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A community service for mental defectives in a rural area
A COMMUNITY SERVICE FOR MENTAL DEFECTIVES IN A RURAL AREA By J. V. M O R R I S ,
M.A., M.D.,
Medical Superintendent, Little Plumstead Mental Deficiency Hospital,
Norfolk. AND
K. F. A L F O R D ,
M.S., CH.B., D.P.H.
Medical Officer of Itealth and Principal School Medical Officer, Norfolk County Council. A community service for mental defectives living in rural areas is much affected by sparsity of population and long distances for travelling. The county of Norfolk has an acreage of 1,302,500 and population (1957) of 383,600 (i.e. 0.29 per acre), of whom 37,000 live in the fringe area of Norwich and 26,500 in King's Lynn. THE
WORK
OF
THE
LOCAL
AUTHORITY
In the county there are 944 ascertained mental defectives living in the community, i.e. 2.46 per 1,000 of the population. Of these, 678 are under statutory supervision, 246 under friendly supervision and 20 under guardianship.
Supervision The supervision of defectives in the community is carried out by 14 mental welfare officers, under the direction of the county medical officer through his non-medical administrative officer for mental health. There are, in addition, 4 trainee assistant mental welfare officers who are receiving inservice training. A special training course was arranged for all field staff in 1948--and an intensive one-day course now takes place annually ,in the mental deficiency hospital. Medical staff, psychologists, nurses and other members of the hospital staff contribute lectures and demonstrations at these courses.
Ascertainment In the year ended 31st December, 1957, 104 mental defectives were ascertained; 69 under Sections 57(3) or 57(5) of the Education Act (1944), and 35 others, most of whom were either over school age or less than 2 years. The examinations are carried out by the Council's medical staff who can, if they wish, consult with hospital specialists in mental deficiency about cases which present any difficulty, including those who are the subject of appeal by parents or guardians.
Training in the Community There are occupation centres at Norwich and King's Lynn for the east and west of the county respectively and two further centres are proposed for 141
142
PUBLIC
HEALTH
VOL.
LXXIII
NO.
4
north and south Norfolk. The Great Yarmouth Authority take cases into their centre from the adjoining areas of the county. Children are brought to the centres by a contract taxi service, escorts being part-time members of the Council's staff. There are nine routes, the total daily mileage being 965, and the longest route covers 162 miles per day for the transport of 10 children. The annual mileage for this service is 173,690. The county was one of the first to appoint home teachers and to organise occasional occupation centres for children living in the more remote parts of the county, which could not be covered by the full-time centres. Two qualified home teachers are employed and they run 6 occasional occupation centres once fortnightly for 52 children in all. In addition, they visit 128 patients in their homes to give industrial training and to advise about management. It is intended to appoint a third teacher soon, and it is hoped that this will enable the occasional centres to be held weekly instead of fortnightly as well as to increase the frequency of home visits to individual patients. When the proposed expansion is completed, it is estimated that 95 ~o of the patients suitable for occupation centre or home-training will be covered by the service. The Council's scheme for home-training of older children and adults provides incentives for the patients. Articles produced are sold, the patient receiving the difference between the cost of the raw materials and the finished product. Although the money earned is small, the satisfaction and sense of achievement on the part of both patients and parents is great.
Home Attendants jbr Parents The Health Committee have pioneered a scheme to give assistance to parents who have low grade children in their homes. Free home attendance is provided on two half-days per week to permit the mothers to leave their homes for shopping or recreation.
