cecily Saunders, who started as a nurse and was impressed with the plight of those dying in these circumstances that she became first an almoner and then a doctor. She has now set out to try to build a hospital for the dying and has got to the point of raising £50,000. She will succeed, I have no doubt, and if any of your Lordships can help her it would be a fine thing. It is a wonderful effort she is making for patients of all denominations, but actually within the Church of England—what the Catholics are doing so well for their people. She is now our greatest authority in this country on the care of the dying. I commend her activities to your Lordships.

I would say one last word, and that is about research into ageing and the differential rates of ageing of tissues. It is an extraordinary thing, this business of growing old. Human tissues repair and replace themselves throughout our lives, and if you take human tissues and grow them in tissue cultures outside the body some will grow for ever, so far as we know. There was taken from a lady called Helen Lane many years ago a tumour which has been sub-cultured and grown in laboratories all over the world. She has been dead for years but her tissues are going on growing indefinitely. They are know as Hela tissues. This apparent agelessness of undifferentiated tissues makes one wonder whether old age as we know it is a normal process or a disease.

There is a clue here. I mentioned at the beginning of my speech a word called "eugeria". There is a condition called progeria, which is very rare. I have seen only one case. It is premature senility occurring in children. The one' I knew was a sweet little girl aged 13, but her body was that of a woman of 70 or 80. She had advanced osteo-arthritis, arterio-sclerosis, and her mind was the mind of an old person. This premature ageing gives one a clue. It must be a disease. It must be that something has gone wrong with that little child and made her tissues grow old far too fast. It may be that in due course we shall be able to prevent this disease so that we shall grow old in years but not old in our minds and bodies; and what very excellent things can follow from that! The question of Life Peerages will have to be thought about again, because goodness knows how long we shall all go on being Peers for life.

A country general practitioner friend of mine, on analysing deaths in his practice over the past four years, found there had been 84 of them among his 2,000 odd patients. The peak age was 80 to 85; there were 7 deaths over 90. He summarised his conclusions in these words: If you can avoid cancer and severe high blood-pressure, you have a very good chance of living to ninety. If, in addition, you can avoid all disease of the heart and blood-vessels, there seems no particular reason why you should die at all—if you are wise enough to live in our village. Here, surely, is a plain case of Back to Methuselah. Your Lordships will remember this excellent play by Bernard Shaw. I thought it was his best. A couple of gentlemen called the Brothers Barnabas lived on Highgate Hill, and they were really prophet biologists. They spotted that it might be possible for people to go on living, because they wanted to go on living, for 300 years without deterioration of the tissues, and then, and only then, would good government of mankind become practicable. To learn wisdom in the conduct of our affairs we need not one lifetime but four. The follies of youth weigh heavier than its achievement; the true wisdom of age more than balances its rigidity and conservatism.

In broad principle, I think the Brothers Barnabas were right. The coming of the antibiotics, modern anæsthesia and modern surgery on the old, has started to make longevity the rule. In the next twenty or thirty years I think we are going to see fresh biochemical advances which may have even more spectacular results. It is true that the Barnabas postulate of isolated peninsulas of longevity is not being realised, but in fact we are achieving a broad advance on a wide front. The advantages which we enjoy in consequence are already showing themselves.

It is interesting to examine the obituaries in The Times and to strike out everything that happened to persons before they were fifty. It soon becomes apparent that we are already a gerontocracy. Both power and influence are largely in the hands of the over fifties. Indeed, our chances of earning an obituary in The Times depends almost on our capacity to earn a living and to work until well into the seventies.

In British politics in particular, a measure of gerontocracy has been established for close on a hundred years. The physical basis for this is to be found in the very arduous conditions of life in the House of Commons. Only the toughest can survive. The banging, slanging side of politics, the glib and fluent rhetoric, and the demagogy are easy enough in one's twenties, thirties and forties, but they are aspects of political childishness, embarrassing and perhaps sometimes even pathetic when they persist into one's sixties and later. By then the elements of the art of politics should have been learned. Here most of the superlative craftsmen are in their sixties, often their late sixties or early seventies. It is part of the art of politics to know not only when to act but also when to take no action. Sometimes action must be swift and ruthless. Sometimes calculated procrastination is the secret of success. At these high levels, often the right thing is the dull thing. To the outsider, the doughy platitude may seem no more than a doughy platitude. Yet it is in fact nicely calculated to mop up a lot of explosive emotion, which could do a lot of harm.

It may be objected that gerontocracy tends to negate the creative or artistic side of politics. Yet experience does not bear this out. If we take three great pieces of political imagination, the liberation of India, the creation of the National Health Service, and the inception of the New Towns, we find that all the principal performers were in their fifties or their sixties. One has always believed that the best hope for mankind lies in more science rather than in less. In recent years this naive belief has been somewhat knocked about, but it has survived and now it is justifying itself. Virtue is a slowly growing plant. To be truly good one must have known evil and survived, and it takes time. For the exercise of the greatest virtue, one needs the greatest capacity to keep on keeping on to the end of the road. By pushing back that end, we increase the sum total of virtue in geometric progression.

4.3 p.m.

