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fabian tract 460 
a family service for the 
mentally handicapped 

chapter 1 myth and community care 1 
2 the dilution of community care 3 
3 failures of policy : the white 
paper reconsidered 7 
4 labour and mental handicap 17 
5 beyond community care 20 

the author 
Walter Jaehnig is an assistant professor 'in the 'School of Journalism 
at Indiana University, USA. He worked as a reporter and 
editor on American newspapers before taking up a post as 
research officer at the University of Essex where he ~carried out 
a study on families with mentally handicapped children. After 
receiving his doctorate in 1974 he worked for a year as a course 
consultant at the Open University. From 1971 to 1974 he was a 
member of the Campaign for the Mentally Handicapped. 

acknowledgementsThe author is very grateful to several people who have commented 
upon an earlier version of this pamphlet and called his 
attention to valuable material that proved helpful in its revision. 
He particularly would like to thank Alan Tyne, Peter Townsend, 
Timothy Booth, Peter Moss, Adrian Sinfield, Oavid Boswell and 
Vince Gorman for their advice and counsel, though of course 
none of these should be held responsible for the views expressed 
in this pamphlet. 

this pamphlet, like all publications of the Fabian Society, 
represents not the collective view of the Society but only the 
views of the individual who prepared it. The responsibility of 
the Society is limited to approving publications it issues 
as worthy of consideration within the Labour movement. 

Fabian Society, 11 Dartmouth Street, London SW1 H 9BN. 
January 1979 I'SSN 0307 7535 ISBN 7163 0460 0 


1. myth and community care 
R{p) 

2J:J/z/7qMore than a decade has passed since 
newspaper allegations of mistreatment of 
mentally handicapped patients at ElyHospital, Cardiff, broke upon the unsuspecting 
public. The report of the official 
enquiry, published .jn 1969 by Richard 
Crossman, Secretary of State 'for Socia']
Services (Report of the Commission of 
Enquiry into Allegations of Ill-Treatment 
of Patients and other Irregularities at the 
Ely Hospital, Cardiff, Cmnd 3975, HMso), 
described disturbing conditions in the 
hospital and provided a lengthy catalogue 
of nursing and management malpractices. 
While many professed surprise that such 
conditions existed within the National 
Health Service, a spokesman for the 
Nati<onal Association for Menta!! Health 
was quoted in the press as saying, " If 
you investigate any major mental hospital 
you are bkely to find that .jt is in the &arne 
boat with overcrowding, staff shortagesand old buildings". 

Time made him a prophet. Highly publicised 
reports of official invest·igationsinto several •other mental hospitals in the 
early 1970s-the Norm•ansfie1d inquirybeing on~y t'he most recent-reiterated 
many of the Bly Committee's findings. 
But in addition, publication of other 
studies, such as Dr. Pau1ine Morris's 
na!tional survey of hosp•itta•ls for the mentally 
handiC'aipped (Put Away, Routledge& Kegan Paul, 1969) and later the Hospibal 
Advisory Service's annual report on 
NHS long~stay institutions, raised fundamental 
questions about ~he appropriateness 
of custodia'! forms of care. The 
offici·a~ response came in 1971 when the 
Conserva!Vive Government pu~ished its 
policy statement, Better Services for the 
Mentally Handicapped {Cmnd 4683) 
HMSO. T'his White Paper, repeatedly and 
consistently re-affirmed by La'bour ministers, 
promised an improved •baiJance between 
hospitals and community services 
for some 1'20,000 severely mental'ly handi capped 
(formerly dMignated " severely 
subnormal " or "mentally deficient")
people and an un:estimated number of 
mi•ldly handicapped people in Englandand Wales. 

