Introduction

Chapter Two outlined the complexity of evacuation arrangements during the Second World War and suggested this had a deleterious impact upon some sick and frail elderly people. Evacuation policy was seen as driven by a concern for the morale of the civilian population rather than as an attempt to meet the needs of dependent groups.

This chapter continues the theme of the importance of civilian morale and charts its relevance to the emergence of social policy reforms for elderly people in the period 1942-48. As the war progressed the care of elderly people ‘at risk’ became seen as important by the government because of the desire to be perceived as sympathetic to the needs of deserving groups. Subsequent to the publication of the Beveridge Report (1942), sensitivity to issues of social justice combined with the improved war situation opened the way for voluntary groups to argue for reforms in both residential and domiciliary services for older people. The extent and form in which the government responded to these pressures is a central feature of this chapter.

The Beveridge Report

The Inter-Departmental Committee on Social Insurance and the Allied Services was appointed in June 1941 by the Minister without Portfolio with terms of reference “to undertake, with special reference to the interrelation of schemes, a survey of existing national schemes of social insurance and the allied services including workmen's compensation, and to make recommendations”. The committee was chaired by Sir William Beveridge and he soon came to dominate the review. His biographer, Jose Harris, claims this was because “the official members were all heavily engaged on other aspects of wartime administration, most of them had been evacuated out of London, and none of them had the time to prepare detailed alternatives to Beveridge's proposals” (Harris, 1977, p 385). As a result, it was decided that the final report should be signed by Beveridge alone and it became widely known as the Beveridge Report.

The report proposed a comprehensive system of insurance to meet the financial needs of those in sickness, unemployment and old age. It also envisaged the creation of some form of national health service and the replacement of the remaining poor law legislation. The report reflected a continuation of previous trends in state intervention rather than any really dramatic change in form and content.

Introduction

Reference was made in the last chapter to the optimism in both central and local government associated with the passing of the 1948 National Assistance Act. The 1949 Ministry of Health Report claimed that the workhouse was doomed and that local authorities were busy planning and opening small, comfortable homes, where old people, many of whom were lonely, could live pleasantly and with dignity. The report claimed “the old ‘master and inmate’ relationship is being replaced by one more nearly approaching that of a hotel manager and her guests’’ (Ministry of Health, 1950b, p 311). Similar views were expressed by a public assistance officer from Middlesex County Council:

This chapter discusses some of the reasons why such hopes were never realised. The first half is concerned to explain how bed shortages in residential homes and hospitals led to a constant questioning of the boundaries between NHS and local authority provision. What was meant by in need of care and attention? Did it include those with physical and mental impairments? The second half of the chapter explores issues about the quality of life in residential homes, including the general criticism which emerged of all forms of institutional provision. Why did such criticism fail to lead to a reassessment of the priority given to residential care as opposed to domiciliary services for elderly people?

The organisation of welfare services

Before developing a detailed analysis of residential care for the period, it is important to outline briefly the main organisational arrangements that emerged during this period for welfare services. The Ministry of Health was responsible for local authority services under the 1946 National Health Service Act (for example, home helps, home nursing) and the 1948 National Assistance Act.

Introduction

In various talks and lectures to managers and practitioners from social services, health and housing, the authors have often run what they like to call a community care quiz. It usually comprises the following questions:

• • When did it become mandatory for social services authorities to provide a home help service?

• • What change was brought in by the 1948 National Assistance Act 1962 (Amendment) Act?

• • “The importance of enabling older people to go on living in their own home where they most wish to be … is now generally recognised”. What was the date of the government publication from which this quotation is drawn?

• • When did government start to include equity tied up in one's house in assessing the client contribution to residential care fees?

• • When did government introduce charges for domiciliary services such as home care?

Thorough readers of this book should be in a position to answer all these questions!

