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Housing for the aged
PUBLIC H E A L T H
The Medical Officer and Old People By JAMES R. PRESTON, B.SC., M.B., CH.B., D.P.H., F.R.F.P.S.,
Medical Officer of Health, and Area Medical Officer of Health, Sutton Coldfield, Chairman, West Midlands and Warwickshire Old People's Welfare COmmittees, Secretary, Sutton Coldfield Old People's Welfare Committee. ' O R K amongst old people, particularly in the voluntary sphere has been one of my greatest interests for the past seven or eight years. There are few other fields of endeavour from which more satisfaction can be obtained, and from which a greater feeling of achievement results. Furthermore, the old people are grateful for any help and advice received--something unusual in the welfare state. I n the preamble to the report of the Ministry of Health for 1955 the Minister states that in his view the three main priorities in the Health Service to-day are: first, to bring existing hospitals to a satisfactory standard and to provide a s ' f a r as possible new accommodation as and where it is needed; second, to ensure that the mental health service xeceives a proper share of the new construction and resources available; and finally lo tackle the problem of making adequate provision for the care of old people. Accepting that there is much work to-be faced, what can an M.O.4~I. do, and what J~acilities, voluntary and otherwise, are there available to meet the needs of}old people? The first thing that strikes me, gs an M.O.H., in m y close connection with many voluntary old people's welfare committees is the relatively few numbers of medical officers of health who take an active interest in the work of these committees an'd, indeed, who are aware of the considerable effort which is expended in the interests of old people by these bodies. I admit that many medical officers do in some small way have contact with the local secretaxies or organisers, but this is not enough. The medical officer of health, or his medical representative, should be at the least a member of the local, or area, old people's welfare committee, and should play his part in some measure in guiding and leading these committees .in view of his local and specialised knowledge.
co-ordination of the services already available, both statutory and voluntary ; and accumulation of information about the normal process of age, i.e., social research. In this respect 1 would refer particularly to the co-ordination of both voluntary and statutory services. I know that many health visitors and many area nursing officers and senior health visitors are members of, and take an active part ifi the work of, voluntary welfare committees, but there are still some'who~ take no interest in this work. I know that many old people's welfare committees would welcome and indeed invite co-operation and membership by the health visiting staff. At the present time, with the staff shortage position in public health departments, it is not easy for health visitors to take on additional responsibility, but nevertheless in view of the importance Of this question I feel that the time is now proper for health visiting staffs of local health authorities to take greater interest in the work for old people generally, and to visit regularly those cases which deserve special attention. The health visitor will then be making a closer approach to the ideal of family visiting. I would also like to see all old people's welfare committees, local, county and regional, inviting representation from health departments where none now exists, so that this co-ordinated linking does take place.
W
Health Department's R f l e There is no doubt in my mind that to date there has been considerable co-operation between welfare departments and old people's welfare committees, and this is an extremely good thing'. However, in view of the fact that a very large proportion of the problems of old age are bound up with and stem from the state of health, or lack of it, it seems logical that health departments as such should take a more active place in this sphere. This particularly applies at the present time, when so many health departments and welfare depaxtments work to some degree independently. Where, however, these departments are under o n e roof, it is easy to unify their efforts and obtain maximum benefits and results. Apart from the health visiting service, the home nursing service and the home help service play a vital part-in the care of old people. Of these I think that by and large the home help supervisors and home help service maintain the closest union with the voluntary bodies, and some supervisors are co-opted to the voluntary organisations, b u t there is no doubt that in some areas there is not much contact, which is a great pity. The criticism also applies to the home nursing services except where the nursing officer or M.O.H. or his representative is in close contact with these voluntary bodies, Again, the work of the
Growing Demand for Services The Ministry's report states that the demand on the services of old people's welfare committee continues to grow. There has been an increase in the number of committees from 1,150 in 1950, to 1,280 in the year under review, 1955. Particularly stressed is the fact that although many effective voluntary visiting services to o l d people exist, these need strengthening and new ones are needed where none at present exist. Apart from the medical officer of health there is the r61e the health visitor has to play in the care of the elderly. This can be classified in.to four parts--the work concerned with the preparation for ageing; maintenance of health in those who have already crossed the threshold of hge; * Presidential address to the Midlands Branch of the Society of Medical Officers of Health, 70
The Medical Officer and Old People
January 1957
'certainly now have this issue fairly and squarely before us, with long waiting lists for admission to chronic sick hospitals. We also have the difficulties of care and attention required by old people in their homes. Medical officers of health have now to direct a considerable portion of their time and thought to these questions, not only in the local authority sphere, but generally.