But has this prolonged period of 
public anxiety and ministerial concern 

actually re~t~ i~ ~~:riel e~~eo)d 

compassionate service for mentally handicapped 
people ? Spokesmen for successive 
Governments and providers of services 
have taken an optimistic, if •somewhat 
narrow, view of recent developments. 
Conceding that much remains to be done 
for the mentally handica~pped the magnitude 
of change thus far has not been 
impressive, they attributed the failure to 
exact more comprehensive improvements 
to the country's general economic situation. 
They nave argued that within these 
financial ·constraints, nonetheless, it is possi'Ole 
to improve conditi·ons in the hospi
·ta~s whi1le simu~taneously encouraging 
greater community provi·sion. Thus in 
1975 Barbara Castle, then Secretary of 
State for Soda1l Services, noted that 
increased expenditure on the menta']
hospi•tals had .pra<ctica'lly eliminated overcrowding 
(by the Department of Health 
and Socral Security's 1969 ~tandards) 
and improved nurse / patient ratios. Local 
authority requeslts f·O'r lO'an approvalfor capi·tal projects (resident·ial and 
training fa'Cilities) reportedlly were running 
well ahead o'f White Paper targets 
before the December 1973 cuts m 
public expenditU're (speech to Nationa1 
Society for Menlta<lly HandicappedChildren conlference). A joint financing 
·arrangement was developed to encourage 
collaboration between health 
and local authorities. The Government's 
consultative dO'cument (Priorities for 
Health and Personal Social Services in 
England, DHSS, 1976) reported that l·ocal 
authori'ties added 3,500 resident·ial places 
and 9 000 adult training centre placesbetwee~ 1969 and 1974, while hospital 
beds for the mentally handicapped were 
reduced by 5,000 during this period. More 
important, the document proposed tha-t 
services for mentally handicapped people 
should receive a!bove average expenditure 
during the lean 1975/ 6 to 1979/ 80 years-
a policy that was reaffirmed in late 1977 
(The Way Forward, DHSS). As Professor 
Peter Mittler, cha·irman of the Natwna•l 
Devdopmentt Group for the Mental'lyHandi·capped, wrote in New Society of 1 
July 1976 "After decades of neg1ect, 
mentally handicapped people are now 
beginning to get nearer 'to the priorities 
they deserve". David Ennals, Secretary 


of State fm Social Services, repeated the 
Government's commitment : " I shall give 
my full backing to the development of 
serV'ices for these groups (the menl!ally ill 
and handicapped, arthritis sufferers, and 
those needing speech therapy). We really 
must promote a more effective balance 
between the hospital and community services 
and improve the quality and atmosphere 
of some uf the hospitals which 
serve the mentally ill or handicapped. ln 
general terms, the right direcrion of 
advance . .. is now clearly mapped out, 
but the task now will be to make the plans 
a reality" (speech to Medical Journalists' 
Association, 4 June 1976, emphasisadded). 

the limitations of 
current policy 

These improvemen1ts, however modest, 
can seem s<atisfying in view of pastfailures. But when presen't policies are 
examined more broadly, lingering questions 
remain without answers. These are 
concerned with the strength of the Government's 
long term commitment to community 
care and discomfort·ing elements 
of the White Paper's pattern ·of services. 
"Community care", quite simply, suggests 
a social, rather than medical, pattern 
of care, with an empt.asis on the 
maintenance of the handicapped person's 
rel·ationships and, where necessary, assistance 
from the non-institut1onal resources 
of 'the community. What place 'therefore 
do -long stay hospitals-df any size or 
location-have in this pattern, particularly 
when the DHss's own statistical 
studies demonstrate th~t the majority of 
men'tally hl!Jndicapped people are not in 
need of medical supervision or treatment? 
" Communi·ty care " is meant to be 
integra~ive, enhancing the individual'~ 
!·inks with his home, neighbourhood and 
community. What benefi'ts therefore do 
institutions such as hostels, whether 
located in the community or ·in 'hospitalgrounds, 'bes'tow upon handicappedpeople : to what extent do they su tain 
these important linkages? FinaHy, "community 
care" 1is meant to be preventive, 
aiming to aid and support the family of 
the handicapped person so that his admis~
ion to a segregative institution may be 

prevented or deferred. Considering that 
about half of the severely handicapped 
people in England and Wales live with 
their families or elsewhere ·in the community, 
what levels of support doe·s ·the 
White Paper provide for them ? Is it possible 
to see the White Paper, as i't appl'iesto the handicapped and their families, as 
any more than an attempt to reformulate 
a "minimum " level of services ? 
And can we be -optimistic a'bout the possibility 
of a comprehensive development of 
long neglected services, financed by a 
growth in spending of less than 3 per cent 
annually? 