THE LORD BISHOP OF LONDON

My Lords, it is with considerable reluctance and hesitation, not to mention nervousness, that I rise to speak to your Lordships on a subject on which I cannot claim the professional knowledge of the two noble Lords who have just spoken. But, as the noble Lord mentioned, the parochial clergy do know rather a lot about the needs of old people and they do communicate those needs to their bishops. Therefore, though some of what I know on this subject is second-hand, the source is pretty reliable.

The impression that one gets of the situation as it is to-day, and particularly in the London area, is that almost everything which is needed for the care of old people is there, but nowhere is it present in adequate size. The various units or departments are doing extremely good work, but nowhere are they adequate to the need. So we have the problem of lack of hospital beds; we have the problem of old people returning home too soon for lack of sufficient post-hospital homes for them, and sometimes going back to conditions which are appalling. I had brought to my notice recently the case of an old lady returning from three weeks in hospital to the room in which she lived alone, which was itself damp, to the bed which had been unmade since she left it three weeks previously to go into the ambulance to go to hospital. The home help service, "meals on wheels" and the district nurses are all doing magnificent work, but nowhere do they seem to be adequate to the need. The home helps in particular, so often themselves at the mercy of their own domestic needs, cannot always guarantee to be there, and often old people are left for almost days on end, seeing practically nobody and having no contact with the outside world.

There is one aspect on this side of the problem to which reference has not been made, but which I think should come into our calculations—namely, that there seems to be a real need for more places in which the senile and mentally infirm old people may have the right kind of care and treatment, preferably not in large mental hospitals, of which they are inordinately afraid, but in small homes where they can keep something of their sense of independence and of being persons.

There are two other points which I want to pick up and which have been mentioned by the two noble Lords who have just spoken. One is the need for dwelling units of the right kind. I am told that in the course of 1960, 39,000 dwelling units specially designed for old people were provided, and that the same number approximately may be expected to have been provided in 1961. With the increase in the percentage of people over the age of 65, it would seem that that rate of progression is quite inadequate. There is a further point which has been borne out clearly by experience: that old people are happier when they can be accommodated in houses or flats suitable for them, not too far away from where their children and their grandchildren are. That is an aspect of the care of old people which is of vital importance in any properly planned housing developments.

Almshouses perhaps should be mentioned, because they have their own part to play in this subject. I know quite a number of almshouses which cannot be modernised through lack of funds belonging to the trustees. When I was rector of the parish to which the noble Lord referred I was also a trustee, and in two cases the sole trustee, of no fewer than eight sets of almshouses and in one case I was practically reduced to putting the slates on the roof with my own hands because there were no funds at all which the trust could draw upon. Something like 35,000 old people are, I am told, in almshouses at the present time. That number could be raised, perhaps not inconsiderably, if the trustees could have access to funds which are not theirs now, or could obtain further charitable donations and perhaps almshouses (though the word is not a popular one nowadays, but something of that kind), if these could be more the object of charitable gifts and legacies than they appear to be at the present time.

Reference has been made to the work of the voluntary agencies. It is to this that I should wish to draw your Lordships' attention more particularly. On the side of providing suitable accommodation, the voluntary societies are doing a great deal, and are stepping up what they can do. The Church Army itself has, I believe, in the last two years provided no fewer than 57 units for old people. They take over large houses, convert them, put someone in charge who has some nursing skill, and eight or nine old people can live quite happily together. Other societies, such as the Abbeyfield Society depending entirely upon charitable gifts for the capital for the conversions, are able to do a great deal. Perhaps more can be done in this way. Perhaps this illustrates, also, that in the care of old people the voluntary element is of very great importance, for what we do for old people we must, I believe, do out of a sense of respect for them, and not out of a sense of something that must be done because there is a social problem to be solved.

I think it was J. A. Froude who, in one of his essays which I had to learn as a schoolboy, said: In the old man nature has fulfilled her work". In the sense that old people have contributed to society, society, in looking after them in their old age when they can no longer look after themselves, is only repaying a debt which one generation owes to another. But it must also do so out of respect for them as persons, and therefore it is only persons who can care for persons in the ultimate resort.

The desperate shortages, which occur in all parts of the services for old people, are shortages of people. "Meals on wheels", home helps, and all the rest, are all short of people. Even more, we are short of a sufficient number of people to relieve the loneliness of the old. Visiting, which is so badly needed and so much appreciated by the old people, is itself not an easy thing to do. Every young clergyman learns in the first three weeks after his ordination that visiting is about the most difficult part of his job, and the part of his work in which he can drop the largest number of bricks in the shortest possible time. Sometimes those who go to visit old people might well have gained something from the sort of training which a parish priest can give to his curates. But the good will exists.

There are just two other points which perhaps I might mention to your Lordships and which are related to this subject. The first is that there seems to be a crying need for closer liaison between the voluntary and the statutory elements in the service of old people. Both respect each other but, perhaps through shortage of manpower and womanpower, they are not sufficiently closely in touch with each other in many cases. The pilot research project which was carried out by the Birmingham Council of Churches, the Report of which has been published under the title of Responsibility in the Welfare State, shows by a great deal of practical inquiry how difficult it is to create a really effective liaison between voluntary and statutory elements in any part of social welfare, not from any lack of goodwill or good intention, but sometimes because the facilities are not there.

