Care or Cant?

By RICHARD M. TITMUSS TT has been one of the more interesting ',characteristics of the English in recent years to employ idealistic terms to describe certain branches of public policy. The motives are no doubt well intentioned; the terms so used express, in civilised phrases, the collective aspirations of those who aim to better the human condition. It is necessary to remember, however, that this practice can have unfortunate consequences. Public opinion—in which I include political opinion—may be misled or confused. If English social history is any guide, confusion has often been the mother of complacency. In the public mind, the aspirations of reformers are trans- muted, by the touch of a phrase, into hard-won reality. What some hope will one day exist is suddenly thought by many to exist already. All kinds of wild and unlovely weeds are changed, by statutory magic and comforting appellation, into the most attractive flowers that bloom not just in the spring but all the year round.

We are all familiar with that exotic hothouse climbing rose, 'The Welfare State,' with its lovely hues of tender pink and blushing red, rampant and rampaging all over the place, often preventing people from 'standing on their own feet' in their own gardens. And what of that everlasting cottage-garden trailer 'Community Care'? Does it not conjure up a sense of warmth and human kindness, essentially personal and comforting, as loving as the wild flowers so en- chantingly described by Lawrence in Lady Chat- terley's Lover?

I have tried and failed to discover in any pre- cise form the social origins of the term 'Com- munity Care.' In pursuing, somewhat idly, this search, I was led to re-read the Report of the Committee on Social Workers in the Mental Health Services (the Mackintosh Report). In three months' time, I would remind you, we shall be celebrating the tenth birthday of the publica- tion of the Report. What progress have we made since 1951 in working out, in terms of the medical, psychological, social and economic needs of the individual, the concept of community care? What does it mean to local councillors and officials, medical officers of health, general practitioners, mental welfare officers, social workers, disable- ment resettlement and employment officers, health visitors, probation officers, psychiatrists and many others? Beyond a few brave ventures, scattered up and down the country from Worth- ing to Nottingham, pioneered by statutory and voluntary bodies, one cannot find much evidence of attempts to hammer out the practice, as dis- tinct from the theory, of community care for the mentally ill and subnormal.

Institutional policies, both before and since the Mental Health Act of 1959, have, on the other hand and without a dortibt, assumed that some- one knows what it means. More and more people suffering from schizophrenia, depressive illnesses and other mental handicaps have been discharged from hospitals, not cured but symp- tom treated and labelled 'relieved.' More and more of the mentally subnormal have been placed under statutory supervision in the corn- munity. It is probably true to say that, relative to the numbers in institutions at a given point in time, there are more people with diagnosed mental illness or handicap of a severe or moderately severe character in the community today than there were in 1951 when the Mackin- tosh Report was published.

There are many reasons for this trend; some positive; others negative. Institutional life as it has been known in the past by those we find difficulty in tolerating can be disabling in its effects, emotionally, physically and socially. Numerous royal commissions and committees of inquiry have discovered in recent years the virtues of the normal social environment—or as near 'normal' as possible—for old people, for the mentally ill, the educationally sub-normal, the handicapped child, the maladjusted, the elderly `ambulant,' and others who need 'care and pro- tection' during some stage in their lives. Yet government policies in other branches of the social services are punishing or frustrating those who are trying to convert the institution into industrial and social therapeutic communities. Take, for example, Fishponds Hospital at Bristol which, like a considerable number of other institutions in Britain, is attempting to de- velop a valuable scheme of industrial and social rehabilitation for its mental patients. If, how- ever, under such schemes a patient is encouraged to earn more than £2 a week he will not only have any benefits for a wife and family reduced or entirely stopped, but he will be liable for a tax of 25 per cent. or so. The Minister of Health has recently decreed that, in order to allow these patients `to stand on their own feet,' this tax• should be raised in the form of higher Health Service and National Insurance contributions.

Therapeutic incentives are proper, it seems, for surtax payers and property speculators but not for the mentally ill, the disabled, the handi- capped and many other under-privileged groups. This is the kind of detail that matters. In a hundred and one ways, this is what doctors and social workers have to think about in the interests of patients and clients. It is at this level of the dynamics of treatment that the concept of com- munity care will be made or marred. If it is to be a reality for many people it must start in the hospital. It must begin with the patients' admis- sion. It must encompass all the social services.

We may pontificate about the philosophy of community care; we may feel righteous because wc have a civilised Mental Health Act on the statute book; but unless we are prepared to examine at this level of concrete reality what we mean by community care we arc simply indulg- ing in wishful thinking. To scatter the mentally ill in the community before we have made adequate provision for them is not a solution; in the long run not even for HM Treasury. Considered only in financial terms, any savings from fewer hospital in- patients might well be offset several times by more expenditure on the police forces, on prisons and probation officers; more unemployment benefit masquerading as sickness benefit; more expenditure on drugs; more research to find out why crime is increasing.

The social legislation of 1946 and 1948, which gave to local authorities practically all the legal powers they required to develop community care, has now been on the statute book for thir- teen years. The Mackintosh Report, to which I have already referred, pointed out that the social services of local health authorities had been `profoundly affected by the National Health Service' in respect to the ascertainment, preven- tion and after-care of the mentally ill and sub- normal. 'It is difficult at this stage,' said the Re- port, 'to be sure to what extent the proposals for a mental health service put forward by these authorities have been implemented.' Is it unfair to suggest that this plaintive utterance could be repeated today?