The concept of community care that 
emerged 20 years •ago from the report of 
the Royai Comm-ission on the Law 
Relating -to Mental IHness and Mental 
Deficierrcy 1954-57 '(Cmnd 169) was both 
comprehensive -in recommending the 
establishment of a wide range of preventive 
serv'ices and family based: "The 
whole approach should be a positive one 
offering help and obtaining the co~operat'ion 
of the patient and his family ...". 
The Roya~ Commission ·recognisedsociety's respons:ibility 'to share the 'burden 
of famil'ies with mental'ly disordered 
members, and 'to provide care for those 
without families : "It should also be 
remembered that the ·sense of 'belonging 
to a fliJffiily may be of great importance 
to the patient. It 'is not always in ·his 'best 
interests to remove him 'from a not 
entirely satisfadtory home to even the best 
run f·oster home or public institution." 

The theme of this pamphlet is that when 
present services for mentallly handicapped 
peop'le are measured against this standard, 
it will be recognised tha't "commun1itycare " 1is nearly as much •a myth as it was 
in 1961 when Richard Ti'tmuss questioned 
the country's commitrrnent and preparation 
to carry it ·out {reprinted .jn Commitment 
to Welfare, 1967). In spite of the 
seemingly irres'isl!ible case for fundamental 
reform made in recent years, the policies 
that have emerged are narrow in their 
conception of 'the problem, timid lin their 
prescriptions and ambiguous in their 
execution. 


2. the dilution of community 
care 

To propose a community care service is 
one matter, to make it a pradica•l reality 
is qu'ite andther. The translation of the 
Royal Commission's broad idea'ls into a 
new pattern of care 'OVer the paslt 20 years 
has been shaped 'by determinations of 
other issues-issues peripherai to the 
problem df mental handicacp 1itself. Fore· 
most was the traditional division of 
political respon&ibility hetween central 
government and local authorities. A 
change in policy !from a hospital based 
service to one founded upon community 
provis'ion 'imp!lied not only 'a substantial 
redistribution ·of financial resources from 
central government (and the NHS) to l·ocal 
authoriVies, but also raised questions about 
whether local commun~ties possessed the 
political will to reassume the responsibhl.
ity for the menta1ly hancJiicapped and 
the ·other groups •in need of communityprovision (loca-l authorities had operatedthe hospitals for the mentally handi capped 
before the establlishment of the 
NHS). In addition, the 1960s and 1970s 
witnessed the emergence of several helping 
professions with respective claims 
over services for mentally handicacpped 
people. But each als·o had •its own concepfion 
of the prob'lem of menta.[ handicap 
and special skills to apply 'to it, and 
the ar-ticulation of their interes'ts further 
compllicated the political process, making 
it more difficult to allocate scarce funds 
straightforwardly without offending competing 
groups. 

Moreover, neither 'the new communityservices nor the emerging professionalism 
of -these groups reversed -the trend toward 
the provisi·on of services ~and ultimately, 
institutionaiisa~ion) as substitutes f-or the 
resources of the handicapped person's 
family. Relatively little attention was paid 
to the potential of different types of 
family structure 'to cope Wibh the problems 
of the handicapped person ·or how 
ancillary services might be offered to complement 
the family's own efforts. The 
pol'itica•l leadership con'tinua'Ily fa~led to 
outline the ·specifications for a comprehensive, 
family based service, or providethe resources rto fund and develop efforts 
alon·g 'these lines. If anyth'ing, the perio-dsince the acceptance ·of the Royal Commission's 
repor·t-supposedly marking the 

elaboration of a " community care " 
policy "-has been a 'growing confusion 
over 'the nature of the needs of handicapped 
people and their families and, 
paradoxical'ly, ·a subtle extension of 'the 
categories of handicapped people seen to 
be in need of insti'tutional care, whe-ther 
in the community or in hosp·ital. 

