- Email: [email protected]
The responsibility of the local authority for the blind
1934.
PUBLIC HEALTH.
123
T h e R e s p o n s i b i l i t y of t h e L o c a l A u t h o r i t y for the Blind. By E.
MACDONALD,M.D• (LOND.), D.P.H•, Medical Officer of Health and School Medical
K.
Officer, County Borough of Stockport.
Few officers have given greater or more sympathetic attention to the matter with which this paper deals than Dr. Macdonald, and the many useful hints and suggestions which he offers are certain to be not only of interest but of real value to others who are called upon to carry out works connected with the welfare of the blind• Dr. Macdonald's paper was read at an ordinary meeting of the Society held in London on November 24th, 1933. HEN, over a year ago, I chose as my subject for this paper that of " The Responsibility of the Local Authority for the Blind," I did so because I had had the rather unusual experience, when I was in Barnsley, of being actually in charge of the blind welfare department of my corporation, which catered for the local blind from every point of view, as the voluntary committee had ceased to exist; but now, even more than then, I feel that the subject is one to lay before you, because of its very real importance to all local government administrators, and especially to the medical officer of health. Before approaching the matter in detail, I would like to try to give a clear understanding of what the problem of the blind is in our country, and to that end I have prepared certain figures (for 1932) taken from the Tenth Annual Report x of the Advisory Committee on the Welfare of the Blind. I also give the
W
TABLE I. TOTAL
1919 1923 1929 1932 1933
NUMBER
.... .... .... .... ....
OF B L I N D
I N E N G L A N D AND W A L E S ,
Males.
Females.
Total•
13.854 18,907 26,515 30,600 --
11,986 17,611 26,212 31,479
25,840 36,518 52,727 62,079 63,408
TABLE DISTRIBUTION
1919-.. 1923 .. 1929 .. 1932 .. 1933 ..
°° V
I
°. ,°
o• • °
OF B L I N D
figures for 1933, which I have just obtained. For purposes of comparison I have included the figures for 1919, 1923 and 1929. Table/.--Reference to Table I will show the numbers of known blind persons in the country on the 31st of March in the year mentioned. The latest figures (for 1933) show a total for the country of 63,408 blind persons, equivalent to the entire population of a town the size of Doncaster or Exeter, and there is no doubt that this figure is still too small. The increase from 25,000 in 1919 to 63,400 in 1933 does not, of course, indicate a great increase in blindness, but merely shows that the benefits now available to the blind have more than doubled the applications for help. Hence the apparent increase in blindness. An obvious deduction to be drawn from this great increase is that much care in registration and certification of the blind is necessary, in order that these benefits shall reach the persons needing them. I shall touch on this point later. Table H suggests that the work of the local authorities in the prevention of blindness among infants and school children is at last bearing fruit• In four years the total of blind children under 16 years of age has dropped by over 400, about one-sixth of the total number• Ninetyfour per cent. of the increase between 1929 and 1932 is among persons over 50 years of age. Table I I I is of general interest, but of no importance to us here. II.
I N E N G L A N D AND W A L E S A C C O R D I N G TO
0-5
5-16
219 231 258 225 244
2,098 2,723 2,438 2,066 2,089
16-50 12,522 15,524 16,496 16,568
AGE
PERIODS.
50+
Unknown.
Total.
23,523 20,423 34,453 43,227 44,343
619 54 65 164
25,840 36,518 52,727 62,079 63,408
PUBLIC HEALTH.
124 ThBLE I I I . NUMBER OF BLIND PERSONS OVER 50 OF PENSION
UNDER BLIND
agencies for which grant would be available. Grants for unemployed or necessitous blind were not included, as there was no statutory power to do so. I will explain later how this relief may be given• The circular attached to the regulations laid down, inter alia, an important point, which tocM authorities should bear in mind,- to the effect that wherever practicable, employment in a workshop is preferable to provision of assistance to workers in their own h o u s e s . It also suggested an outline for a scheme of home workers, and stated that there should be allowed one home teacher to 50 blind persons in an urban area, and one t o 30"{n a rural area. O n
IN RECEIPT
PERSONS ACT,
1920,
SECTION I,
1923 1929 1932 1933
.... .... .... ..
9,921 17,516 21,057 21,670
..
JANUARY;.
Table IV, however, shows that in 1932, for the first time, the age-period 0 to 1 year was not the worst period for the commencement of blindness ; that has now shifted to the 60 to 70 age-group, the 50 to 60 age-group being second, and the 0 to 1 group third. This position has
TABLE I V . AGE INCIDENCE OF BLINDNESS.
Year. 1919 .. 1923 .. 1929 .. 1932 .. 1933 ..
0-1
1-I0
10-20
20=30
21 "4 20 "5 16"5 14"7 14"4
10"8 10.9 8.4 7.2 7.0
9.4 8.2 6,9 6.1 6.1
9-7 8"9 8"2 7"4 7"3
been maintained in 1933. Having now demonstrated, I think, the importance of the problem, I will pass on to a description of the ways in which it is being tackled. First, I will discuss as briefly as possible the legal powers of a local authority, which enable the blind to be assisted. Legal Powers of Local Authority.--The interest of the local authority in the blind is of comparatively recent date, although as long ago as 1893, education of blind children was provided for. The first real connection between the local authority and the blind came with the passing of the Grant regulations of 1919, 2 which necessitated consultation between the Ministry of Health and the local authority before any voluntary agency was recognised by the former for the purposes of grant. This very fact made the local authority take an interest in the blind. These Grant regulations were superseded by the Local Government Act, 1929, but they are, nevertheless, of considerable moment to us, because they contain suggestions for schemes, and definitions Which are still of value. Reference to circular 1086, published in March, 1930, will confirm this point. The Grant regtilations, together with the accompanying circular, 7/BD, of August 7th, 1919, dealt with those services of voluntary
30-40 9"7"
9'2 8"8 8"2 8"3
40-50
50-60
60-70
70~-
11-0 10.6 11.2 11.2 11.5
9-5 12.6 14.9 16.0 16.3
9.6 12.0 15.9 18.0 17.9
6-4 7,0 9.2 11-2 11.2
this last point, of course, the number of home teachers must vary according to the type of work, but now, 14 years later, only one authority (Barnsley) has an allowance of anything like the standard suggested, and this authority has one home teacher to 56 blind persons ; all the others one to more than 56, t h e average being one to 157. The definition of blindness still in use by the Ministry was laid down in these regulations-a blind person is one who is too blind to perform work for which eyesight is essential. The regulations further mentioned the amount of grant payable to an approved agency, and as the amounts have much influenced the work of the local authorities, I give them here :-£20 per annum per approved workshop employee. £20 per annum per approved home worker. £13 per annum per approved " home " inmate. £5 per annum per approved " hostel "inmate• Grant of 50 per cent. towards expenses of tools, etc., and various grants towards books and publications, and to certain associations. The regulations also laid down..important rules for the keeping of registers, for the control and management of workshops, ?imptdyees, etc.