Perhaps both centrally and locally a good deal could be done to make sure that those who want to help can find the old people who need their help, and can help at the points and with the skills which are most needed. For instance, one finds youth clubs doing odd jobs of great importance for old people, like a little house-decorating, going round visiting, or weeding the garden—work of very great importance to the young and of no less importance to the old whom they serve. Other youth clubs hear of this and they think what a very good idea it is, but they have the utmost difficulty in finding any old people to practice on, because the liaison does not exist to put those who want to help in touch with those who need the help.

I believe that here is something that, without any great degree of administrative control, might be made much more effective than it is at the present time. In saying that, I should not wish to appear in any way critical of the services which the local authorities give and of their desire to co-operate with the voluntary services. It is sometimes due just to a lack of someone whose business it is.

Along with that goes another problem which old people experience, and that is, in a sense, the multiplicity of those who can help them. The old people do not know to whom to turn. It is the borough for this; it is the county council for that; it may be the National Assistance; or they may be going to the wrong place. They are not very mobile, if they are mobile at all, and something of the kind of service which the W.V.S. supplies so well seems to be particularly needed to assist the old people to get the help which they require. But, my Lords, this is essentially a personal problem for the old people.

The Lord Mayor of London is in process of trying, with the help of the mayors and lord mayors of the boroughs in the country, to make this Christmas, as he calls it, very specially an old people's Christmas, in which the younger generation bring something of the family life to old people, particularly those who are lonely. That is a splendid thing, but it would be a disaster if on January 1 we forgot all about old people again.

One can only hope that, as a result of the thinking, the action and, perhaps, the publicity which may spring from a debate such as this, more volunteers may be forthcoming, and more people may accept the challenge to be volunteers, to assist all that the medical and other services can provide, in making sure that as many old people as possible are happily independent for as long as they can be.

4.17 p.m.

BARONESS SWANBOROUGH

My Lord, to me falls the extreme privilege of telling the right reverend Prelate, on behalf of the House, how deeply we have appreciated his speech, and especially of saying how thrilled those of us who are keen on this particular subject are to have him speak with so much authority and so much deep understanding of things which, of necessity, cannot be under his immediate jurisdiction. From my own point of view, having heard the right reverend Prelate in other places, I feel that we shall be very fortunate if we have the opportunity of hearing him again and again, even if that removes him a little from his diocese.

I feel there is a very great deal that has been written in the newspapers and said in speeches about the care of old people, which is not absolutely fair. The amount of work which is being done for old people hi this country to-day is greater than it has ever been before, and I believe out-distances anything which is being done anywhere else in the world. But I think that a great deal more must be done, and I think that in examining how those things are to be done there is one thing which perhaps comes well from me, because I am an old person myself, and that is that old people do not like to be termed as "old people". This generic grouping of everybody who is over a certain age level can be hurtful to some of the people who come within that group. Although as yet I am ready to give as good as I get, I am sure that the moment I feel incapacitated I shall feel it extremely strongly myself.

I am quite sure that old people want to remain in their own homes, and there, fore I should like to address myself to a different aspect from the one which was taken by the first two speakers in as much as they spoke mostly on the hospital angle. I should like to speak from the point of view of the old persons living in their own homes, and I should like to do so as someone who has done a good deal of work with human beings, which has made me absolutely convinced that domiciliary care is the thing we must look to on a long-term basis. I think we ought to do this, rather than consider the institutionalisation of the individual, although, of course, it is going to be necessary to have redress in the way of homes or places where nursing can be given, in addition, naturally, to the extra beds which we should like to see in hospitals. I feel that this is one of the most important things we can consider. I should like to see domiciliary care made as perfect as possible, so that we can achieve the maximum results with the least dislocation to the individual we are trying to serve.

I believe that old people of to-day require services on a modern basis, not on a charitable, patronage basis, and I think that the statutory aid of to-day means care by many people in addition to the professionals. To my mind it is necessary to have a subtle and intelligent integration of voluntary services and statutory aid; and I would disagree with the right reverend Prelate in thinking that the most necessary thing to-day is extra volunteers. I think the volunteers are there if one calls for them in the right way, but I think that finance and the opportunity to serve are both very necessary assets if you are going to use the volunteer to the full extent.

I think that we must admit that the one who has the ultimate responsibility is the statutory body which has to accept the difficult case; it has the hardest job of all, and I am quite certain that this debate would be of little value if we were not able to put into practical words what we should like to see the responsible people doing as a result of the debate. Those of us who are involved on a national basis know that the shortage to-day is for homes where old people, destitute or with an income, can have nursing, care and attention because they are too frail, either mentally or physically, to be cared for in their own homes. Anyone who, like myself, has endless requests for help knows how sad it is not to be able to answer the people who write to one as to where they can get relief for their problem or where they can get admission for the patient.