Mem'bers of the Royal Commission 
thought it should be a du'ty of local 
authofi:uies to prov'ide •integvative and preventive 
·services ; this general approach 
was adopted in 'the Mental Health Act 
of 1959. One of the Act's objectives was 
to establish a comprehens'ive community 
serv1ce to meet the needs of all types of 
mental'ly disordered patients not requiring 
hospital (medica.J) treatment. Circulars 
issued by 'the Mlin~stry of Heaclth made 
many services, including re~idential 
accommodation, obligatory on ~ocal 
authorities. But in an important circular, 
the minisury sharply restricted 'the categories 
of persons Tikely to need reS'idential 
care in community acoommoda'tion to : 
firstly the " educational su'bnormal or 
mal•adjusted young people who are in 
employment 'but need . .. some care and 
guidance which cannot be sufficiently provided 
in 'their own homes; secondlypatients discharged from hospital needing 
some support on re-entering commun'ity 
l'ife and thirdly elderly infi'll11 
persons who do not need 'the service and 
resources of a hospital" (Ministry of 
Health Circu1ar 9I59). Sections 12 and 
13 of the Mental Health Act added a 
fourth category : chi'ldren unable to 
attend junior training ·centre dai•ly because 
of distance or ·~ack o'f transpottation. 

The Younghusband Working Party reported 
while "the Mental Health Act was 
moving through Parliament (Report of 
the Working Party on Social Workers 
in the Local Authority Health and Welfare 
Services, Ministry of Hea1'th, Department 
of Health for Scotland, 1959). Commenting 
on ·impending changes in the 
mental health ·services. the working party 
wrote: " Perhaps most important of all 
are efforts to make it possible for the 
family to care for 'i'ts physically or men tally 
handicapped members .. . The tendency 
i·s now to provide for them in the 


community and accordingly there will be 
increasing demands on the soci,a:l services 
to enable all but 'the lowest grades to lead 
satisfactory 1ives in the community and 
to make full use of their abilities, l'imitw 
though these may be". 

Perhaps not surprisingly, considering the 
sulbject of the Younghusband Working 
Party's deliberations, the social worker's 
role was claimed to be pivo'ta'l. In fact, 
the working party described the needs of 
various segments of the population in 
terms of the level ·of train'ing and skill 
required from social workers to helpbhem. This shifted the attention from the 
fa!m'ily's instrumental needs to the social 
worker's recognition of the family'sproblems. Practical difficul'ties 'involved 
in •caring for a mentally handicappedctrild for example cou1d be explained 
away as psychological problems with the 
family 'itself. The working party described 
an instance in wll'ich a simple request for 
material help called attention to a com-
pl'icated 'and troubled situation : " Caring 
for a menta!1y defective child may often 
place heavy emotional and physical strain 
on the family. The social worker must be 
able to give steady and continuous support, 
eventually perhaps help tthe parentsto evaluate the respedive claims of 'their 
normal cll'ildren and the defective chi'ld. 
In one instance 'the mother of a seriously 
defective child saw the problem only as 
one of obtain'ing help 'to ena'ble her to 
carry on somehow. But the observer could 
see other problems". The working partydescribed the mother as " over-prottective" 
'and said that "she may have felt 
responsible for his defect." 

Quite likely if her child had not been 
handicapped and the mo'rher was " overprotedtlive 
", the social worker never 
would have come in contact Wi'th her. In 
this sense, •a mdther's request for assistance 
became an invitation for ·an exercise 
in family pathology; the family's practical 
needs were superseded by the professional 
an·ogance of case-work. This 
confusion between need for assistance 
and the family's vulnerability Ito professional 
analySis was a theme runningthroughout the Younghus'band report. 
Too little attention was paid Ito the pro


fessed or felt needs of families, and the 
nature of the relationship be'tween the 
social worker and 'the users of the general 
social services '(for a further discussion, 
see Adri,an Sinfield's Which way for social 
work? Fabian Society, 1970). 