Take, for example, the question of trained staff. This is what the Mackintosh Report had to say ten years ago : The scope of the mental health services in this country has been greatly enlarged in recent years with the result that there has been a pro- gressive increase in the demand from employing authorities for the services of mental health workers. The representatives of these employing authorities concur with our other witnesses in reporting an acute shortage of trained social workers in every branch of the mental health services, One local authority after another has stated that no applications have been received in response to repeated advertisements for psy- chiatric social workers; some authorities have resorted to making appointments of partly trained or untrained workers, while others have been obliged to leave posts vacant for long periods. The number of social workers who have qualified by completing the mental health course is exceedingly small in relation to the demand: indeed, some authorities report that they arc, finding difficulty in securing even the services of untrained workers in mental health.

The Ministry of Health, in its Report for 1950-51, welcomed the Mackintosh recommenda- tions; summarised the findings of a 'Community Care Survey' in 1950 (the Ministry had adopted the term by then); and reported that the workers studied, whether duly authorised officers or others, 'were for the most part keenly interested in their work and anxious for further training to fit them for it.'

Ten years later, and two years after the pub- lication of the Younghusband Report, they are still waiting. Whether they are still as keen on their work 1 would not venture to say. They are certainly overworked.

In 1951 eight psychiatric social workers were employed full-time by the 145 local health authorities. In 1959 there were twenty-six; an increase of 2.25 per year. At this rate it will take another fifty-three years (AD 2014) before some- one can say that there is an average of one psy- chiatric social worker to each authority.

Now let us take finance—still one of the best crude criteria of our commitment to community care. In 1949-50 total expenditure by local authori- ties in England and Wales on all mental health and mental deficiency services was £1,300,000. In 1959-60 it was approximately £3,500,000. If we allow for price changes, the additional ex- penditure on capital and current account comes to about £1,225,000 at 1959 prices. If we further alloW, for the increase in the total population of the country; for the larger increase in the total of mentally ill people in the community seeking or needing treatment (judged by turnover, diagnostic and discharge rates); and for the increase in the number of the mentally sub- normal under statutory supervision and training, it is probable that we are now spending a smaller amount per head on community care for the mentally ill (as distinct from the mentally sub- normal) than we were in 1951. And what we are spending today is substantially less than the sum of £4,900,000 paid out in compensation and ex- penses in dealing with fowl pest in Great Britain in 1959-60.

It may be said, and no doubt the Minister said it yesterday, that the future looks more promis- ing for community care than the past. Local authorities have replied to ministerial circulars asking them for a 'general statement of sub- sequent intentions.' These, 1 would guess, have been vaguely and optimistically converted in the Ministry into estimates of rising expenditure in the next few years. The last ten Annual Reports of the Ministry, for anyone who cares to read them, have set the pattern for statements of general intention. Now we have reached the point when the Ministry believes we should reduce the number of beds in hospitals for mentally ill and subnormal patients. It is suggested that the present proportion of 3,500 beds per million population may be reduced by half over the next fifteen years, and that the number of long-stay patients may be expected to decline steadily to nil.

This implies a quite remarkable degree of optimism concerning the rapidly rising rate of re-admissions; of faith in the capacity and wil- lingness of general practitioners to participate in community care; of trust in the energy and vision of local health and welfare authorities; and of belief in the efficacy of the block grant as a means of developing community care, Or it could mean that our society is increasingly un- willing to accept responsibility, socially and financially, for those who do not recover quickly, and those who do not conform to our expecta- tions of medical productivity. To transform the bad old mental hospital into the therapeutic in- stitution will be an expensive process. Let us, therefore, runs the argument, get rid of them altogether. At the same time there is a tendency, a:, Dr. Hayward has recently observed, to deny the existence of mental illness altogether, and to pretend that mental hospitals belong to the bad wicked past.' Arc we in fact,' he concluded, 'preparing for a future psychiatric retrogression, in which we have first-class patients in the general bpspitals, and second-class and third-class patients somewhere else, more forgotten than they were before?' If we are expected to take these official state- ments of intention seriously then I would plead for three acts of policy as an assurance that we really mean business in the immediate develop- ment of community care: first, a specific ear- marked grant to local authorities for community care services for the mentally ill and subnormal of f10,000,000 for 1961-62; second, central government grants for all social work students and training courses (irrespective of specialit) in the universities and technical colleges and the establishment of courses in fifteen of these col- leges by October, 1962; third, a royal commis- sion on the recruitment and training of doctors with special reference to the need for education in social and psychological medicine.

As the National Association for Mental Health has long recognised, the need for trained and qualified staff in all fields of community care is very great. To aid effectively the work of such staff, we also need more doctors—including general practitioners and public health officers— who are better equipped to understand and deal with the social and psychological aspects of medical care. The reform of medical education has for long been debated. I doubt whether much will be achieved until we have had a royal com- mission. At present, we are drifting into a situa- tion in which, by shifting the emphasis from the institution to the community—a trend which in principle and with qualifications we all applaud —we are transferring the care of the mentally ill from trained staff to untrained or ill-equipped staff or no staff at all.