Our starting point in this chapter has to be to emphasise once again the relevance of such ‘knowledge’ to an understanding of present community care debates. In saying this, we make no claim to have offered a factual objective history of the past. This book is partial in what it has covered and the sources it has drawn upon, and the information collected has been shaped into a ‘story’ through the influence of our theoretical assumptions. Nevertheless, we believe that our study helps to undermine both ‘the Golden Age’ myths of the left and ‘the Disaster Years’ myths of the right about the early development of community care policy and practice in this country. This book concludes by considering a number of the present day issues in terms of what we have concluded about how they were or were not addressed in the past.

The health and social care interface

One of the clearest messages which emerges from our study of the development of welfare services for elderly people is that politicians and policy makers have struggled to define ‘what is health’ and ‘what is welfare’ right back into the Poor Law period. Initially the distinction was between being ill and hence not to blame for being destitute and being a welfare case and hence deserving of the label of ‘pauper’.

Introduction

The legislative framework for service development for older people laid down by the 1946 National Health Service Act and the 1948 National Assistance Act placed the emphasis on institutional provision. And yet the first section of this chapter underlines how there was agreement by the early 1950s that elderly people should remain in their own homes for as long as possible. Despite this, there was no dramatic shift of resources from hospitals and residential homes to domiciliary services, housing and income maintenance schemes.

This chapter focuses narrowly on arguments about those domiciliary services that were eventually to be located in social services departments. What kind of arguments were made in their favour and how did perceptions vary about their function? What was seen as the role of voluntary organisations in service provision? How did these arguments relate to perceptions about the responsibilities of families to their elderly relatives?

Staying at home and care by the ‘family’: the arguments

There was a broad consensus throughout the 1950s and 1960s that elderly people should remain in their own homes for as long as possible for their own happiness and also to reduce financial pressure on the state. The first of these arguments was strongly put by Townsend:

The ‘financial pressure’ case was put forward by Sheldon at the 1954 International Association of Gerontology Conference. He stressed the burden of old age dependency on the rest of the community in terms of hospital and residential care provision. This created a need to encourage and support “their general vigour under natural surroundings and their craving to maintain independence up to and even beyond the best possible moment”; this would reduce “the demands on permanent accommodation” (Sheldon, 1955, pp 15-26). The Ministry of Health shared such sentiments.

History lessons

The community care component of the 1990 National Health Service and Community Care Act was meant to have set a clear direction for the provision of welfare services for older people (and for a wide range of other client groups) in the 1990s and beyond. Social services authorities were to be the lead agency with a responsibility to develop user-centred care management, strategic community care planning and a mixed economy of providers based upon a thriving independent sector.

However, the message of many commentators is one of Care in chaos (Hadley and Clough, 1996) as local authorities struggle to meet their expanded responsibilities within available resources. A key feature of these critiques is often a comparison of the limitations of the market ideology of the 1990 reforms (efficiency and consumer responsiveness coming from providers competing for ‘business’) with the more welfare-orientated ideology of the past with its emphasis on a right to free services. Thus, Dominelli and Hoogvelt (1996) complain of the move in social work from needs-led to budget-led provision and from the direct provision of services to the managing of services provided by others.

A rather different line of complaint has been articulated by the 1997 Labour government which has expressed enormous frustration at the continued failure of health and social services to work in partnership to the advantage of those elderly people with both health and social care needs (Means and Smith, 1998, ch 9). This is leading them to explore the potential of some kind of community care authority in which the resources of both agencies would be pooled, an approach which could be linked to the proposal in the NHS White Paper that purchasing in the health service should be driven at the locality level by general practitioners (GPs) and primary care groups (DoH, 1997).

As social scientists with a long-standing interest in the history of welfare services for older people, we remain more convinced than ever that these contemporary debates about future direction and current problems can be very helpfully illuminated by exploring the past.