My plea to-day would be for more accommodation for the really elderly who need some form of skilled care because of their mental or physical state. But I feel it is tremendously necessary, if we are going to get help for old people, to see that help comes in a shape in which it can be useful to the younger ones. However devoted a daughter, a granddaughter, a son, a niece or a sister may be, there comes a time when, for mental or physical reasons, residential care must be available for certain people. To-day the inadequacy of the provision is very evident to those of us who get letters from people about their mothers, their mothers-in-law or their fathers who have to be looked after in their homes while, at the same time, the writers are trying to bring up a young family. Often the three generations suffer, and again and again a breach comes between husband and wife and between parents and children because the house is too small, the situation is not possible for nursing, or the old persons themselves present too great a difficulty.

In the past, it was generally accepted that the sick and the handicapped could go to a hospital and that the lonely would be far better off in a home. That theory survived until the 'fifties. Then the realisation came that men and women are happier and maintain their strength and their health much better if they continue in their own homes with such services as are necessary available to them. From this has developed a special series of efforts such as housing, domiciliary care and all sorts and kinds of other services for the elderly. It is within this cadre of services that the "meals on wheels" service, which is at present being debated in another place, has come into day-to-day acceptance as a necessity for those who cannot arrange for their own feeding. The figure for the "meals on wheels" service, which was debated in this House not very long ago, has once more gone up, and, although national figures are not available, I know from the point of view of my own organisation that we are now delivering meals at the rate of three million a year. More could be done if more backing were available in the way of finance, the tools with which to do the job and the premises in which to do it.

Like everybody else, I should like to pay my first tribute to the district nurse. I think that the district nurse is a most wonderful woman who can be called upon to do any job in the country, and her work for the old people on the domiciliary basis is completely indescribable. The district nurse obviously works through the doctor. And the district nurse, the doctor, the health visitor, the home help and the "meals on wheels" service together provide very valuable props to those who wish to remain in their own homes as long as ever it is possible. But all these services are in short supply in regard to the trained people who are operating them, and local authorities are not always willing to incur the expenditure necessary to provide more home helps and more "meals on wheels". Where home helps are used imaginatively, they can go in the morning and in the evening, and the old person is in this way kept ambulant, and they have already been shown to be a tremendous strength to the community.

During the 'sixties there was much more realisation that people living in their own homes do not need constant care and attention but need only the props I have just mentioned, which can be provided through the Health Service. In addition, as the right reverend Prelate and others have mentioned, there are the other things that help so much to keep interest, and therefore health. Occupations and interests which can be supplied by those who wish to help and are ready to assist exist all over the country. The necessity to invoke these depends on the personality of the liaison officer, or the person who is going to link statutory aid to voluntary services; and, as the right reverend Prelate has mentioned, this is a delicate but nevertheless a very necessary function for them to perform.

From the voluntary angle, I have had the experience of working with the biggest single organisation in the whole of the world operating for old people, and from this experience I have gained a vast amount of knowledge about what old people need and what old people like. A great deal is done in the way of clubs for the able-bodied and for ambulant old people, which keeps them well. My own organisation is responsible for some 2,000 of these, and people of good will and understanding run these clubs and do endless things in the way of providing occupations, interests, hobbies and diversions, as well as friendships, holidays and all the things that are necessary. But the people we are all worried about are those who are a little frail but nevertheless are very often ambulant. Clubs with special interests and special facilities are run, but more—much more—attention needs to be paid both by the statutory services and by the voluntary services to the sick and handicapped in their own homes. They do not need to be institutionalised, but they need not only nursing but general care and friendship. which means the extension of good neighbourliness so that the little jobs can be done for them and they do not feel alone.

Under Part III of the National Assistance Act—which, as my noble friend Lord Taylor said, covers care and attention—a superb piece of work has been done throughout the whole of Great Britain, and this has not been an easy task to carry through. National organisations have done a great deal, but I should like to state quite categorically that the great credit for accomplishment must go to the local authorities. They have achieved a most remarkable total throughout the whole of the country; and if you travel, as I do, up and down, North, South, East and West, you cannot but marvel at what has been achieved in the time to transform yesterday into to-morrow.

What I should like to see is all the existing services interlaced so that co-operation results in the team working really together. Where teams work together they work well with the hospital geriatrician and his assistants, with the almoner, the medical officer of health and his staff, the health visitors, the home nurses, the home help organiser and the voluntary services. In those places where the team works as a whole, it is possible to get so much more comfort to those who require it. But co-operation is specially needed between the hospital and the local authority. Within the local authority area the different departments of the local authority co-operate well together, but distance and different municipal boundaries are apt to make a dislocation in handling machinery, and too often co-operation between hospital and local authority health and welfare services is not as good as it could be. This is partly because of ignorance and partly through lack of information being passed from one person to the other.

On the everlasting problem of finance, there is the fact that one lot of finance stems from the national purse and the other from the local. This is a very serious and a very difficult thing, and it is something which must be recognised by all those who are working in this field.

In some areas where the co-operation is good, volunteers are asked, very often at a moment's notice, to get the home ready when a sick, old person who lives alone is to come out of hospital. In this case the almoner rings up the voluntary service and asks that the room or house be prepared and aired, a fire put on, and that a lot of help be given during the first few days immediately following the day when the old person comes out of hospital. The number of places where this service is used is not as many as it should be, and unfortunately, when it is not used, it means that the nurse does this work when she is needed for much more important work in true nursing, instead of doing what could be termed domestic household jobs.

