SOCIETY TODAY

Between health and social services

Kenneth Urwid

The eyes of the public sector's big spenders are on the Whitehall computers. Local authority social services committees, born in 1971 and carrying the firmest instruction to write against the clock, have sent to the Department of Health and Social Security their first examination paper in the shape of a ten-year plan from 1973-1983. They seek substantial investment. It is a time for gestation. The ten-year plan's value as a predictor must be qualified by four factors: the vagaries of population growth and movement, the instinct of the public about what they will and won't pay for, actual governmental decision in the decade, and the EEC.

Social service provision directly affects one in eight of us — the grossly insecure, the vulnerable, the handicapped. Indirectly it is every man's affair. Probably for the first time since 1971 it is possible to see the wood instead of the trees: and to identify groups of people specially liable to injury if the planning goes wrong.

Social provision is everywhere co-terminous with the health service. The whole border territory calls for review, not least because the National Health Service itself is moving into a quite new phase.

Four groups of people who currently make a dramatically large claim on in-patient beds within the £2,313 million health service, the mentally ill, the mentally handicapped, the physically handicapped, and the more frail elderly, are vitally concerned in any definitive indication of present Whitehall and local authority intentions for the social services. A fifth group, the adult liomel'els-, also impinge more than marginally on the two services (witness the number who shuttle themselves between hospitals, railway arches, and the overnight hostels). Argu

ably, as a rapid flow of ministerial statements presages, the majority of these persons have either now or very soon a lien on a place in the community and away from the hospital. Social services committees are the catalyst.

These 550,000 persons make up a remarkable I per cent of the United Kingdom population overall. Remarkable because either in an acute or chronic condition they have special needs and bite deep into the country's resources, substantially but not entirely within the hospital service. Currently they account for at least £440 million per annum of our national spending. Remarkable also because they include many isolates who live in limbo, have no roof over their heads, and never want to see a doctor.

It is a very demanding exercise to take thought for this heterogenous group at one and the same time: to leave open the option of expeditous in-patient care in acute cases whilst elaborating a sufficiently flexible pattern of care and self-reliance in the community: to predict both for the . present and future hospital inpatient population in the groups named how long they should stay in hospital. At present the social needs of these 550,000 people are provided for in proportions of about twenty to one by the hospital service and by community-based agencies — voluntary associations or the local authorities. Spokesmen for the hospital service argue vehemently that a majority might be elsewhere: for some of them, though physically hale, are even taking up beds in surgical wards. It is a common recognition that an unspecified number are in hospital because there is nowhere else for them to go.

But the alternatives to hospital provision have to be spelled out with maximum care. I see abun

dant evidence of the readiness of local councils to make neighbour hood provision for these vulner able people a viable reality rather than a pipedream. Yet there is substantial danger now that the whole nation-wide operation will be bogged down at the level of

moralistic intent:. ranking high in the political exhortation stakes, but with a low priority in the practical think-tank.

And it is not possible really to blame our national accounting system, even though it has led the government innocently to assume that the financing of so revolu tionary a change, the off-loading of this substantial commitment from the hospital service to the local authorities, could be carried through by the injection of a few extra millions into rate support grant.

The present danger is much more subtle. We postpone the decisions because we do not really know how to make them: having no precision in judging who can from hospital and who might best stay.

I am appalled by the naiveté of the political assumption that hos pital doctor and neighbourhood social worker will quickly agree about the merits of community care — in general and in the specific. In my expectation, they won't. And I know of noparallel situation where two separate professions — arguing it must be said around the heads of a largely captive, certainly very impressionable audience — will be in a position actually to make the decision about the chronic patient's reentry into the open community. Of course you can rule over him by scarcity of alternatives: we always have done so. If there is no community care for him few will openly put him outside the hospital gates. But rapidly we must widen the options for him. While this calls for capital and revenue expenditure, it calls even more for a bonus in public goodwill. The discovery of a few private landladies who will give appropriate houseroom to the mentally ill, the mentally handicapped, or the physically handicapped coming from hospital is almost the equivalent of a six-figure gift to the local authority.

Again, the government has been fabricating some remarkable grapeshot to fire at the large psychiatric hospitals and hospital for ,the mentally handicapped. But, faut de mieux, the large hospital, units look set fair to continue — at least around the great conurbations. The only way to effect their closure is by intensifying community care schemes — the day hospitals, the group homes, the hostels.

Add to the credit side his economic yield outside the hospital. In a still under-employed Britain the risk of temporary unemployment for the mentally ill, mentally handicapped, or physically handicapped will be endemic. Yet the risk must be taken. Long years in hospital will leave many ill-equipped to earn except in sheltered' employment — and new highly localised sufficently capitalised productive work units will have to be created, The 30,000 places in Val ing centres must be set against potential demand in the very nel future from 60,000 claimants.. I corollory is to call for i mediate consideration of sili' working in the centres.

The voluntary societies (I1° National Association for Meat Health and the disablement s0,. port groups) have a natural still' in the whole operation. I susp that local authorities will be 101 ready to move through th waters without their effectol pilotage. The British like to lea!, crucial pieces of caring work ° the volunteer. But there is 0 room for laissez-faire, Voluntal societies, unless they are decent': endowed and their coffers e°11 stantly reinforced by legacies, regularly turn to local councils secure cash advances for their e tended operations. It is trio° parently clear that the bett 'among them are already tired their soliciting role when, as the, laver, they are only doing the loci authorities' work for them. So it Would be foolish not to se one weathervane immediately 10 hand in the government's 10,8A sanction allocation for 191 which is the traditional gre', light to local authorities to 1:°°,' row and spend money in capli6 works: in this instance, to buy e°1 equip the shells within which vtio nerable people can function.°_, live. There has certainly D% nothing grandiose about ti year's award. Wjlat local authnq ties get when they apply for 10° sanction is always part of our Or nomic barometer reading. 111 government's curbs are traditie; al. Perhaps when local authorit!i1. ask twice this year, as they they could be spared the goveti'r men t's standard references tr scandalous under-provision Lundy and Rockall, which barn:4 by contrasting strangely luxuriant capital growth in IA' cash ire and London.

The tragedy is that commu, care is dreadfully patchy: CO. siderate to the few but not to Of many. At one extreme the signs°„, accumulating social presstt;t could,not be more ominous: 25 P`,,, cent more people drawing sti„,° plementary benefit in two

more pressure in consequence health and social services.

But merely to accede to ..„0 • , pressure is to ensure that far tu, many people will become school; ed tri' poverty and passivity. opportunity now before sdo,v, services committees is certain': no less than that awaiting ec110. tion committees earlier in the cely tury. Those education committee!: added millions within a few Yeat; to the country's economic asSe"; by turning the clear vulnerabilit) of child serfs caught up by our dustrial society into a springhon e for wide social advance. 1.11e whole apparatus of social servIco provision is not only relevant till people who, long sequestered to their hospitals, are ready noW live and where possible earn re' the community. It is even the touchstone of our national chemy: evidence of our capacil really to improve our person° standard of life.