The working parity also noted 'that : " It 
is salutary to reflect that 'the demands 
made on the health and wel1'a·re services 
... are rapidly increasing. The services 
for the general classes of handicappedpersons have touched only 'the fringe of 
need; an expansion of aH forms of community 
caTe for the mentally disordered 
has been recommended and the importan'Ce 
of more effective preventive work 
witth famlil~es is generally accepted." 

However it made no real attempt to 
define these needs, the nature 'and scope 
of service 'fequired, or 'the form "effective 
preventive work " might take. 
Although the report was a !Gng time in 
the making, 'the working party did not 
itself investiga'te consumer needs, nor did 
it exhibit 'its 'awareness of social needs 
that h'ad 'been established in social 
research since the war. 

In 1963 the Government issued Health 
and Welfare: The Development of Community 
Care (Cmnd 1973) in which local 
authority healtth and welfare plans for 'the 
nex't decade were pubfished. The intentions 
were laudable ; the document 
described " community care " in this 
way: " . . _ 'to help !them J!ive as nearlynormal J.ives as the nature and extent of 

1

their disabilities aHow . . . the objectis a1ways to give the utmost opportunity 
to develop his potential'iltoies. Accordingly 
the mental health services provide help 
in all the main aspects of ordinary life, 
in the home and 'at work". SerV'ices 
should be family ·oriented 'and based upon 
the home : "It is usually bes't for the 
menta,lly disordered person in the community, 
whether adu'lt or child, to live at 
home when this is possible. The willingness 
and ability of relatives to provide a 
home depend on the severity of the disabil'ity, 
'the size of the family, and the 
effect of fue mentally disordered member 
and the rest of the family on one another. 

But the services provided inside and out



side the home can improve an unfavourable 
situation and make it unnecessaryto seek an alternative. Advice and supportfrom a social worker or health visitor ·Or 
rhe services o'f •a home help oan make a 
significant difference. A<ccess to tra'ining,
occupation and socia'l facilities in cen'tres 
and clubs, and the availability olf shor't 
periods •of residen'tia'l ca•re, 'Can make all 
the difference in keeping the family 'together" 
(emphasis added). 

But The Development of CommunityCare {op dt) also described the likelihood 
thalt more men'taHy disordered persons 
would need residential care. The 
Government f.or examp'le :broadened its 
heretofore restricted categories of personsneeding inshtutional accommodation to 
include children attending jun;ior train•ing 
centres because " of 'the situa't!ion at 
home". No description was prov·ided of 
the sort of home environment the document's 
authors had •in mind, nor did the 
plan specify who would make the 
decision to insti'tu'tionaiise the child. Perhaps 
in jus6fica'tion, the report recommended 
that residential provision should 
resemble " a real home ": " Nevertheless, 
there will always be many ca<ses in which 
an <tlternative home <is needed. A foster 
home or •suitable l·odgings may be the 
best arrangemen't. The right 'background 
can, however, be established 1in premisesbuilt •or specially adap'ted a:s res'iden'rial 
accommodation for the menta'ily disordered". 


This m'inor shi•ft in poJ.icy would have 
been inconsequential had the remainder of 
the document, which signal1ed local 
authority •oommuni'ty care iintention<s, been 
more promi·sing. l't has been described 
elsewhere a:s " one of 'the most d'iSiappointing 
pub1<ica'1:ions in lhe mental health field 
for many years" (Peter Mittler, The 
Mental Health Services, Flabian Rese·arch 
Series 2!52, 1966). The published figures 
demons'trated holw unprepared local 
authorities were 1to aocept their new 
respons"ibilti'ties, and exposed great .geogmphical 
disparities in the quantity of 
servi·ces planned f.or •the 'future. And 
<tl'though the plan was intended as a companion 
'for the 1962 hospital plan (A