public health inspectors would not appear on the face of it to have much connection with old people's welfare, but in the course of their duties they can obtain a wealth os information, and can pass this through the health department. The medical officer of health plays his part in guiding his Council in the needs of old people in t h e area, and he can by close contact with voluntary committees, who have considerable experience and knowledge of local needs, obtain in many instances much helpful advice. He can often pass on the feelings of those chiefly interested in this problem to the right quarters. If we accept that co-operation with; and active participation in, voluntary old people's welfare work is an essential for the medical officer of health, what can such an old people's welfare committee offer? The average well-run old people's welfare committee, being composed of representatives of all active welfare organisations and bodies in an area, has invariably organised a home visiting service, carried out by voluntary, visitors, and has in many cases a co-ordinated meals-on.-wheels service. In addition the committee provides entertainment and can invariably arrange holidays for old people at suitable resorts. Furthermore many committees have considerable financial resources, and a - m/~dical officer can often obtain supplementary equipment for old people, items which cannot be l~rovided by the local authority servicesl Some old people's welfare committees provide chiropody services, laundry service, night sitters, and special transport. The most important service provided is the home visiting service, which can supplement the health visiting services in certain ways and can be an excellent medium for bringi n g out the requirements and needs of old people in the area. A health department which is working closely with such an_ organisation can find the greatest benefit in so doing.
The facts and the problem of chronic sick and the aged are well known. Straightforward arithmetic shows us that there now are six people of working age for every person over working age, and in 25 years time there will be four persons of working age to each person over working age. With this prospect there is no doubt that a great task faces the health and welfare services, not to mention the national economy. What can we do to ease this problem? Cert~lin medical officers have by close liaison with the hospital management committees and regional hospital boards, co-ordinated the waiting lists, and all practitioners in their areas pass the request for admission of chronic sick through the health department. In this way a reasonable degree of priority of admission is settled, a n d the cases requiring the most care, and who need to be admitted urgently, obtain proper priority in reference. Owing to the scarcity of beds, however, the backwash falls on the home nursing and home help services. These at the moment are, in nearly every instance, working, or over-working, at full bore and I think the voluntary organisations carl give much help in keeping old people at home by supplementing these services.
Ancillary Services Some local authorities provide excellent ancillary services for old people--washing services for soiled linen, excellent meals-on-wheels services, and night sitters, which just turn the balance in favour of care and attention at h o m e - - b u t where no such services are provided statutorily, they are often provided voluntarily. I am not suggesting that this is so in unbounded measure--there is yet much improvement and expansion needed--but the voluntary organisations are indeed aware of the useful help and supplementation they can give, and are working to that end. It might be an advantage if more geriatricians could be appointed on a part time basis; in co-operation with the regional hospital board, to organise and co-ordinate the hospital and domiciliary services for old people. I feel that at the moment geriatricians are forced to a one-sided view and tend to think of old people in the main as units in hospital beds or in a hospital annexe. If they had a broader picture, with their co-operation many of the old people who find their way into chronic sick h o s p i t a l s would never get there, and other cases of a more suitable nature would be admitted.
Aged at Home " T h e needs of old people in their own homes, especially those living alone, continues to attract attention," commented the Ministry of Health's report. ',As indicated last year, a co-ordinated partnership o f statutory and voluntary domiciliary services is the key to ,providing the right service where it is needed, and at the right time, whether directed towards avoiding or. delaying admission to residential care by providing practical help or friendly service, or designed to ensure that those who live alone are not unknown to those who might help them. Co-operation between statutory a n 6 voluntary visiting services is all important for this purpose." When many of us were resident or newly qualified medical officers, we did not come across much in the way of problems of the aged, because they were invariably removed from our responsibility, and 20 years ago the problem of the aged in their homes only came to our notice occasionally. Have we developed, therefore, a more humane outlook to the problems of old people, or have we developed a conscience as to their fate and welfare? We
In spite of some pessimists, there are still available to medical officers of health many new fields of endeavour and that of old people's care and welfare is one of the brightest. 71
PUBLIC HEALTH
The Medical Officer and Old People
we turn our health education efforts towards provision for old age, the development of hobbies, labour-saving devices to assist elderly people in their homes? Can we provide suitable work which will retain their interest? Much is being d o n e - - m o r e can be done. Let us join with our voluntary organisations and work together for the benefit of the elderly. Let medical officers of health and health departments take their rightful place i n the care of the aged, not only in their local authority obligations, but in the wider sphere of the work of voluntary old people's welfare committees.