1934.
PUBLIC HEALTH.
So much for the Grant regulations of 1919. In 1920, the Blind Persons Act, the magna charta of the blind, was passed, and immediately the local authority was brought into intimate relationship with the service. Section 1 of the Act granted the old age pension to blind persons at the age of 50, instead of 70, as it is for the ordinary population. This section does not concern us, except for certain points with regard to the alleviation of the needs of old necessitous blind, to which I wilt refer later. Section 2 is the most important from our point of view. Sub-section (1) lays upon every local authority the duty of making arrangements for promoting the welfare of the blind, and permits the council to provide or maintain workshops, hostels and homes for the blind. The arrangements must be approved by the Minister, and a scheme laid before him outlining the proposal of the local authority. Sub-sections (2) and (3) of section 2 are financial. Sub-section (4) discusses the appointment of an ad hoc committee of the council to carry out the work for the blind. This committee may have co-opted members, but two-thirds of its members must be members of the council, it need not be an ad hoc committee, but there is no doubt that such a committee is preferable. (The last remark is mine.) Section 3 of the Act makes the War Charities Act, 1916, apply to a~encies for the blind, and puts the duty of registration of such agencies on the local authority. The next important piece of legislation for the blind is the Education Act, 1921, which embodies all the previous Acts in this connection. Sections 51 and 52, respectively, place: the duty of education of a blind child on the parents and on the local education authority , and define their different responsibilities. It should be noted that it is not a reasonable excuse tbr a parent to say that there is no school accommodation within a certain distance, as in the case of ordinary children. Section 61 extends the period of compulsory education to 16 year~ in the case of a blind child, and by section 62 the local education authority is empowered to provide schools. The parents may be held liable to contribute towards the expense of educating a blind child (section 65), and section 69 defines a blind c h i l d as one who is too blind to be able to read the
12,~
ordinary school-books used by children, obviously a much wider definition than that under the Blind Persons Act, 1920, and one that is the cause of some confusion at times. Blind persons older than 16 years can also be educated by the local education authority under their higher educat{on schemes, the Board of Education usually paying 50 per cent. grant towards the cost of approved expenditure, as for elementary education. Local Government Act, 1929.--The next legal enactment of any importance in regard to the blind is the Local Government Act, 1929. The effect of this measure on work for the blind was very far-reaching, and really twofold in its action : - (I) The grants usually paid direct by the Ministry to voluntary agencies are now paid through the local authority. The Ministry has to formulate a scheme under section t02 (I) of the Act for the payment of these grants, and such a scheme a has recently been passed for the next grant period. The scheme has to be prepared by the Minister on submission to him of the local authority's proposals, after the local authority has consulted with the voluntary agency. The scheme takes into consideration (a) the grant paid direct to the voluntary agency by the Ministry prior to the passing of the Local Government Act; (b) the contribution of the local authority to the voluntary agency (50 per cent. of approved expenditure was attowcd by the Ministry), and (c) anv new proposals bv the voluntary agency. This sum of money has now to be paid by the local authority to the voluntary agency and, as a result, the duty of supervision of the voluntary a~ency now devolves entirely on the l('xal authority, instead of on the Ministry of Ilcalth as formerly. Itl circular I()8@, already rot'craved to, the Ministry of tlealth advises the local authority in detail as to how best to carry out this work of supervision. Besides these block grants, the local authority is allowed to make grants to the vohmtary agency, although the method adopted varies. Some make a capitation grant for workshop employees and home workers ; a 50 per cent. grant towards the salary of the i~,,me teach,.'ra ; a capitation grant for each registered blind person, and grants towards approved cxp~l~d~ture. In addition augmentation grants may be paid. The exchequer grant paid by way of Mock grants included, as is known, a sum of
126
PUBLIC HEALTH.
£5,000,000, new money for progress and development of health services, including those for the blind. (II) The Local Government Act also permits any local authority (sections 4 and 5) to make a scheme declaring all assistance to the blind to be carried out under the Blind Persons Act, and not under the poor taw. The spirit of the Local Government Act was the break-up of the poor law, and although (his section 5 is permissive, in my opinion every local authority should make the necessary declaration. The following is an example of such a declaration :-" It is hereby declared that all assistance to necessit~ ous persons, for which provision is made in the services set out in this clause, shall be provided exclusively by virtue of the Act or Acts under the heading of which the service is set out, and not by way of poor relief : (After giving examples of various services, ie mentions) " Blind Persons Act, 1920. " The provision of domiciliary assistance to Blind Persons. ''4 It should be noted that the declaration can usually only be made in respect of domiciliary assistance, but under section 2 of the Blind Persons Act, 1920, local authorities may also provide homes or other places for the reception of the blind. Referring to the question of supervision, probably the best way for a local authority to carry out this duty 5 is to appoint someone definitely experienced in such supervision, and such a person is not usually found on the existing town hall staff. This duty has been delegated by the majority of local authorities in the northern area to a special supervisor in the employment of the Northern Counties Association. I have had experience of this gentleman's work, and I think a similar arrangement could with advantage be entered into by any local authority with its particular counties association. The local authority, under the scheme made by the Minister under section 102(1) of the Local Government Act, already has to contribute to the funds of the counties association; for a small affiliation fee the local authority may enjoy these further benefits, i . e . , of supervision of the local agency, and expert advice, in the approval of employees, for example. Such are the legal powers under which the local authority acts. I will now discuss the actual work that the local fiuthority does or can do for the blind. First, registration and certification of the blind. An absolute fundamental for a satis-
JANUARY,
factory scheme is that there should be accurate registration and certification of the blind in the area. Circular t086 states : " Efficient registration is essential to the success of any scheme for the welfare of the blind." Registers must be kept, and the local authority must approve their form, and see they are kept up to date. For some considerable time it has been realised that no person should be entered in the blind register unless he or she has Lcen medically examined by a recognised ophthalmic surgeon. Recently a circular of the Ministry of Health (circular No. 1353) has laid down this recommendation definitely. This circular is based on a Report of the Prevention of Blindness Committee of the Union of Counties Association for the Blind, 6 to which I would refer you, and marks a most important step forward in the administration of the blind services of the country. The Ministry requests all local authorities to use form B.D.8 (Examination for Admission to Register of Blind Persons), which was included with circular t 3 5 3 . You will be aware, of course, that no exact standard of visual acuity, such as, for example, less than sixsixtieths, is laid down, beyond which a person may be considered blind, but circular 1 3 5 3 gives the Ministry's opinion on this point. What constitutes an ophthalmic surgeon is also laid down in this circular. The Board of Education, in circular 1431, have also adopted the use of this form of certification for the school medical service. Coupled with the need for accurate certification of the blind is the need for further knowledge on the prevention of blindness, and there is no doubt that the extended use of the new form will produce most valuable information on this point. Those who have not read the recent report on " Hereditary Blindness " w h i c h was reviewed in PUBLIC HEALTH in August last (p. 353), are recommended to do so. As regards the question of certification and registration of blind children, the Education Act definition is wider than that of the Blind Persons Act. The former reads : " Too blind to read the ordinary school-books." It has been suggested that only those children who have been taught Braille should be registered ,under the Blind Persons Actd Great care should be exercised in training children under the Education Act definition, otherwise it may be found, when they become
1934.