Hospital Plan for England and Wales, 

Cmnd 1604), the Government declined 
to provide guidance or ·suggest standards 
for loca<l rauthori'ty services. Indicators 
concerned with ·services f'Df rhe men'llallyhandicapped were restricted 'to the number 
of adult and junior tra'in'ing centre 
places a vail able and .p'lanned. Supportservices were defined only in terms of 
staffing ratios for heallh visi'tors, home 
helps, home nurses, midwives and social 
workers-not all of whom, •obviously, 
would be •concerned direCtly with famiJries 
of men'Vally handicapped peop1e. It would 
not seem possible to measure the effectiveness 
of commun'ity services solely in 
terms o!f residenri·al and training places 
available or staffing ratios (lthoug'h this 
numbers game is still standard practice 
·at '!!he DHSS). But nowhere drid 't'he Governmen't 
in The Development of Community 
Care '(ibid) provide the level of 
concern and leadership thJat was evident 
in the hospita1 plan. 

the Seebohm report 

By 1968 when the Seebohm repor't

(Report of the Committee on Local 
Authority and Allied Personal Social 
Services, Cmnd 3703, HMSO) was published, 
1'he consequences df rh'is •leadership 
vacuum were a:pparent. The Comm'i'ttee 
wrdte: "The widespread 'belief that we 
have 'community care' df ~he mentallydi•sordered is, for many parts of the 
country, still a sad illusion and judging 
by published plans wi'll remain so for 
years ahead". The Seebohm Committee, 
with its emphasis on adm'inistrative efficiency 
and profess'ionalism, did little to 
remedy this. Writ<ing often and somewhat 
ambiguous•ly of " an effect:ive family service 
" the Commit<tee made l'ittle a'tternptto describe this service ·or how it would 
aid f.amilies of the mentally handicapped. 
Constituent ·elements ·of wha~ the RoyalCommission considered to 'be a famiiyservice were virtually ignored in Seebohm; 
home helps for exam'ple were recommended 
for families of the physkaHyhandi'capped .but never mentioned with 
reference to 'the mentally handicapped. 
At times \Seebohrn appeared to suggestwhat would have been ,obStruct;ions to an 
effective family service: the Committee 


recognised •a chronic prdblem in co-mdina'ting 
efforts of health and welfare 
workers and recommended that responsibility 
for the menta'lly handicapped should 
be held by soc'ilal servi•ces dep·artments. 
But it a.Jso invested great responsibility f·or 
the mentally disordered in tihe publicheal'th doctor {in what remained of the 
old local health departments): " In ·the 
task of co-ordination, the •contrihu'Vion of 
the publi·c health doctor, the communityphysician of the future _ _ . wi'll, we 
believe, be crucial . . _ For i·ts part, a 
social services department of tihe kind we 
have proposed should :be well placed to 
collaborate wi1th other social agencies as 
well as with the local medical services ". 

Why 't'htis cdllaborati.on should take place 
in ~he future when it had no't in the past 
was not ex<pl'atined by the Seelbdhm Committee. 
A numtber of surveys had found 
that suc'h co~ordination was one of the 
unresolved difficulties of the pre-Seebohm 
health and welfare services. A comparative 
study, for examp1e, of services for the 
men'tally handicapped in seven local 
authorities discovered that profess:ional 
providing services-genertai practitioners, 
health visitors, social workers, clinic 
doctors and ·oVhers-tended to v!iew 'their 
own •role as predominant •and assumed 
that Olthers were doing t!he co-ordinating.
As the authors of the project report 
wrote: "The •lesson to be drawn is not 
that the multi-tude oof services now av•ailable 
should 1\Je reduced, or even that fewer 
people shoul1d he involved, bu't rtatiher that 
more effective means of co-ordina'tingtheir activities 'have to be dev!ised" (see 