H o w m a n y proper surveys of local needs of old people. have been carried out? How many health departments h a v e registers of old people, and if not, how can the requirements o f this large group be d e t e r m i n e d - - a group which requires more care than almost any other? Where such comprehensive surveys have been carried out much valuable information has been obtained. Where else can we turn? Can we try to stimulate a moi'e humane outlook in the relatives of old people? Can we bring back in them a Sense of moral responsibility which seems to have been driven out by the welfare state? Can
Housing for the Aged By L. J. T U C K E R , A.R.I.B.A.,
Borough ArchiteCt and Housing Manager, County Borough of Doncaster they have a general dislike of other people's radios and children. In H o l l a n d the problem has been tackled by siting old persons' dwellings in the form of a square leading directly off a main road. I n considering the type of accommodation most suitable to old persons the speaker said that the prejudice against fiats is now diminishing but in multi-storeyed flats fitted with lifts it is best to house the old people as high as possibie in order to remove them from street noises and particularly the noise of playing children. In Cleveland, Ohio, a 14-storey, 156-unit, elevator apartment block for housing old people is sited among two-storey houses for families with small children. The block is designed to provide mainly for elderly couples and single old people but small numbers of families occupy accommodation on each f l o o r to provide a reasonable mixture of younger and older people. On the first floor there is a welfare and community centre for the old with dining and meeting room, lounge and games and crafts room. Some of the older residents are used as porters and lift-men, etc. In all types of dwelling the most popular type of accommodation a p p e a r s to be that with separate living room and bathroom. In addition there should be a kitchen, w.c., proper food storage, an indoor coal store a n d an easy method for disposal of refuse. A second bedroom is useful in case of illness and also allows for the occasional visitor. Unfortunately it adds considerably to the cost. Very careful consideration should be given to the fittings installed in accommodation of this nature. Floor coverings should not be polished, stairs should be shallow and without winders and it is essential that good stout handrails be. provided on both sides o f the stairs. Cupboards should be arranged at a convenient height so that shelves can be reached without having to stand on chairs. The cooker, either gas or electric, should be of the high-level oven type. The bath should be a low sided type with stay handles and the bottom of the bath should have a non-slip base. Efficient modern heating appliances should be installed and wherever possible the bedroom should be heated.
VERY effort is to be made to relieve the hardships E and difficulties of old people and at the same time to ease tile provision of normal housing allocation to younger families. Throughout the country there is a large number of old people living in houses in which their families have been reared. These families have now grown up and left and the houses are therefore larger than required by the old people. By providing smaller dwellings for the old people the larger houses are freed at reasonable rents for younger families in need. Difficulty is encountered in persuading old couples to move from the house, and often the district, where they have their roots. T h e solution therefore appears to be to offer small houses or bungalows near where they are already living. The problem is further complicated b y the fact that the amount of disability experienced by old people varies considerably. Some are capable of looking aftei" .themselves and doing their own housework and able to move around easily. A t the other extreme are the persons who need more or less f d l l care and attention. The first category is able to thrive quite satisfactorily among the community of younger people, and for these bungalows built among general housing developments meet the requirements admirably. A H o ~ e Plus Flat
There was a recent introduction in Doncaster of a 289 storey house, the ground floor of which forms a flat for an elderly couple,, the first floor and the roof space being designed as a normal house for a younger couple with a family. F o r the less active old persons a bungalow colony appears satisfactory ; a community spirit is gradually built up for people with similar limitations of activity and if accommodation fojr a distri.ct nurse is provided nearby this arrangement works quite satisfactorily. It has been found that generally old people prefer to be rehoused on main roads where they can see things taking place. Traffic noises do not seem to bother them but * From an address delivered to the Yorkshire Branch of the Society of Medical Officers of Health on July 27th, 1956, 72
The Medical Officer and Old People By JAMES R. PRESTON, B.SC., M.B., CH.B., D.P.H., F.R.F.P.S.,