PUBLIC HEALTH.
16 years of age, that they are not registrable under the Blind Persons Act, and are no longer trainable. Progress reports should be available to the local education authority, and a special report at least six months before the training ceases, and there should be close co-operation between the training authority (the local education authority) and the Blind Persons Act committee. I have known cases in which a child has been trained as blind, and then, when aged 16, has not been considered blind: the training has therefore largely been wasted. This suggests, of course, that there has not been proper co-operation between the two bodies concerned. I recognise, however, that it is extremely difficult at times to be positive as to the extent of a child's blindness. This matter is fully dealt with in circular 681 of March 29th, 1926, issued by the Ministry of tiealth. The question of accurate certification of all blind persons is obviously important when it is realised that, for the area of the Northern Counties Association, the expenditure by the local authorities alone is approximately £500,000 a year, and is steadily increasing. This is quoted from a paper by Dr. Joseph, Medical Officer of Health of Warrington. 8 It is interesting to note that in Glasgow an ophthalmic clinic has been commenced for the purpose of certification. Other authorities use the school oculists for this service. A fee of £1 ls. 0d. is recognised as adequate by the British Medical Association for the certificate, and I am of opinion that this fee should be paid by tile local authority, not by the voluntary agency. It is very distinctly in the interests of the local authority that certification should be accurate. Now let us pass oll to a consideration of what tile local authority can do for the different classes of blind person. (I) The children under five years of age. There were 225 such cases in 1932, 9 and usually very little requires to be, or can be, done for them. Should it be necessary, the local authority may send them away to special homes, and the National Institute for the Blind provides sunshine homes for their acceptance. There are three sunshine homes in the country, and the cost to the local authority for maintenance is £38 5s. 0d. per annum (for parents somewhat less). These children should, of course, be registered under the Blind Persons Act, 1920, but can usually be cared for in their homes, and supervised by the maternity and
127
child welfare health visitors, acting in conjunction with the Blind Persons Act Committee. (II) The children of school age, 5 to 16 years. The total for this group in the country in 1932 was 2,066. 9 I have already mentioned the powers given to the local education authority in the Education Act, 1921. There are about 30 to 40 schools (referred to in the National Institute for the Blind year book) for blind children in the country, and in the case of those owned by the National Institute for the Blind, the cost to the local education authority is £60 per annum. The National Institute for the Blind also has a special school of 30 places in Devonshire for mentally retarded, though not certifiable, blind children. The fees here would cost the local authority £81 10s. 0d. per annum. But there is a large class of partially blind children to which I must refer. Bishop Itarman 1° estimates that there is one myope to every 500 ordinary school children. Myope classes, or as they are better caTled, sight-saving classes, are of paramount importance, and every local education authority should make such provision. Myopes should not be registered under the Blind Persons Act. (III) Next we pass to the large class of blind persons over 16 years of age. Some of these are training, some trainable but not trained, some employed, some unemployable, and so on. (a) In 1932 there were 1,6191.1 blind persons in training, and a further 643 trainable, but not yet trained. The local authority should take a vital interest in training all possible persons. This is an economic desirability. The cost of training wilt be saved in public assistance, it is, however, very important to select suitable training for blind persons in view of their capability, and also of their prospect of employment. There should be a very close liaison between the training authority and the workshop. Circular 387 of the Ministry of Health states :--" The sole purpose of training a blind person is to make him as independent as his blindness and his capacity permit." It is of interest to note 12 that the number of trainees is diminishing, due no doubt to the decreasing number of entrants. There is no age-limit to those who may be trained, but it is usually not feasible to try and train blind persons who are over 50 years of age. There are 43 training schools in England and Wales approved by the Board of Education, to which trainees may be sent (a list is given in the National Institute for the Blind year book).