Collaboration with Voluntary Bodies In 1957, the Norfolk and Norwich Society for Mentally H a n d i c a p p e d Children established a small industrial centre in Norwich. Apart from financial support from the County Council for cases from the county area, the county medical officer of health and his non-medical administrative officer for mental health are members of the Management Sub-committee of the centre. Meals are provided by the Norwich City school meals service. THE
WORK
OF
THE
HOSPITAL
SPECIALIST
S T A F F
(1) Mental Deficiency Diagnostic Service A central clinic is held fortnightly at Norwich in local authority premises. The staff comprises two specialists, a clinical psychologist, a psychiatric social worker and the medical representative of the county medical officer. Patients
A
COMMUNITY
SERVICE
FOR
MENTAL
DEFECTIVES
143
are seen at the request of medical officers of health, general practitioaers and other interested bodies from the hospital catchment area and these fall into two main categories--(a) those over school age who present problems in diagnosis, treatment, job placement, or who have come into conflict with the law, and (b) children of school age or under, whose degree of defect renders them unsuitable to attend an ordinary guidance clinic. Fifty-one patients were seen in the first six months of 1958. Patients living long distances from the centre, both adults and children, are seen at peripheral child guidance clinics, being given special appointments to avoid their mixing with the children who are not defective. (2) Child Guidance Clinics Child guidance clinics are held in local authority premises, specialists being provided by the hospital, while psychological and other staff are supplied by the local health and education authorities. When defectives are seen, the ancillary professional staff of the clinic give assistance to the medical specialists, and the appropriate field officers associated with the patient in the community attend. The opportunity is frequently taken of holding a case conference on the spot in order to arrive at the most suitable and practical solution. Children with moderate degrees of defect, whether they present psychiatric problems or not, are seen at the child guidance clinics for more detailed diagnosis, and to assist the local education authority in its decision as to notification under Section 57(3) or 57(5), or for advice as to other disposal. The majority of children do not, of course, exhibit any significant degree of defect of intelligence. The position is simply that the door of the child guidance clinics is opened a little wider than usual to children with some measure of mental defect. As mentioned earlier, where the degree of mental defect is obtrusive and likely to be an embarrassment to patients or parents attending child guidance clinics, the patients are diverted to the special mental deficiency diagnostic clinics. Whether the patients are seen at orthodox child guidance clinics, special mental deficiency diagnostic clinics or at their own homes, reports are sent to both their general practitioner and medical off• of health. Advisory Service The advice of hospital specialists is available to medical officers of health on any aspect of mental deficiency practice, by letter, telephone or personal interview. A consultant is a member of the committee which selects patients for the industrial centre, and advises about employment within the centre if accepted. Domiciliary visits are paid when requested or where the consultant considers the mental condition will be more adequately assessed if the home back-ground can be observed. Short Term Admissions The hospital has operated a short-term admission scheme since 1951. In 1957, 176 patients were received under the terms of Circular 5/52, of whom
144
PUBLIC
HEALTH
VOL.
LXXIII
NO.
4
86 came from the county of Norfolk. Of these, 17 were admitted for diagnosis and advice about disposal. In every case, medical and psychometric investigation was carried out and reports sent to the medical officer of health and the patients' general practitioner. This service, which is handicapped by shortage of medical, nursing and ancillary staff, is in urgent need of further development. Dental Out-Patients Service Low grade and epileptic defectives are not welcomed by ordinary dental surgeries, and about 40 patients are admitted to the hospital each year for dental attention. SUMMARY
The provision of a co-ordinated mental health service in thickly populated regions has been frequently reported, but the organisation of such a service in country areas presents a more difficult problem. In this report, an account is given of a community service for mental defectives in a large rural county. Under this scheme, the hospital service provides full diagnostic and specialist facilities, and special mental defective diagnostic clinics have been established, join@ staffed by the hospitals and the local health authority. Such an interlocking of the two services, as is envisaged in the Report of the Royal Commission, can only be achieved by a spirit of goodwill and understanding on both sides.
M.A., M.D.,
Medical Superintendent, Little Plumstead Mental Deficiency Hospital,
Norfolk. AND
K. F. A L F O R D ,
M.S., CH.B., D.P.H.
Medical Officer of Itealth and Principal School Medical Officer, Norfolk County Council. A community service for mental defectives living in rural areas is much affected by sparsity of population and long distances for travelling. The county of Norfolk has an acreage of 1,302,500 and population (1957) of 383,600 (i.e. 0.29 per acre), of whom 37,000 live in the fringe area of Norwich and 26,500 in King's Lynn. THE
WORK
OF
THE
LOCAL
AUTHORITY
In the county there are 944 ascertained mental defectives living in the community, i.e. 2.46 per 1,000 of the population. Of these, 678 are under statutory supervision, 246 under friendly supervision and 20 under guardianship.
Supervision The supervision of defectives in the community is carried out by 14 mental welfare officers, under the direction of the county medical officer through his non-medical administrative officer for mental health. There are, in addition, 4 trainee assistant mental welfare officers who are receiving inservice training. A special training course was arranged for all field staff in 1948--and an intensive one-day course now takes place annually ,in the mental deficiency hospital. Medical staff, psychologists, nurses and other members of the hospital staff contribute lectures and demonstrations at these courses.
Ascertainment In the year ended 31st December, 1957, 104 mental defectives were ascertained; 69 under Sections 57(3) or 57(5) of the Education Act (1944), and 35 others, most of whom were either over school age or less than 2 years. The examinations are carried out by the Council's medical staff who can, if they wish, consult with hospital specialists in mental deficiency about cases which present any difficulty, including those who are the subject of appeal by parents or guardians.
Training in the Community There are occupation centres at Norwich and King's Lynn for the east and west of the county respectively and two further centres are proposed for 141
142
PUBLIC
HEALTH
VOL.
LXXIII
NO.