List of those interviewed

Dame Geraldine Aves, OBE

Lord Amulree, KBE

Marjorie Burke, OBE

Elizabeth Carnegy-Arbuthnott, OBE

Sir Harold Fieldhouse, KBE

Jack Hanson, OBE

Kathleen Halpin, CBE

Elspeth Hope Murray, OBE

David Hobman, CBE

Robin Huw Jones, CBE

Hugh Mellor

Laura Nepean-Gubbins

Professor Roy Parker

John Peter, CB

Dorothea Ramsey

Dame Enid Russell-Smith

Mike Simpson, OBE

Alice Sheridan

Maurice Speed

Professor Peter Townsend

S.F. Wilkinson, CB

Correspondence was exchanged with

Kathleen Slack

William K. Sessions

Professor Roger Wilson

Introduction

This chapter discusses the availability of services for frail and sick elderly people in the Second World War, and suggests that the quality of this provision was often influenced strongly by arguments about whether or not these elderly people were war victims. It was often claimed that war victims had a right to special care from the state which avoided any possible stigma through association with Poor Law provision. The social needs of groups not defined as war victims were seen as a low priority in conditions of war.

The chapter therefore begins by providing a brief outline of state provision for elderly people in 1939 followed by a more detailed outline of the limitations of public assistance institutions (PAIs) for the frail and sick. Next the disruption caused first by the establishment of the Emergency Medical Service (EMS) and then by the bombing raids from Autumn 1940 onwards is examined. This will be followed by a consideration of the responses made by central and local government to this situation in terms of billeting and evacuation arrangements. A central theme throughout the chapter is that little attempt was made to direct help to those elderly people most ‘at risk’ through illness and frailty; rather attention was focused upon those elderly people who might have the capacity to disrupt civilian morale either through their behaviour (for example, in air raid shelters) or through their complaints (for example, to the press).

Before attempting these tasks, the limitation of what has been achieved needs to be stressed. An attempt has been made to unravel policies towards certain groups of elderly people that were being implemented at a time of major civil disruption. To fully examine the bombing raids, the EMS and the evacuation arrangements would require more extensive research than it was possible to carry out. Not only this but the main subjects of the study – frail and sick elderly people – were far from being the central concern of senior civil servants and key politicians. Instead, the disrupted lives of elderly people and the implications of this disruption for Poor Law and evacuation policy tended to be dealt with by relatively junior officials on a case-by-case basis. As Titmuss explains, “the interminable corresponding, interpreting, minuting and accounting on this or that issue went on steadily among the lower and middle ranks of officialdom” (Titmuss, 1976, p 235).

Introduction

The Seebohm Report recommended the establishment of:

Most of these recommendations were incorporated into the 1970 Local Authority Social Services Act and the new social services departments came into operation in April 1971. These departments were headed by directors of social services whose backgrounds were in the personal social services and who normally possessed some form of social work qualification. Residential homes for elderly people, the home help service, meals and lunch club provision, laundry facilities, aids and adaptations and counselling services were all included in this new department.

A major reorganisation of the NHS was under consideration at the same time, with a focus on the need to reduce the inefficiencies associated with the tripartite structure established by the 1946 Act. (For general accounts of NHS reorganisation, see Brown, 1979 and Levitt and Wall, 1985.) Increasingly, the local authority health services had become seen as “a rag-bag of functions” (Brown, 1979, p 6) that needed to be integrated into the hospital and GP services. The end result of these deliberations was the 1973 Health Service Reorganisation Act, by which Brown has claimed that “basically, the local authority services were nationalised and brought under the same management as hospital services, while the administration of family practitioner services was aligned with the new authorities” (p 22). District nurses and health visitors were no longer to work in a local authority department; they were to be responsible to a district nursing officer who would be a member of a district management team of the health authority. It was the district nursing officer who would have primary responsibility for the allocation of district nursing and health visitor staff; this might or might not involve their location in GP practices. The post of medical officer of health was abolished. Each district management team instead included a community physician whose task was to assess needs and evaluate service provision within the community.