PUBLIC HEALTH. The local authority should also submit the names of candidates for special correspondence courses run by the College of Teachers of the Blind, 224, Great Portland Street, London, W.1.13 (b) When the trainee is passed out from his training school, it is desirable that he should be absorbed in the local workshop. A very second-best scheme is to find him work at home as a home worker. In 1932, there were 9,12411 persons in employment, and a further 374 trained but not employed. The local authority can usually help this class by augmentation of wages. Various schemes of augmentation are in practice, but probably the best makes use of a sliding scale in the case of the workshop employee. The Ministry has discussed this scale in detail in memo. 64/BD. In the case of the home worker a flat rate augmentation is recommended. In Barnsley a flat rate of augmentation of £1 a week was paid to each employee, whether in the workshop or at home. It should be noted that the local authority must recognise every employee before grant is paid, and further, in the case of home workers, must recognise the occupation as being a suitable one. This recognition should be on as wide a basis as possible, and should include employees in ordinary factories or workshops. In circular 1086 of March 21st, 1930, the Ministry discusses this question of recognition, and desires the following conditions to be fulfilled (1) The occupation should not be a mere pastime, but should be definitely on the plane of industrial effort, in order that the home worker may be in a position to maintain himself out of his earnings, assisted by augmentation, as in the case of an employee in a workshop. (2) The occupation should be such as to enable the association which supervises the scheme to render tangible and continuous services to the home worker. It must be remembered that as a blind person cannot, as a rule, earn enough to support himself, his wage must be augmented. A good standard of work should be insisted on, as the public have a right to expect a reasonably good quality of goods to be available for purchase. There is no necessity to sell the goods made by blind persons as a form of charity. We always used to say that the goods sold in our blind shop were so good they sold themselves. The local authority can assist considerably by purchasing goods from the blind themselves, for example, firewood, baskets
j AN UAR",,
of different types, brooms for the cleansing department, socks for the public assistance committee. A point to remember is that workshop employees are insurable under the Unemployment Insurance and National Health Insurance Acts. Home workers are not usually so insurable. Another duty of the local authority is to supervise the general conditions of the workshop, and the Advisory Committee comment favourably on the good effect the connection of the local authority has had in this matter. The local authority has also power under the juvenile employment bureau to place blind persons in work. (c) By far the largest class of blind person is that of the unemployable and often necessitous blind. There were 48,02814 such in 1932, and of these, 21,057 were in receipt of the blind pension under section 1 of t h e Blind Persons Act. This pension is 10s. a week. Unless a declaration has been made under Part I of the Local Government Act, it must be realised that there is nothing in the Blind Persons Act that relieves the public assistance committee of the duty of assistance. But, as I stated earlier, it is highly desirable that such a declaration should be made, and in any case most local authorities have made a scheme for augmentation of the income of necessitous and/or unemployable blind persons. Various forms of augmentation exist, but the two with which I have had connection allow for making up of the income of the blind persons to a specified amount. In one instance, if the blind person was a householder, the income was made up to 25s. a w e e k ; if not, up to 20s. No period of qualifying residence is permissible Is before augmentation is granted. Where a scheme for augmenting the income of necessitous blind persons is in operation, if a person genuinely moves into the area of the local authority, augmentation must commence at once on application--after registration and certification, if necessary, of course. A difficulty sometimes arises when the blind person is eligible for the old age pension at 50, and also for a contributory pension at 65, for the latter ceases at 70 years, and unless additional augmentation is given, hardship may result. Another service the local authority may render this class is to provide aged and lonely blind persons with a home, on the cottage homes principle. Finally, a few remarks on the administration
1934.
PUBLIC HEALTH.
of the service. The interest of the local authority in the blind has nowadays become so great that I am definitely of opinion that this service should be administered as a branch of the local authority's services, and not chiefly by a voluntary committee. I do not, of course, wish to divorce voluntary effort entirely from the care of the blind, for I realise the enormous amount of devoted service that has been given in this connection, but I believe that from the point of view of the great expenditure involved alone, the local authority should have a greater say in the spending of that money, and in the administration of the service, than it usually has. T h e training of blind persons, whether of school age or older ; the running of the workshop, and the care of the workshop employee ; the supervision of the home worker; the disposal of the goods produced by the blind, and the augmentation of income, whether earned by employees or paid to necessitous blind, are all duties which, in my opinion, the local authority can administer better than any voluntary body. I consider, however, that there should be a voluntary committee, with a close connection with the statutory committee of the council, whose duties it will be to raise funds for providing the blind with outings, concerts, and other matters which are not properly within the purview of the local authority. It is, in fact, necessary' that such a committee should exist, as the National Institute for the Blind, which usually undertakes the collection of funds in a district, apparently is not able to enter into an arrangement with a committee of the local authority. As regards which department of the local authority should administer the service, I believe that it should be in the control of either the education or the health department. Both these departments are so intimately bound up with the welfare of the blind that if they have not some definite and intimate liaison with its administration, an inefficient service is sure to result. T h e medical officer of health should interest himself keenly in this matter, because, although it is not the subject matter of this paper proper, any consideration of the care of the blind must bring out that of t h e prevention of blindness, and prevention, of course, is entirely a matter for the health department. For those who wish to make a fuller study of the subject, I have inserted references to the various circulars of the Ministry of Health, as
129
well as to the Acts of Parliament, but probably the most fruitful source of information will be found in the reports of the Advisory Committee for the Welfare of the Blind appointed by the Minister of Health. T e n such reports have been presented--the last early in i933. I have not touched on the question of prevention of blindness, nor have I done more than mention the work of the voluntary agencies. Such were not the subject of this paper. T h e problem of the blind is no small part of the problem of local government, and the enormous alleviation in that distress which was, unfortunately, so common in our country before the passage of the Grant regulations of 1919 and the Blind Persons Act, 1920, bears eloquent witness to the work that is being done on behalf of the blind by the voluntary bodies and the local authorities. T h e pathos of blindness comes home to us all at times, and I trust that this contribution may stimulate a greater interest in the subject, and lead to more work being done for these unfortunate citizens of our land. BIBLIOGRAPHY.
Where reference is made to the Annual Reports of the Advisory Committee on the Welfare of the Blind to the Minister of Health, this is shown thus : Tenth Annual Relbort of Advisory Committee. 1 Tenth Annual Report of Advisory Committee. Pages 26, 27, 4 and 10. 2 Circular 7 BD. Regulations and Rules of August 7th, 1919. Circular 1306 of Ministry of Health, March 17th, 1933, and Welfare of the Blind (Contributions) Scheme, 1933. Declaration by County Borough of Barnsley under Local Government Act, 1929. 5 Tenth Annual Report of Advisory Committee. Page 6. " Report by the Prevention of Blindness Committee of the Union of Counties Associations for the Blind, 1931. Special Report of Advisory Committee, 1932. 8 G. W. N. Joseph, M.D., D.P.H., Medical Officer of Health, Warrington. Medical Officer, October 29th, 1932. 9 Tenth Annual Report of Advisory Committee. Page 27. I°N. Bishop Harman, F.t~.e.s. British Medical Jour~zal, January 28th, 1933. l~Tenth Annual Report of Advisory Committee. Page 29. ~2Tenth Annual Report of Advisory Committee. Page 11. ~aEighth Annual Report of Advisory Committee. Page 19. ~4Tenth Annual Report of Advisory Committee. Page 10. 15Ninth Annual Report of Advisory Committee. Page 18.