"Meals on wheels" are delivered to old people at the request of just the same authorities as I mentioned in the team. An example of co-operation is the way in which it is arranged that old persons coming out of hospital can have their home prepared for them, and have a home help on the days when "meals on wheels" are not delivered, and in consequence can be sure of a hot meal each day of the week. Another great avenue of service through "meals on wheels" is that it means that someone calls regularly at the house and can report at once to the authorities if all is not well. This is also the advantage of what we all hope to see become a real fact—namely, an organised visiting scheme. Volunteers are not anxious, indeed are not capable, to take on the jobs of those people who have trained professionally; but unless a home help, district nurse, or doctor—all people highly skilled and in short supply—is used to best advantage, we shall not be giving the maximum service to the old people themselves.

I think we must face the fact that we shall never have enough staff, whether at local authority or at hospital level, to do all the jobs which have to be done, and many of us feel that much work, such as visiting, ought to be done on the basis of good neighbourliness by religious bodies, voluntary organisations and individuals, whether they live in the vicinity or not. Too often I find people pontificate, blaming and parcelling out to others the opprobrium which, perhaps, they ought to take upon themselves. What should be done, I am quite convinced, is that each community should undertake to do, both professionally and voluntarily, the things which are required within the community, never losing sight of the fact that neither professionals nor volunteers can take the place of the family. There are many people available who could do this work because of their experience of life and also because of their readiness to help; and if only they could he called upon to do this, I am sure that they would answer the call.

I feel that freedom of living, of decision and of action, is strengthened to a great degree by providing domiciliary care for people, instead of institutionalising them. I would rather anything happened than that we started thinking of putting the elderly into homes. I would rather that old people had slightly less scientific care given to them, and that they could live their own life in their own way, than that they have to live away from the things they love. Surely it is not beyond our capacity to have in this country, on a local basis, sufficient places for those who cannot remain in their own homes, but to have such places more on the basis of attention and care in a practical way, rather than imitation hospitals, with rules and regulations and all the things which are necessary in a hospital but which are not necessary in a home-from-home which exists merely to give extra care and kindly nursing help.

It is time that we faced this problem more courageously. I beg that we do not imitate those nations which are more flamboyant than we are, but which are not, I believe, our equals in this field. Can we not have an understanding of what the outlook of human beings really is? Do we need to be so bemused by the little triumphs of science in a vast world of suffering that we pay too much tribute to rules and regulations and standards and not enough to the human beings we are trying to serve? The shortage of a place to which a person, whether destitute or with an income, can go to have ordinary care and nursing attention is very great, and the absence of such a home is a real tragedy. It always seems to turn on the question of standards and diplomas. The keynote is always the same—shortage of trained staff. But if old people are in their own homes, life moves on steadily to its close, and the end is viewed with dignity and with courage, without feeling that it is necessary to have a clinical atmosphere and a required standard of assistance against the final moment.

The people I talk with and the places I visit make me more and more confident that man is not doing a service to man if, by his scientific discoveries, he sets himself to extend the breathing period of a man's life when, in fact, that man is no longer "alive"; and although I must make it clear that I speak only for myself, I would plead that it is better to make life peaceful, as the human machine runs down, than to use artificial means to back up scientific discoveries. After years and years of work with old people, I would beg that everything be done which is at all possible to let them live their lives out in their own homes; that a sufficient number of places be available for those who need some continuous skill in their care and that the end may be allowed to come peacefully, rather than that it should be a clinical extension of a painful period. If emotionalism were got rid of and a real feeling were to ride supreme, it should be possible to give real support to those who are approaching the last stage of their journey. And because the men and women of this land are worthy of their country, I feel we should endeavour to supply the ways to strengthen their courage and uphold their dignity in the shape they would wish.

4.37 p.m.

EARL FORTESCUE

My Lords, I should like to offer my humble tribute to the right reverend Prelate for a remarkable maiden speech which, I am sure, will be very helpful to your Lordships in considering this problem. The noble Lord, Lord Amulree, has done great service in raising the question, because it is a very important problem and one which is going to get larger and larger. Modern science has succeeded—I was going to say admirably, but I am not quite sure that that is the right word—in prolonging life, but it has not succeeded so far in prolonging vitality (I am not sure that that is the technical word). There is an increasing number of elderly who are going downhill, but going down so slowly that they cannot die. It is for these that the nation has to find some solution.

I venture to think, although I have no statistics on the subject, that the average age of noble Lords in this House is higher than the average age of those in another place, and so it is only appropriate that the start and the prod on behalf of the old should come from here. Much of the ground has been covered by previous speakers, but there are one or two points which I should like to raise. In the rural areas, there are in many villages many houses quite unsuitable for old people to hang on to in their old age. The houses are bad, but they hate to be turned out of them in order that the houses can be improved. However, they are keeping young couples out of those houses.