1 Thought They Were Supposed to be 
Doing That, The Hospital Centre, 1972). 

Events would seem Ito have reduced further 
the possibility of co-ordination of 
serV'ices from the socia'l services departmen't. 
In 1971 responsibility for rhe junior 
trainling centres '(now special schools)
passed, logica.Jly, to education authorities, 
general practitioners, hea'lth visitors and 
school health offici•als are now associated 
with area health authoriries established 
by the 197'4 re-organisation of the 
National Health Service. In terms of earlycon1Jacts w'i1h the mentally handicapped 
child, tihe social services department 

would seem to pJoay a secondary role-
perhaps reducing the possibility of 
developing an effective f.amrily-•support service. 
It is now qui'te possible, if not likely, 
that the departmen't wi'll not know of the 
chil'd's existence, mudh less of hiis ofam'ily'sneed for assistance, until he is of school 
leaving age. The DHss's Harvie Oommittee 
·on residential care noted trhis problem : 
" In our Vliew l!hese haphaZJard arrangements 
are undesira'b'le and should not 
con'tinue. The •social services departmentshould be rourinely noti·fied whenever it is 
estab'l'ished that a family has a mentaHy 
han'dicapped child. We 'believe that the 
fami•ly ... s-hould •have a social worker 
nomirrated, who would have the special 
duty of keeping regular con'ta•ct with the 
fami-ly and of ensuring thl!!t it receives all 
the appropriate support and material 
help" (Mentally Handicapped Children 
in Residential Care, 1974). 

The ConserV'ative reorganisa:tion of the 
National Health Service exacerbated this 
problem •of health and social services coordination. 
The medica:! profession fought 
La:I:>our's earlier attempts 'to 11ie healtlh 
services more closely to local government, 
preferring instead to dea~ directlyw'ith central government (see Barbara 
Castle's discussion df this point in NHS 
Revisited, Fabian 11ract 440, 1976). The 
corrtinuing diV'ision therefore between 
sooi·al servli•ces departments, !financed 
t!hrough local councils and the Treasury 
financed health service 'has ·acted as a 
pdtent disin·cen'five to the development of 
support services. As long as local authorities 
could Shift responsibility for supporting 
a lhandica'pped person off the rates byadmitting him to hospital, lit had no compeH<
ing incentive to develop it'S local services. 
Similarly, while 'the hospital service 
was bolstered by a'Pparent local authority 
demands <for accommodation, it could 
con:tinue to make powerful claJims for 
funds from the Government. It 'is againstthis l>tanda!'d that the 'Present Government's 
joint financing arrangement must 
be measured. 


3. failures of policy: the 
white paper reconsidered 
The long awaited Whi,te Paper ·On mentlal 
handicap aoppeared in June 1971, .between 
the prospective re-organisation of the 
loca1 social services and the NHS. Thoughits rhetoric suggested a renewed commit· 
ment to •the Royal Commiss'ion's principles, 
its pradtical propo·sals conveyedhesi'tancy, oaution and compromise. J.t 
called for a continued extensi·on •of the 
community 'Care concept, but estimated 
that after 20 years a hospital populationof 34,000 (about 56 per ·cent of 1969 
levels) would 'be retained. lit emphas'ised 
the impo·rtance of suppor.tive services f.or 
menta1ly handicapped people tand 't'hei·r 
famil1ies, but predi·cted that more handicapped 
people would go into residential 
care in the future. It exhorted local 
authorities to make greater efforts on behalf 
of the men'tally handicapped, and 
oalle'd for greater coUaboraVion between 
heal~h and social ·services departments in 
planning services_jbut presented a spending 
programme heavily weighted 1in faV'our 
o'f moderni•sing the hospi~al service. 

the case againsthospital care 

Neverthele~s. the Government presen1ted 
in fhe Wihilte Paper .a strong case against 
the long-stay hospitals and VheJir segregative 
pattern df care, not'ing that manyinstitutions were too ·old, too large and 
too remdte from it!heir patients' 'COmmuni't'ies. 
" Isola'tion •also affects pwfessiona:
l work, 'CUtting off staff and patients 
from the rest .of medicine, nursing and 
sooral work, and tending to ~n'hi'bi't rhe 
dissemination and appi'ication of ideas 
and methods, inc1uding meiVhods of management, 
which have proved benetidal in 
o~her hospitals". Hospitals were overcrowded 
·and under staffed, pr·ovi'dingpatients with l'ittle a•ctivity, privacy ·Or 
amenity. More important, under such 
conditions " hospital 'Jtrealtment ' is 
restrkted to meeting the patients' most 
basic physical needs". 'J1he White Paperquoted extensively from rhe fiTst report of 
t'he NHS's Hospital Advisory Service. 
which h'ad a'ttributed many problems in 
the hospitals to bad management: " 'J1hese 
con'ditions are the fault of management 
at all levels, no't ·df ward staff, and the 
latter are under~anda'bly resen'tful of 