PUBLIC HEALTH.
123
T h e R e s p o n s i b i l i t y of t h e L o c a l A u t h o r i t y for the Blind. By E.
MACDONALD,M.D• (LOND.), D.P.H•, Medical Officer of Health and School Medical
K.
Officer, County Borough of Stockport.
Few officers have given greater or more sympathetic attention to the matter with which this paper deals than Dr. Macdonald, and the many useful hints and suggestions which he offers are certain to be not only of interest but of real value to others who are called upon to carry out works connected with the welfare of the blind• Dr. Macdonald's paper was read at an ordinary meeting of the Society held in London on November 24th, 1933. HEN, over a year ago, I chose as my subject for this paper that of " The Responsibility of the Local Authority for the Blind," I did so because I had had the rather unusual experience, when I was in Barnsley, of being actually in charge of the blind welfare department of my corporation, which catered for the local blind from every point of view, as the voluntary committee had ceased to exist; but now, even more than then, I feel that the subject is one to lay before you, because of its very real importance to all local government administrators, and especially to the medical officer of health. Before approaching the matter in detail, I would like to try to give a clear understanding of what the problem of the blind is in our country, and to that end I have prepared certain figures (for 1932) taken from the Tenth Annual Report x of the Advisory Committee on the Welfare of the Blind. I also give the
W
TABLE I. TOTAL
1919 1923 1929 1932 1933
NUMBER
.... .... .... .... ....
OF B L I N D
I N E N G L A N D AND W A L E S ,
Males.
Females.
Total•
13.854 18,907 26,515 30,600 --
11,986 17,611 26,212 31,479
25,840 36,518 52,727 62,079 63,408
TABLE DISTRIBUTION
1919-.. 1923 .. 1929 .. 1932 .. 1933 ..
°° V
I
°. ,°
o• • °
OF B L I N D
figures for 1933, which I have just obtained. For purposes of comparison I have included the figures for 1919, 1923 and 1929. Table/.--Reference to Table I will show the numbers of known blind persons in the country on the 31st of March in the year mentioned. The latest figures (for 1933) show a total for the country of 63,408 blind persons, equivalent to the entire population of a town the size of Doncaster or Exeter, and there is no doubt that this figure is still too small. The increase from 25,000 in 1919 to 63,400 in 1933 does not, of course, indicate a great increase in blindness, but merely shows that the benefits now available to the blind have more than doubled the applications for help. Hence the apparent increase in blindness. An obvious deduction to be drawn from this great increase is that much care in registration and certification of the blind is necessary, in order that these benefits shall reach the persons needing them. I shall touch on this point later. Table H suggests that the work of the local authorities in the prevention of blindness among infants and school children is at last bearing fruit• In four years the total of blind children under 16 years of age has dropped by over 400, about one-sixth of the total number• Ninetyfour per cent. of the increase between 1929 and 1932 is among persons over 50 years of age. Table I I I is of general interest, but of no importance to us here. II.
I N E N G L A N D AND W A L E S A C C O R D I N G TO
0-5
5-16
219 231 258 225 244
2,098 2,723 2,438 2,066 2,089
16-50 12,522 15,524 16,496 16,568
AGE
PERIODS.
50+
Unknown.
Total.
23,523 20,423 34,453 43,227 44,343
619 54 65 164
25,840 36,518 52,727 62,079 63,408
PUBLIC HEALTH.
124 ThBLE I I I . NUMBER OF BLIND PERSONS OVER 50 OF PENSION
UNDER BLIND
agencies for which grant would be available. Grants for unemployed or necessitous blind were not included, as there was no statutory power to do so. I will explain later how this relief may be given• The circular attached to the regulations laid down, inter alia, an important point, which tocM authorities should bear in mind,- to the effect that wherever practicable, employment in a workshop is preferable to provision of assistance to workers in their own h o u s e s . It also suggested an outline for a scheme of home workers, and stated that there should be allowed one home teacher to 50 blind persons in an urban area, and one t o 30"{n a rural area. O n
IN RECEIPT
PERSONS ACT,
1920,
SECTION I,
1923 1929 1932 1933
.... .... .... ..
9,921 17,516 21,057 21,670
..
JANUARY;.
Table IV, however, shows that in 1932, for the first time, the age-period 0 to 1 year was not the worst period for the commencement of blindness ; that has now shifted to the 60 to 70 age-group, the 50 to 60 age-group being second, and the 0 to 1 group third. This position has
TABLE I V . AGE INCIDENCE OF BLINDNESS.
Year. 1919 .. 1923 .. 1929 .. 1932 .. 1933 ..
0-1
1-I0
10-20
20=30
21 "4 20 "5 16"5 14"7 14"4
10"8 10.9 8.4 7.2 7.0
9.4 8.2 6,9 6.1 6.1
9-7 8"9 8"2 7"4 7"3
been maintained in 1933. Having now demonstrated, I think, the importance of the problem, I will pass on to a description of the ways in which it is being tackled. First, I will discuss as briefly as possible the legal powers of a local authority, which enable the blind to be assisted. Legal Powers of Local Authority.--The interest of the local authority in the blind is of comparatively recent date, although as long ago as 1893, education of blind children was provided for. The first real connection between the local authority and the blind came with the passing of the Grant regulations of 1919, 2 which necessitated consultation between the Ministry of Health and the local authority before any voluntary agency was recognised by the former for the purposes of grant. This very fact made the local authority take an interest in the blind. These Grant regulations were superseded by the Local Government Act, 1929, but they are, nevertheless, of considerable moment to us, because they contain suggestions for schemes, and definitions Which are still of value. Reference to circular 1086, published in March, 1930, will confirm this point. The Grant regtilations, together with the accompanying circular, 7/BD, of August 7th, 1919, dealt with those services of voluntary
30-40 9"7"
9'2 8"8 8"2 8"3
40-50
50-60
60-70
70~-
11-0 10.6 11.2 11.2 11.5
9-5 12.6 14.9 16.0 16.3
9.6 12.0 15.9 18.0 17.9
6-4 7,0 9.2 11-2 11.2
this last point, of course, the number of home teachers must vary according to the type of work, but now, 14 years later, only one authority (Barnsley) has an allowance of anything like the standard suggested, and this authority has one home teacher to 56 blind persons ; all the others one to more than 56, t h e average being one to 157. The definition of blindness still in use by the Ministry was laid down in these regulations-a blind person is one who is too blind to perform work for which eyesight is essential. The regulations further mentioned the amount of grant payable to an approved agency, and as the amounts have much influenced the work of the local authorities, I give them here :-£20 per annum per approved workshop employee. £20 per annum per approved home worker. £13 per annum per approved " home " inmate. £5 per annum per approved " hostel "inmate• Grant of 50 per cent. towards expenses of tools, etc., and various grants towards books and publications, and to certain associations. The regulations also laid down..important rules for the keeping of registers, for the control and management of workshops, ?imptdyees, etc.