It has always struck me that there is an obvious solution to this problem. In every village there are now many council houses, but it has rarely occurred to the councils concerned to think that, when they put up, say, two council houses, they could put up something for the elderly in between. If, when each pair of council houses is erected, another building on ground floor only was put between them, comprising a bed-sitting room, a kitchen and a bathroom, an elderly person or an elderly couple could continue there. It is an admirable feature of country life that neighbours will look after the old and then they do not feel in any sense isolated or dependent.

I have had the advantage of a conversation on the subject with an admirable local general practitioner, who is a man not only of wide experience but also of a very warm heart. He tells me that neighbourly sentiment towards the elderly is as strong as it ever was, but family sentiment is not what it was. The younger generation no longer take it as a matter of course and as a happy duty to look after their parents in their old age, and there is a certain reluctance on the part of parents to inflict themselves on the younger generation. Something needs to be done about that, and if these (for want of a better word) maisonettes could be provided, they would go a considerable way towards a solution in rural areas.

One aspect which has not been touched on in this debate so far is that of the elderly of the professional classes. There are many pensioners on an old-scale pension which has depreciated. In that connection, I would mention the Army pensions after the First World War, which were reduced. There are many widows of pensioners who find themselves in straitened circumstances. There are public servants of both sexes who have spent their lives doing admirable work and in their old age find themselves unable, because they have very limited means, to "make a do of it". Despite what the noble Baroness said on institutionalisation, I think that many of these people are better and happier in homes of some sort.

There are a good many such homes already. My noble friend Lord Mackintosh of Halifax, to whom I was speaking this morning, is appealing for the Methodist Homes for the Elderly. Many professional bodies, including the clergy and doctors, run homes for the elderly or give assistance to them. There is an extraordinary demand for voluntary homes. These homes have many advantages. Old people need some help, someone to come in and see to things every day. That can be done with a good deal less labour if the units are of a certain size. If 100 elderly people want some assistance every day in their own homes, the number of man-hours or woman-hours required to look after them is considerable, whereas if there is a unit of about 50, much less labour is required—something in the proportion of 25 for running an establishment of 50 to 75 persons—and it is a good deal easier to get.

I have to do with one such home (for want of a better word) and when I go into it, I am often reminded of the hexameter of Virgil: Tempora mutantur, nos et mutantur in illis. My Latin pronounciation is out-of-date, so may I render it this way?: Times do change hut who would ever have thought we should finish up like this. No, my Lords, it is not a matter of laughter; it is very sad. I think that we must do all we can to help these people.

One of the major problems is finance. Many of these people can afford to make a contribution which covers housekeeping, but the renting or purchase of buildings and their maintenance takes a great deal of doing. The institution with which I am concerned, and a number of others, have had enormous help from charitable trusts, but, as an instance of our difficulties, a few months ago, we had an excellent opportunity of extending by buying a freehold nearby at a figure in the neighbourhood of £80,000. A quick look round showed us that a number of charitable trusts would help quite a bit, so we made a bid for it and bought it. But how were we to raise the rest? Just at that moment, the "squeeze" came, and although we have been very fortunate in getting the money we needed, it has been a matter of great difficulty and, in these times, of considerable expense. I think that the Government could help the elderly enormously if, for recognised bodies such as the one I have described, there was some ready source of finance, either charitable or at a reasonable rate. That is all I have to say.

4.47 p.m.

LORD BEVERIDGE

My Lords, I should like to begin by adding my welcome to the maiden speech of the right reverend Prelate the Lord Bishop of London. I do so with all the more pleasure because I found myself agreeing with nearly everything that he said. My noble friend Lord Amulree, who sits beside me on this Bench, formally drew the attention of Her Majesty's Government to deficiencies in the arrangements for the care of the elderly, both sick and infirm; But I am glad that he did not limit himself to considering things which should be done for the sick and infirm, and I was particularly glad when he emphasised housing and "meals on wheels". For even those who are not sick or infirm, housing and meals are needed. My noble friend did not limit himself to the formal words of his Motion and I shall not limit myself either.

Old people all over the country although they may not now be sick or infirm, are living in conditions which will undoubtedly lead to sickness or infirmity. In dealing with sickness and infirmity, prevention is infinitely better than cure, and prevention, no less than cure, means understanding the causes. We all know pretty well the main course of the trouble with old people today. It is, first, the growth in their number. Whether it is their fault or that of the doctors that they go on living in such numbers I will not say, but more than anything else this growth puts before us the vast deficiency in housing all over the country. That has to be tackled somehow. Then there is the second cause of inflation, destroying savings and making assistance rather than pensions seem indispensable. Then there is the disappearance of what used to be called domestic service, and what is now called home help. That is altering enormously the life of old people and the possibility of their having comfortable lives, and is one of the problems of the old which cannot be exaggerated. Those three things that I have mentioned are common to all old people.

There is one other that is common to old people in Britain, and it is that they are not confined to one part but are to be found all over Britain. Some help for dealing with old people is needed everywhere, though it is not by any means the same help that is required everywhere, and still less the same help for all old people, because the actual needs of old people differ greatly, just as the action needed to help them differs.