4
north and south Norfolk. The Great Yarmouth Authority take cases into their centre from the adjoining areas of the county. Children are brought to the centres by a contract taxi service, escorts being part-time members of the Council's staff. There are nine routes, the total daily mileage being 965, and the longest route covers 162 miles per day for the transport of 10 children. The annual mileage for this service is 173,690. The county was one of the first to appoint home teachers and to organise occasional occupation centres for children living in the more remote parts of the county, which could not be covered by the full-time centres. Two qualified home teachers are employed and they run 6 occasional occupation centres once fortnightly for 52 children in all. In addition, they visit 128 patients in their homes to give industrial training and to advise about management. It is intended to appoint a third teacher soon, and it is hoped that this will enable the occasional centres to be held weekly instead of fortnightly as well as to increase the frequency of home visits to individual patients. When the proposed expansion is completed, it is estimated that 95 ~o of the patients suitable for occupation centre or home-training will be covered by the service. The Council's scheme for home-training of older children and adults provides incentives for the patients. Articles produced are sold, the patient receiving the difference between the cost of the raw materials and the finished product. Although the money earned is small, the satisfaction and sense of achievement on the part of both patients and parents is great.
Home Attendants jbr Parents The Health Committee have pioneered a scheme to give assistance to parents who have low grade children in their homes. Free home attendance is provided on two half-days per week to permit the mothers to leave their homes for shopping or recreation.
Collaboration with Voluntary Bodies In 1957, the Norfolk and Norwich Society for Mentally H a n d i c a p p e d Children established a small industrial centre in Norwich. Apart from financial support from the County Council for cases from the county area, the county medical officer of health and his non-medical administrative officer for mental health are members of the Management Sub-committee of the centre. Meals are provided by the Norwich City school meals service. THE
WORK
OF
THE
HOSPITAL
SPECIALIST
S T A F F
(1) Mental Deficiency Diagnostic Service A central clinic is held fortnightly at Norwich in local authority premises. The staff comprises two specialists, a clinical psychologist, a psychiatric social worker and the medical representative of the county medical officer. Patients
A
COMMUNITY
SERVICE
FOR
MENTAL
DEFECTIVES
143
are seen at the request of medical officers of health, general practitioaers and other interested bodies from the hospital catchment area and these fall into two main categories--(a) those over school age who present problems in diagnosis, treatment, job placement, or who have come into conflict with the law, and (b) children of school age or under, whose degree of defect renders them unsuitable to attend an ordinary guidance clinic. Fifty-one patients were seen in the first six months of 1958. Patients living long distances from the centre, both adults and children, are seen at peripheral child guidance clinics, being given special appointments to avoid their mixing with the children who are not defective. (2) Child Guidance Clinics Child guidance clinics are held in local authority premises, specialists being provided by the hospital, while psychological and other staff are supplied by the local health and education authorities. When defectives are seen, the ancillary professional staff of the clinic give assistance to the medical specialists, and the appropriate field officers associated with the patient in the community attend. The opportunity is frequently taken of holding a case conference on the spot in order to arrive at the most suitable and practical solution. Children with moderate degrees of defect, whether they present psychiatric problems or not, are seen at the child guidance clinics for more detailed diagnosis, and to assist the local education authority in its decision as to notification under Section 57(3) or 57(5), or for advice as to other disposal. The majority of children do not, of course, exhibit any significant degree of defect of intelligence. The position is simply that the door of the child guidance clinics is opened a little wider than usual to children with some measure of mental defect. As mentioned earlier, where the degree of mental defect is obtrusive and likely to be an embarrassment to patients or parents attending child guidance clinics, the patients are diverted to the special mental deficiency diagnostic clinics. Whether the patients are seen at orthodox child guidance clinics, special mental deficiency diagnostic clinics or at their own homes, reports are sent to both their general practitioner and medical off• of health. Advisory Service The advice of hospital specialists is available to medical officers of health on any aspect of mental deficiency practice, by letter, telephone or personal interview. A consultant is a member of the committee which selects patients for the industrial centre, and advises about employment within the centre if accepted. Domiciliary visits are paid when requested or where the consultant considers the mental condition will be more adequately assessed if the home back-ground can be observed. Short Term Admissions The hospital has operated a short-term admission scheme since 1951. In 1957, 176 patients were received under the terms of Circular 5/52, of whom
144
PUBLIC
HEALTH
VOL.
LXXIII
NO.
4
86 came from the county of Norfolk. Of these, 17 were admitted for diagnosis and advice about disposal. In every case, medical and psychometric investigation was carried out and reports sent to the medical officer of health and the patients' general practitioner. This service, which is handicapped by shortage of medical, nursing and ancillary staff, is in urgent need of further development. Dental Out-Patients Service Low grade and epileptic defectives are not welcomed by ordinary dental surgeries, and about 40 patients are admitted to the hospital each year for dental attention. SUMMARY
The provision of a co-ordinated mental health service in thickly populated regions has been frequently reported, but the organisation of such a service in country areas presents a more difficult problem. In this report, an account is given of a community service for mental defectives in a large rural county. Under this scheme, the hospital service provides full diagnostic and specialist facilities, and special mental defective diagnostic clinics have been established, join@ staffed by the hospitals and the local health authority. Such an interlocking of the two services, as is envisaged in the Report of the Royal Commission, can only be achieved by a spirit of goodwill and understanding on both sides.