1934.
PUBLIC HEALTH.
So much for the Grant regulations of 1919. In 1920, the Blind Persons Act, the magna charta of the blind, was passed, and immediately the local authority was brought into intimate relationship with the service. Section 1 of the Act granted the old age pension to blind persons at the age of 50, instead of 70, as it is for the ordinary population. This section does not concern us, except for certain points with regard to the alleviation of the needs of old necessitous blind, to which I wilt refer later. Section 2 is the most important from our point of view. Sub-section (1) lays upon every local authority the duty of making arrangements for promoting the welfare of the blind, and permits the council to provide or maintain workshops, hostels and homes for the blind. The arrangements must be approved by the Minister, and a scheme laid before him outlining the proposal of the local authority. Sub-sections (2) and (3) of section 2 are financial. Sub-section (4) discusses the appointment of an ad hoc committee of the council to carry out the work for the blind. This committee may have co-opted members, but two-thirds of its members must be members of the council, it need not be an ad hoc committee, but there is no doubt that such a committee is preferable. (The last remark is mine.) Section 3 of the Act makes the War Charities Act, 1916, apply to a~encies for the blind, and puts the duty of registration of such agencies on the local authority. The next important piece of legislation for the blind is the Education Act, 1921, which embodies all the previous Acts in this connection. Sections 51 and 52, respectively, place: the duty of education of a blind child on the parents and on the local education authority , and define their different responsibilities. It should be noted that it is not a reasonable excuse tbr a parent to say that there is no school accommodation within a certain distance, as in the case of ordinary children. Section 61 extends the period of compulsory education to 16 year~ in the case of a blind child, and by section 62 the local education authority is empowered to provide schools. The parents may be held liable to contribute towards the expense of educating a blind child (section 65), and section 69 defines a blind c h i l d as one who is too blind to be able to read the
12,~
ordinary school-books used by children, obviously a much wider definition than that under the Blind Persons Act, 1920, and one that is the cause of some confusion at times. Blind persons older than 16 years can also be educated by the local education authority under their higher educat{on schemes, the Board of Education usually paying 50 per cent. grant towards the cost of approved expenditure, as for elementary education. Local Government Act, 1929.--The next legal enactment of any importance in regard to the blind is the Local Government Act, 1929. The effect of this measure on work for the blind was very far-reaching, and really twofold in its action : - (I) The grants usually paid direct by the Ministry to voluntary agencies are now paid through the local authority. The Ministry has to formulate a scheme under section t02 (I) of the Act for the payment of these grants, and such a scheme a has recently been passed for the next grant period. The scheme has to be prepared by the Minister on submission to him of the local authority's proposals, after the local authority has consulted with the voluntary agency. The scheme takes into consideration (a) the grant paid direct to the voluntary agency by the Ministry prior to the passing of the Local Government Act; (b) the contribution of the local authority to the voluntary agency (50 per cent. of approved expenditure was attowcd by the Ministry), and (c) anv new proposals bv the voluntary agency. This sum of money has now to be paid by the local authority to the voluntary agency and, as a result, the duty of supervision of the voluntary a~ency now devolves entirely on the l('xal authority, instead of on the Ministry of Ilcalth as formerly. Itl circular I()8@, already rot'craved to, the Ministry of tlealth advises the local authority in detail as to how best to carry out this work of supervision. Besides these block grants, the local authority is allowed to make grants to the vohmtary agency, although the method adopted varies. Some make a capitation grant for workshop employees and home workers ; a 50 per cent. grant towards the salary of the i~,,me teach,.'ra ; a capitation grant for each registered blind person, and grants towards approved cxp~l~d~ture. In addition augmentation grants may be paid. The exchequer grant paid by way of Mock grants included, as is known, a sum of
126
PUBLIC HEALTH.
£5,000,000, new money for progress and development of health services, including those for the blind. (II) The Local Government Act also permits any local authority (sections 4 and 5) to make a scheme declaring all assistance to the blind to be carried out under the Blind Persons Act, and not under the poor taw. The spirit of the Local Government Act was the break-up of the poor law, and although (his section 5 is permissive, in my opinion every local authority should make the necessary declaration. The following is an example of such a declaration :-" It is hereby declared that all assistance to necessit~ ous persons, for which provision is made in the services set out in this clause, shall be provided exclusively by virtue of the Act or Acts under the heading of which the service is set out, and not by way of poor relief : (After giving examples of various services, ie mentions) " Blind Persons Act, 1920. " The provision of domiciliary assistance to Blind Persons. ''4 It should be noted that the declaration can usually only be made in respect of domiciliary assistance, but under section 2 of the Blind Persons Act, 1920, local authorities may also provide homes or other places for the reception of the blind. Referring to the question of supervision, probably the best way for a local authority to carry out this duty 5 is to appoint someone definitely experienced in such supervision, and such a person is not usually found on the existing town hall staff. This duty has been delegated by the majority of local authorities in the northern area to a special supervisor in the employment of the Northern Counties Association. I have had experience of this gentleman's work, and I think a similar arrangement could with advantage be entered into by any local authority with its particular counties association. The local authority, under the scheme made by the Minister under section 102(1) of the Local Government Act, already has to contribute to the funds of the counties association; for a small affiliation fee the local authority may enjoy these further benefits, i . e . , of supervision of the local agency, and expert advice, in the approval of employees, for example. Such are the legal powers under which the local authority acts. I will now discuss the actual work that the local fiuthority does or can do for the blind. First, registration and certification of the blind. An absolute fundamental for a satis-
JANUARY,
factory scheme is that there should be accurate registration and certification of the blind in the area. Circular t086 states : " Efficient registration is essential to the success of any scheme for the welfare of the blind." Registers must be kept, and the local authority must approve their form, and see they are kept up to date. For some considerable time it has been realised that no person should be entered in the blind register unless he or she has Lcen medically examined by a recognised ophthalmic surgeon. Recently a circular of the Ministry of Health (circular No. 1353) has laid down this recommendation definitely. This circular is based on a Report of the Prevention of Blindness Committee of the Union of Counties Association for the Blind, 6 to which I would refer you, and marks a most important step forward in the administration of the blind services of the country. The Ministry requests all local authorities to use form B.D.8 (Examination for Admission to Register of Blind Persons), which was included with circular t 3 5 3 . You will be aware, of course, that no exact standard of visual acuity, such as, for example, less than sixsixtieths, is laid down, beyond which a person may be considered blind, but circular 1 3 5 3 gives the Ministry's opinion on this point. What constitutes an ophthalmic surgeon is also laid down in this circular. The Board of Education, in circular 1431, have also adopted the use of this form of certification for the school medical service. Coupled with the need for accurate certification of the blind is the need for further knowledge on the prevention of blindness, and there is no doubt that the extended use of the new form will produce most valuable information on this point. Those who have not read the recent report on " Hereditary Blindness " w h i c h was reviewed in PUBLIC HEALTH in August last (p. 353), are recommended to do so. As regards the question of certification and registration of blind children, the Education Act definition is wider than that of the Blind Persons Act. The former reads : " Too blind to read the ordinary school-books." It has been suggested that only those children who have been taught Braille should be registered ,under the Blind Persons Actd Great care should be exercised in training children under the Education Act definition, otherwise it may be found, when they become
1934.