I had the good fortune of realising how great is the work done when about a month ago I paid a visit to Belfast in Ulster to learn what they were doing about old people. I was enormously impressed with what I saw there. I think that if every town in the country could do as much good for old people as Belfast does—not necessarily the same things—where very happy circumstances surround them, and there is agreement between all the interested people in the city, the solution to the problem of old people would take a great step forward. I realise, of course from talking to the chairman of the body that provides institutions—perhaps 30 or 40—for old people who are sick, that there are some people who need recurrent nursing. You cannot put them in ordinary small homes, and you do not want to fill up the hospitals with such people. In Belfast they have several homes, each for 30 or 40 people, and the moment they need full nursing care they can get it rapidly without putting an end to the work of the hospitals. That, I thought, was an excellent institution. From what I heard, I did not think it necessary to visit them, but I went to see some houses that have been established within the last year for housing old people who had really nothing wrong with them except loneliness.

I welcome the emphasis put on loneliness by the right reverend Prelate, because this is one of the main troubles of old people: loneliness coming perhaps through their having no children or careless children, or the loss of a wife or friend, so that in effect they have no home. That loneliness may easily lead to infirmity and to much worse. It so happens that I am concerned with the Abbeyfield Society mentioned by the right reverend Prelate, and I am glad to say (I hope this may also please the noble Earl who spoke last) that this Society wishes to be able to cover everywhere where its work is needed. It is worked by local committees. In Belfast there is a most vigorous Abbeyfield Society. I went to see what they were doing, and I saw three homes for lonely people with nothing wrong with them except loneliness. But loneliness is a horrible thing for old people. In Belfast they were in homes established within a year, completely furnished, and good homes in every possible way. There, for some fortunate reason they seem to have much more money to spend on this than, say, in Oxford, the city in which I live; and also let me say that I am sure the houses in Belfast do not cost as much as do the houses in Oxford.

In Belfast, as I say, there were these three homes; there are two more on the way, and they are going to spread them all over Ulster. I had a meeting with all the representatives of the neighbouring towns which were going to do exactly the same thing. They provide homes for people, limited in number to four or five or four to six, because if the number goes beyond that they may become something like small institutions. These homes provide a separate room for each person without any furniture, unless they ask for it. They can bring their own furniture and be surrounded by their own possessions. They have the feeling of privacy when they want it, but they can call on somebody else and get companionship if they want it. They have lighting, heating, food, home help and occupation—all these things are thought of for them. I will not go into the finance of it, but will only say that if they cannot pay themselves we find the National Assistance Board very sympathetic indeed when they know that these people are being put into good and not bad conditions. I was deeply moved by what I saw there.

I saw, among other people, an old man of 84—much older than I am—who had fought against the Boers in 1899, had gone on being a soldier and had lived very happily indeed with his wife. They had no children, but his wife looked after him until she died about a year and a half ago. Think what happens to an old soldier whose wife dies and he has no one to look after him. What happened was that he went into an Abbeyfield home. There are four old ladies there, and I think the four old ladies and the housekeeper between them compete as to who shall best look after the old man. I am making a plea for old men; they want to be helped by old women, although there are relatively few of them. After a married life without children the death of your wife is a terrible break unless there are other children or friends who come to the rescue.

I want to urge upon your Lordships that the unhappiness of old people to-day—and there is plenty of it—is a disgrace to our affluent society. The only question is: Who is going to wipe this disgrace from our British record; and by doing what? It cannot he done by any one body. The Government must obviously be greatly concerned with housing generally. The old people have made the housing shortage. You cannot cure the housing problem by leaving them without homes. You have to build more homes and it is no good building them for anybody. Somehow you have to get a priority for the old people, and you have to fit the homes to old people. I am an old person, and I know I could not live anywhere and everywhere with perfect happiness as I live in Oxford to-day. There are some advantages, even in Oxford. The Government should seek every co-operation from the local authorities and any voluntary organisation. I put housing as the first charge upon the Government, whatever it is.

I do not want to talk about inflation, but, of course, the Government, the employers and the trade unions among them could combine to halt the further destruction of the value of money, because inflation makes saving for old age seem nonsense; and it is nonsense for many people. I have always believed that happiness for the citizens of this country should come partly from the State, partly from voluntary organisations, partly from people helping others and partly from people helping themselves. I was glad to note one particular society on my visit to Belfast. Let me say at once that the last thing I would suggest is that this is the only possible society; there are many excellent societies working for old people.

It so happens that we had invented for us a few years ago a particularly good idea as to what solitary old people, not in ill health, needed in order to live and to be saved from ill health. Although we do not normally put a nurse into an Abbeyfield home, there is no chance of an old man or old woman in an Abbey-field home falling ill and not seeing a doctor until it is too late to be cured. That is one of the common evils of old people. It may well be that as the numbers grow some kind of help (not full nursing) for people when they are beginning to be ill is a thing we ought to develop to prevent their illness from going further.

That is all I have to say, except how thankful I am that this House, concerned so deeply with social problems, has once again called attention to the unhappiness of old age and to the need for joint action to end it. I think I may say that practically every speaker, in one way or another, referred to both those points and supported joint action to end unhappiness and to prevent the trouble that we have to-day from leading to something worse in the shape of illness and misery. Let me return to my thesis: that prevention of infirmity is better than cure. In order to get prevention, we have to deal with the problem of old people as a whole. If the Government, the local authorities and the various voluntary organisations, without any jealousy or quarrelling one with another, will take this debate to heart and do together all they can as a result of this debate, then I think we may say that the House of Lords has once more done a great service to Britain.