Medical Officer of Health, and Area Medical Officer of Health, Sutton Coldfield, Chairman, West Midlands and Warwickshire Old People's Welfare COmmittees, Secretary, Sutton Coldfield Old People's Welfare Committee. ' O R K amongst old people, particularly in the voluntary sphere has been one of my greatest interests for the past seven or eight years. There are few other fields of endeavour from which more satisfaction can be obtained, and from which a greater feeling of achievement results. Furthermore, the old people are grateful for any help and advice received--something unusual in the welfare state. I n the preamble to the report of the Ministry of Health for 1955 the Minister states that in his view the three main priorities in the Health Service to-day are: first, to bring existing hospitals to a satisfactory standard and to provide a s ' f a r as possible new accommodation as and where it is needed; second, to ensure that the mental health service xeceives a proper share of the new construction and resources available; and finally lo tackle the problem of making adequate provision for the care of old people. Accepting that there is much work to-be faced, what can an M.O.4~I. do, and what J~acilities, voluntary and otherwise, are there available to meet the needs of}old people? The first thing that strikes me, gs an M.O.H., in m y close connection with many voluntary old people's welfare committees is the relatively few numbers of medical officers of health who take an active interest in the work of these committees an'd, indeed, who are aware of the considerable effort which is expended in the interests of old people by these bodies. I admit that many medical officers do in some small way have contact with the local secretaxies or organisers, but this is not enough. The medical officer of health, or his medical representative, should be at the least a member of the local, or area, old people's welfare committee, and should play his part in some measure in guiding and leading these committees .in view of his local and specialised knowledge.
co-ordination of the services already available, both statutory and voluntary ; and accumulation of information about the normal process of age, i.e., social research. In this respect 1 would refer particularly to the co-ordination of both voluntary and statutory services. I know that many health visitors and many area nursing officers and senior health visitors are members of, and take an active part ifi the work of, voluntary welfare committees, but there are still some'who~ take no interest in this work. I know that many old people's welfare committees would welcome and indeed invite co-operation and membership by the health visiting staff. At the present time, with the staff shortage position in public health departments, it is not easy for health visitors to take on additional responsibility, but nevertheless in view of the importance Of this question I feel that the time is now proper for health visiting staffs of local health authorities to take greater interest in the work for old people generally, and to visit regularly those cases which deserve special attention. The health visitor will then be making a closer approach to the ideal of family visiting. I would also like to see all old people's welfare committees, local, county and regional, inviting representation from health departments where none now exists, so that this co-ordinated linking does take place.
W
Health Department's R f l e There is no doubt in my mind that to date there has been considerable co-operation between welfare departments and old people's welfare committees, and this is an extremely good thing'. However, in view of the fact that a very large proportion of the problems of old age are bound up with and stem from the state of health, or lack of it, it seems logical that health departments as such should take a more active place in this sphere. This particularly applies at the present time, when so many health departments and welfare depaxtments work to some degree independently. Where, however, these departments are under o n e roof, it is easy to unify their efforts and obtain maximum benefits and results. Apart from the health visiting service, the home nursing service and the home help service play a vital part-in the care of old people. Of these I think that by and large the home help supervisors and home help service maintain the closest union with the voluntary bodies, and some supervisors are co-opted to the voluntary organisations, b u t there is no doubt that in some areas there is not much contact, which is a great pity. The criticism also applies to the home nursing services except where the nursing officer or M.O.H. or his representative is in close contact with these voluntary bodies, Again, the work of the
Growing Demand for Services The Ministry's report states that the demand on the services of old people's welfare committee continues to grow. There has been an increase in the number of committees from 1,150 in 1950, to 1,280 in the year under review, 1955. Particularly stressed is the fact that although many effective voluntary visiting services to o l d people exist, these need strengthening and new ones are needed where none at present exist. Apart from the medical officer of health there is the r61e the health visitor has to play in the care of the elderly. This can be classified in.to four parts--the work concerned with the preparation for ageing; maintenance of health in those who have already crossed the threshold of hge; * Presidential address to the Midlands Branch of the Society of Medical Officers of Health, 70
The Medical Officer and Old People
January 1957
'certainly now have this issue fairly and squarely before us, with long waiting lists for admission to chronic sick hospitals. We also have the difficulties of care and attention required by old people in their homes. Medical officers of health have now to direct a considerable portion of their time and thought to these questions, not only in the local authority sphere, but generally.