PUBLIC HEALTH.
16 years of age, that they are not registrable under the Blind Persons Act, and are no longer trainable. Progress reports should be available to the local education authority, and a special report at least six months before the training ceases, and there should be close co-operation between the training authority (the local education authority) and the Blind Persons Act committee. I have known cases in which a child has been trained as blind, and then, when aged 16, has not been considered blind: the training has therefore largely been wasted. This suggests, of course, that there has not been proper co-operation between the two bodies concerned. I recognise, however, that it is extremely difficult at times to be positive as to the extent of a child's blindness. This matter is fully dealt with in circular 681 of March 29th, 1926, issued by the Ministry of tiealth. The question of accurate certification of all blind persons is obviously important when it is realised that, for the area of the Northern Counties Association, the expenditure by the local authorities alone is approximately £500,000 a year, and is steadily increasing. This is quoted from a paper by Dr. Joseph, Medical Officer of Health of Warrington. 8 It is interesting to note that in Glasgow an ophthalmic clinic has been commenced for the purpose of certification. Other authorities use the school oculists for this service. A fee of £1 ls. 0d. is recognised as adequate by the British Medical Association for the certificate, and I am of opinion that this fee should be paid by tile local authority, not by the voluntary agency. It is very distinctly in the interests of the local authority that certification should be accurate. Now let us pass oll to a consideration of what tile local authority can do for the different classes of blind person. (I) The children under five years of age. There were 225 such cases in 1932, 9 and usually very little requires to be, or can be, done for them. Should it be necessary, the local authority may send them away to special homes, and the National Institute for the Blind provides sunshine homes for their acceptance. There are three sunshine homes in the country, and the cost to the local authority for maintenance is £38 5s. 0d. per annum (for parents somewhat less). These children should, of course, be registered under the Blind Persons Act, 1920, but can usually be cared for in their homes, and supervised by the maternity and
127
child welfare health visitors, acting in conjunction with the Blind Persons Act Committee. (II) The children of school age, 5 to 16 years. The total for this group in the country in 1932 was 2,066. 9 I have already mentioned the powers given to the local education authority in the Education Act, 1921. There are about 30 to 40 schools (referred to in the National Institute for the Blind year book) for blind children in the country, and in the case of those owned by the National Institute for the Blind, the cost to the local education authority is £60 per annum. The National Institute for the Blind also has a special school of 30 places in Devonshire for mentally retarded, though not certifiable, blind children. The fees here would cost the local authority £81 10s. 0d. per annum. But there is a large class of partially blind children to which I must refer. Bishop Itarman 1° estimates that there is one myope to every 500 ordinary school children. Myope classes, or as they are better caTled, sight-saving classes, are of paramount importance, and every local education authority should make such provision. Myopes should not be registered under the Blind Persons Act. (III) Next we pass to the large class of blind persons over 16 years of age. Some of these are training, some trainable but not trained, some employed, some unemployable, and so on. (a) In 1932 there were 1,6191.1 blind persons in training, and a further 643 trainable, but not yet trained. The local authority should take a vital interest in training all possible persons. This is an economic desirability. The cost of training wilt be saved in public assistance, it is, however, very important to select suitable training for blind persons in view of their capability, and also of their prospect of employment. There should be a very close liaison between the training authority and the workshop. Circular 387 of the Ministry of Health states :--" The sole purpose of training a blind person is to make him as independent as his blindness and his capacity permit." It is of interest to note 12 that the number of trainees is diminishing, due no doubt to the decreasing number of entrants. There is no age-limit to those who may be trained, but it is usually not feasible to try and train blind persons who are over 50 years of age. There are 43 training schools in England and Wales approved by the Board of Education, to which trainees may be sent (a list is given in the National Institute for the Blind year book).