5.6 p.m.

BARONESS SUMMERSKILL

My Lords, we have all listened to the noble Lord, Lord Beveridge, make his plea for the aged and lonely. If he will forgive my saying so, I think it was a poignant speech, and when his voice goes out to the old and lonely at least I can assure him that they will derive some comfort in knowing that he, whose name is known all over the country, has spoken on their behalf. I must admit that I cannot understand why he says that women should look after men, and not men look after women, but we will not cross swords on that.

LORD BEVERIDGE

Because women can, and do, look after men, and men only make a mess of trying to look after women.

BARONESS SUMMERSKILL

I must confess that we women like looking after men. But I cannot offer my services to the noble Lord, because I have a very nice man to look after, and the noble Lord will realise that I have not time to look after both.

LORD BEVERIDGE

I have two nice women and four children and stepchildren, all looking after me.

BARONESS SUMMERSKILL

The noble Lord makes me suspect that he is a polygamist. However, we did not think that at this stage of our lives we should be crossing swords on the question of feminism.

The noble Lord has emphasised the point that the matter we are discussing to-day, the needs of the aged and infirm, is not spoken about enough in either House of Parliament. Indeed, what has happened to-day is that the noble Lord, Lord Amulree, has focused attention on the needs of a very large group in the community which does not possess a pressure group in either House of Parliament. I would say that in the last few years their voices have been heard more often, for reasons which the noble Lord will realise. There are in this country to-day more than 2 million people aged 75 and over whose needs cannot be ignored. My noble friend Lord Taylor talked about the physiological condition of the aged. I observed that the noble Lord, Lord Beveridge, tended to talk about the middle classes when he talked about domestic servants. He will realise that home helps help the classes who never had domestic servants in their lives before.

I would say that the real tragedy of old age, in all income groups, lies in the fact that, as a rule, physical deterioration precedes mental degeneration. Consequently, there is a growing aged population, physically incapable of conducting a normal life but sufficiently agile mentally to suffer profoundly from the apparent desertion of relatives and friends, and from the frustration and inadequacy which dependence on others instils. In my opinion, that is the real tragedy of old age. Only if this important aspect of ageing is kept in mind can plans be made to meet the real needs of the aged and infirm.

It is not always recognised that privacy is very important to an old person although he or she is physically enfeebled. The description by Dickens of the workhouse of the 19th century is deplorable to our modern way of thinking. Then masses of people of all kinds were put into large rooms and just left. The importance of privacy is that to the aged poor the only status symbol remaining is a humble home, with its simple belongings, and it is a tragedy to be deprived of that state in one's few remaining years. Therefore I would say that the present need is for more accommodation for those who are anxious to remain independent but who need some supervision.

I have arrived at precisely the same analysis as the noble Lord, my noble friend, Lord Beveridge. He is quite right, of course, in his decision that a room of one's own is what is needed generally in old age for the reasons I have given. He has described buildings which he has seen. Here I would remind noble Lords of the unit opened at Mansfield this year, which would seem to meet this need. There, there are double and single bed-sitting rooms provided in bungalow units, each providing accommodation for ten residents with a housekeeper in charge. There is a housekeeper, my Lord Beveridge, a woman.

LORD BEVERIDGE

Of course.

BARONESS SUMMERSKILL

Furthermore, the residents have been allowed to bring their own furniture, which is a humane and wise provision. Now, if all housing authorities provided adequately equipped bed-sitting rooms in buildings where some supervision could be exercised, this would meet the need of many aged people desperately clinging to their independence, and at the same time, of course, release large numbers of flats for young people.

When you are old there is a curious psychological desire to get back to the womb, to get warmth, to get comfort, to get privacy. And that psychological desire is translated into a yearning for a place of one's own, small and cosy. Wonderful flats have sometimes been shown, with a bedroom, sitting room, kitchen and bathroom. But the aged want to be kept warm, they want to sleep in the room they have heated all day with their bodies and their small amount of fuel. These are the things which the housing authorities should understand.

LORD BEVERIDGE

You are describing me.

BARONESS SUMMERSKILL

That is a great compliment from the noble Lord.

The joint circular which I think has been issued by the Ministry of Housing and Local Government and the Ministry of Health and local authorities was an admirable document. Despite this circular, which has taken many civil servants many months and years, I have no doubt, to write, unfortunately there is no guarantee that the excellent services will be used by those in greatest need, for this simple reason: there is no register of the aged. That is why we occasionally read of tragic cases of men or women dying in a room, an old man or woman dying alone without companions and days elapsing before that tragic discovery is made. Therefore, I want to urge those in authority that there should be some system of notification in order to ensure that the large number of aged living alone are adequately cared for. Furthermore, this would facilitate co-ordination of the services and so prevent overlapping and consequent waste of effort.

I have heard the noble lady, Baroness Sw