public health inspectors would not appear on the face of it to have much connection with old people's welfare, but in the course of their duties they can obtain a wealth os information, and can pass this through the health department. The medical officer of health plays his part in guiding his Council in the needs of old people in t h e area, and he can by close contact with voluntary committees, who have considerable experience and knowledge of local needs, obtain in many instances much helpful advice. He can often pass on the feelings of those chiefly interested in this problem to the right quarters. If we accept that co-operation with; and active participation in, voluntary old people's welfare work is an essential for the medical officer of health, what can such an old people's welfare committee offer? The average well-run old people's welfare committee, being composed of representatives of all active welfare organisations and bodies in an area, has invariably organised a home visiting service, carried out by voluntary, visitors, and has in many cases a co-ordinated meals-on.-wheels service. In addition the committee provides entertainment and can invariably arrange holidays for old people at suitable resorts. Furthermore many committees have considerable financial resources, and a - m/~dical officer can often obtain supplementary equipment for old people, items which cannot be l~rovided by the local authority servicesl Some old people's welfare committees provide chiropody services, laundry service, night sitters, and special transport. The most important service provided is the home visiting service, which can supplement the health visiting services in certain ways and can be an excellent medium for bringi n g out the requirements and needs of old people in the area. A health department which is working closely with such an_ organisation can find the greatest benefit in so doing.
The facts and the problem of chronic sick and the aged are well known. Straightforward arithmetic shows us that there now are six people of working age for every person over working age, and in 25 years time there will be four persons of working age to each person over working age. With this prospect there is no doubt that a great task faces the health and welfare services, not to mention the national economy. What can we do to ease this problem? Cert~lin medical officers have by close liaison with the hospital management committees and regional hospital boards, co-ordinated the waiting lists, and all practitioners in their areas pass the request for admission of chronic sick through the health department. In this way a reasonable degree of priority of admission is settled, a n d the cases requiring the most care, and who need to be admitted urgently, obtain proper priority in reference. Owing to the scarcity of beds, however, the backwash falls on the home nursing and home help services. These at the moment are, in nearly every instance, working, or over-working, at full bore and I think the voluntary organisations carl give much help in keeping old people at home by supplementing these services.
Ancillary Services Some local authorities provide excellent ancillary services for old people--washing services for soiled linen, excellent meals-on-wheels services, and night sitters, which just turn the balance in favour of care and attention at h o m e - - b u t where no such services are provided statutorily, they are often provided voluntarily. I am not suggesting that this is so in unbounded measure--there is yet much improvement and expansion needed--but the voluntary organisations are indeed aware of the useful help and supplementation they can give, and are working to that end. It might be an advantage if more geriatricians could be appointed on a part time basis; in co-operation with the regional hospital board, to organise and co-ordinate the hospital and domiciliary services for old people. I feel that at the moment geriatricians are forced to a one-sided view and tend to think of old people in the main as units in hospital beds or in a hospital annexe. If they had a broader picture, with their co-operation many of the old people who find their way into chronic sick h o s p i t a l s would never get there, and other cases of a more suitable nature would be admitted.
Aged at Home " T h e needs of old people in their own homes, especially those living alone, continues to attract attention," commented the Ministry of Health's report. ',As indicated last year, a co-ordinated partnership o f statutory and voluntary domiciliary services is the key to ,providing the right service where it is needed, and at the right time, whether directed towards avoiding or. delaying admission to residential care by providing practical help or friendly service, or designed to ensure that those who live alone are not unknown to those who might help them. Co-operation between statutory a n 6 voluntary visiting services is all important for this purpose." When many of us were resident or newly qualified medical officers, we did not come across much in the way of problems of the aged, because they were invariably removed from our responsibility, and 20 years ago the problem of the aged in their homes only came to our notice occasionally. Have we developed, therefore, a more humane outlook to the problems of old people, or have we developed a conscience as to their fate and welfare? We
In spite of some pessimists, there are still available to medical officers of health many new fields of endeavour and that of old people's care and welfare is one of the brightest. 71
PUBLIC HEALTH
The Medical Officer and Old People
we turn our health education efforts towards provision for old age, the development of hobbies, labour-saving devices to assist elderly people in their homes? Can we provide suitable work which will retain their interest? Much is being d o n e - - m o r e can be done. Let us join with our voluntary organisations and work together for the benefit of the elderly. Let medical officers of health and health departments take their rightful place i n the care of the aged, not only in their local authority obligations, but in the wider sphere of the work of voluntary old people's welfare committees.