PUBLIC HEALTH. The local authority should also submit the names of candidates for special correspondence courses run by the College of Teachers of the Blind, 224, Great Portland Street, London, W.1.13 (b) When the trainee is passed out from his training school, it is desirable that he should be absorbed in the local workshop. A very second-best scheme is to find him work at home as a home worker. In 1932, there were 9,12411 persons in employment, and a further 374 trained but not employed. The local authority can usually help this class by augmentation of wages. Various schemes of augmentation are in practice, but probably the best makes use of a sliding scale in the case of the workshop employee. The Ministry has discussed this scale in detail in memo. 64/BD. In the case of the home worker a flat rate augmentation is recommended. In Barnsley a flat rate of augmentation of £1 a week was paid to each employee, whether in the workshop or at home. It should be noted that the local authority must recognise every employee before grant is paid, and further, in the case of home workers, must recognise the occupation as being a suitable one. This recognition should be on as wide a basis as possible, and should include employees in ordinary factories or workshops. In circular 1086 of March 21st, 1930, the Ministry discusses this question of recognition, and desires the following conditions to be fulfilled (1) The occupation should not be a mere pastime, but should be definitely on the plane of industrial effort, in order that the home worker may be in a position to maintain himself out of his earnings, assisted by augmentation, as in the case of an employee in a workshop. (2) The occupation should be such as to enable the association which supervises the scheme to render tangible and continuous services to the home worker. It must be remembered that as a blind person cannot, as a rule, earn enough to support himself, his wage must be augmented. A good standard of work should be insisted on, as the public have a right to expect a reasonably good quality of goods to be available for purchase. There is no necessity to sell the goods made by blind persons as a form of charity. We always used to say that the goods sold in our blind shop were so good they sold themselves. The local authority can assist considerably by purchasing goods from the blind themselves, for example, firewood, baskets
j AN UAR",,
of different types, brooms for the cleansing department, socks for the public assistance committee. A point to remember is that workshop employees are insurable under the Unemployment Insurance and National Health Insurance Acts. Home workers are not usually so insurable. Another duty of the local authority is to supervise the general conditions of the workshop, and the Advisory Committee comment favourably on the good effect the connection of the local authority has had in this matter. The local authority has also power under the juvenile employment bureau to place blind persons in work. (c) By far the largest class of blind person is that of the unemployable and often necessitous blind. There were 48,02814 such in 1932, and of these, 21,057 were in receipt of the blind pension under section 1 of t h e Blind Persons Act. This pension is 10s. a week. Unless a declaration has been made under Part I of the Local Government Act, it must be realised that there is nothing in the Blind Persons Act that relieves the public assistance committee of the duty of assistance. But, as I stated earlier, it is highly desirable that such a declaration should be made, and in any case most local authorities have made a scheme for augmentation of the income of necessitous and/or unemployable blind persons. Various forms of augmentation exist, but the two with which I have had connection allow for making up of the income of the blind persons to a specified amount. In one instance, if the blind person was a householder, the income was made up to 25s. a w e e k ; if not, up to 20s. No period of qualifying residence is permissible Is before augmentation is granted. Where a scheme for augmenting the income of necessitous blind persons is in operation, if a person genuinely moves into the area of the local authority, augmentation must commence at once on application--after registration and certification, if necessary, of course. A difficulty sometimes arises when the blind person is eligible for the old age pension at 50, and also for a contributory pension at 65, for the latter ceases at 70 years, and unless additional augmentation is given, hardship may result. Another service the local authority may render this class is to provide aged and lonely blind persons with a home, on the cottage homes principle. Finally, a few remarks on the administration
1934.
PUBLIC HEALTH.
of the service. The interest of the local authority in the blind has nowadays become so great that I am definitely of opinion that this service should be administered as a branch of the local authority's services, and not chiefly by a voluntary committee. I do not, of course, wish to divorce voluntary effort entirely from the care of the blind, for I realise the enormous amount of devoted service that has been given in this connection, but I believe that from the point of view of the great expenditure involved alone, the local authority should have a greater say in the spending of that money, and in the administration of the service, than it usually has. T h e training of blind persons, whether of school age or older ; the running of the workshop, and the care of the workshop employee ; the supervision of the home worker; the disposal of the goods produced by the blind, and the augmentation of income, whether earned by employees or paid to necessitous blind, are all duties which, in my opinion, the local authority can administer better than any voluntary body. I consider, however, that there should be a voluntary committee, with a close connection with the statutory committee of the council, whose duties it will be to raise funds for providing the blind with outings, concerts, and other matters which are not properly within the purview of the local authority. It is, in fact, necessary' that such a committee should exist, as the National Institute for the Blind, which usually undertakes the collection of funds in a district, apparently is not able to enter into an arrangement with a committee of the local authority. As regards which department of the local authority should administer the service, I believe that it should be in the control of either the education or the health department. Both these departments are so intimately bound up with the welfare of the blind that if they have not some definite and intimate liaison with its administration, an inefficient service is sure to result. T h e medical officer of health should interest himself keenly in this matter, because, although it is not the subject matter of this paper proper, any consideration of the care of the blind must bring out that of t h e prevention of blindness, and prevention, of course, is entirely a matter for the health department. For those who wish to make a fuller study of the subject, I have inserted references to the various circulars of the Ministry of Health, as
129
well as to the Acts of Parliament, but probably the most fruitful source of information will be found in the reports of the Advisory Committee for the Welfare of the Blind appointed by the Minister of Health. T e n such reports have been presented--the last early in i933. I have not touched on the question of prevention of blindness, nor have I done more than mention the work of the voluntary agencies. Such were not the subject of this paper. T h e problem of the blind is no small part of the problem of local government, and the enormous alleviation in that distress which was, unfortunately, so common in our country before the passage of the Grant regulations of 1919 and the Blind Persons Act, 1920, bears eloquent witness to the work that is being done on behalf of the blind by the voluntary bodies and the local authorities. T h e pathos of blindness comes home to us all at times, and I trust that this contribution may stimulate a greater interest in the subject, and lead to more work being done for these unfortunate citizens of our land. BIBLIOGRAPHY.
Where reference is made to the Annual Reports of the Advisory Committee on the Welfare of the Blind to the Minister of Health, this is shown thus : Tenth Annual Relbort of Advisory Committee. 1 Tenth Annual Report of Advisory Committee. Pages 26, 27, 4 and 10. 2 Circular 7 BD. Regulations and Rules of August 7th, 1919. Circular 1306 of Ministry of Health, March 17th, 1933, and Welfare of the Blind (Contributions) Scheme, 1933. Declaration by County Borough of Barnsley under Local Government Act, 1929. 5 Tenth Annual Report of Advisory Committee. Page 6. " Report by the Prevention of Blindness Committee of the Union of Counties Associations for the Blind, 1931. Special Report of Advisory Committee, 1932. 8 G. W. N. Joseph, M.D., D.P.H., Medical Officer of Health, Warrington. Medical Officer, October 29th, 1932. 9 Tenth Annual Report of Advisory Committee. Page 27. I°N. Bishop Harman, F.t~.e.s. British Medical Jour~zal, January 28th, 1933. l~Tenth Annual Report of Advisory Committee. Page 29. ~2Tenth Annual Report of Advisory Committee. Page 11. ~aEighth Annual Report of Advisory Committee. Page 19. ~4Tenth Annual Report of Advisory Committee. Page 10. 15Ninth Annual Report of Advisory Committee. Page 18.