H o w m a n y proper surveys of local needs of old people. have been carried out? How many health departments h a v e registers of old people, and if not, how can the requirements o f this large group be d e t e r m i n e d - - a group which requires more care than almost any other? Where such comprehensive surveys have been carried out much valuable information has been obtained. Where else can we turn? Can we try to stimulate a moi'e humane outlook in the relatives of old people? Can we bring back in them a Sense of moral responsibility which seems to have been driven out by the welfare state? Can
Housing for the Aged By L. J. T U C K E R , A.R.I.B.A.,
Borough ArchiteCt and Housing Manager, County Borough of Doncaster they have a general dislike of other people's radios and children. In H o l l a n d the problem has been tackled by siting old persons' dwellings in the form of a square leading directly off a main road. I n considering the type of accommodation most suitable to old persons the speaker said that the prejudice against fiats is now diminishing but in multi-storeyed flats fitted with lifts it is best to house the old people as high as possibie in order to remove them from street noises and particularly the noise of playing children. In Cleveland, Ohio, a 14-storey, 156-unit, elevator apartment block for housing old people is sited among two-storey houses for families with small children. The block is designed to provide mainly for elderly couples and single old people but small numbers of families occupy accommodation on each f l o o r to provide a reasonable mixture of younger and older people. On the first floor there is a welfare and community centre for the old with dining and meeting room, lounge and games and crafts room. Some of the older residents are used as porters and lift-men, etc. In all types of dwelling the most popular type of accommodation a p p e a r s to be that with separate living room and bathroom. In addition there should be a kitchen, w.c., proper food storage, an indoor coal store a n d an easy method for disposal of refuse. A second bedroom is useful in case of illness and also allows for the occasional visitor. Unfortunately it adds considerably to the cost. Very careful consideration should be given to the fittings installed in accommodation of this nature. Floor coverings should not be polished, stairs should be shallow and without winders and it is essential that good stout handrails be. provided on both sides o f the stairs. Cupboards should be arranged at a convenient height so that shelves can be reached without having to stand on chairs. The cooker, either gas or electric, should be of the high-level oven type. The bath should be a low sided type with stay handles and the bottom of the bath should have a non-slip base. Efficient modern heating appliances should be installed and wherever possible the bedroom should be heated.
VERY effort is to be made to relieve the hardships E and difficulties of old people and at the same time to ease tile provision of normal housing allocation to younger families. Throughout the country there is a large number of old people living in houses in which their families have been reared. These families have now grown up and left and the houses are therefore larger than required by the old people. By providing smaller dwellings for the old people the larger houses are freed at reasonable rents for younger families in need. Difficulty is encountered in persuading old couples to move from the house, and often the district, where they have their roots. T h e solution therefore appears to be to offer small houses or bungalows near where they are already living. The problem is further complicated b y the fact that the amount of disability experienced by old people varies considerably. Some are capable of looking aftei" .themselves and doing their own housework and able to move around easily. A t the other extreme are the persons who need more or less f d l l care and attention. The first category is able to thrive quite satisfactorily among the community of younger people, and for these bungalows built among general housing developments meet the requirements admirably. A H o ~ e Plus Flat
There was a recent introduction in Doncaster of a 289 storey house, the ground floor of which forms a flat for an elderly couple,, the first floor and the roof space being designed as a normal house for a younger couple with a family. F o r the less active old persons a bungalow colony appears satisfactory ; a community spirit is gradually built up for people with similar limitations of activity and if accommodation fojr a distri.ct nurse is provided nearby this arrangement works quite satisfactorily. It has been found that generally old people prefer to be rehoused on main roads where they can see things taking place. Traffic noises do not seem to bother them but * From an address delivered to the Yorkshire Branch of the Society of Medical Officers of Health on July 27th, 1956, 72