crrtJCJsm they have sometimes received ". 
The White ~aper concluded: " Fundamentally, 
what has happened <is that outdated 
views have continued to <influence 
rhe aUocation of financial and other 
resources to many hospital'S for t'he 
mentally handicapped. In some places 
a'ttitudes have not kept 'P'a•ce with new 
knowledge about the latent capacities of 
the mental'ly handicapped, pulilic expectations 
·Of better services and tlhe generalrise in the standard af l•iving. Too li·ttle 
account has been taken of the increasing 
'burden p'l•aced on the hospital staff bychan·ges in the make-up of the patientpopulations ". 

'J1he signifi·cance of 'thi•s expianaJtion was 
its perception of Vhe 'hospitaols' problems in 
terms of ·a lack of resources. It f·ollowed 
that their solu>rion must he in the allocation 
of greater resources to the 'hosp'ital 
service. 'J1he Governmenlt accordinglyannounced ill: was stepping up the >interim 
programme to upgmde the existing hospitals 
'begun in 1969 by Ri·chard Cwssman 
Jiol1owing pulili•cation of 'fhe Ely 
report. The White Paper als·o ·cllllled for 
the constructi·on over a period of yearsof new hospitals •contain'ing a maximum 
of 200 beds (based •On local population 
bases •of 250,000). Meanw'hi·le hospitalpopulations would be reduced by some 
26,000 patients by lt'he expansion ·of community 
residential provision. 

It is difficult to a•Pgue w'it<h the deci~ion 
to upgrade existing fadli'tlies, improving 
rhe conditions of me for people who have 
spent long periods ·in hospital and staff 
as welL •But •this would seem •to 'be a pro· 
gramme rhat needs 'to 'be monitored 
closely, for the ·greater t'he investment 
th'at is made in the existing inslfi'tutions, 
the more difficult it wiH be ·one day to 
abandon 'the large ihospita'ls entirely in 
favour of ·a more ·integrative pattern of 
care. 

Other elements of ithe Whi1te Paper mightbe questioned more ba-si:cally. Nowhere, 
in the White Paper or elsewhere, did the 
Government present evidence supporting 
the decision to construct the new, 200Jbed 
subnormal'ly hospitals or, for that matter, 
vhe 'future 'hospit·al p·opulation o.f 34,000 


people. 11he DHSS's own s'tatisti·cal studies 
seemed to show that tlle great majority o'f 
present hospi'ta:l patients were not in need 
of medical treatment and possessed sub· 
stanti<l'l capa<oities fm self oare. Of 64,000 
patients in 1970, 78 per cent were 
ambulant, 70 per cent continent, 68 per 
cent had no behaviour di~orders, and 58 
per cent needed no as~istance in feedingwashing and dres9ing themselves. This is 
in spilte of lthe fact that 59 per cent of al<l 
patients over age 5 received no educati·on 
or training at aU :in rhospi'ffil (see 'the 

Census of Mentally Handicapped Patients 
in Hospital in England and Wales at the 
end of 1970, DHSS, 1972). Even amongthe most severely handicapped patients,
54 per cenlt could care for 'themselves and 
were neither non-ambulant, incontinent 
or behaY'iour-disordered (the firgure rises 
to 82 per cent when mitdly handi•capped 
patients are considered). These figures,
quite obviously, are not in accord with 
public perceptions of mentally handi· 
capped people in rhospirta:l. Peri·odi·oa'llyhowever an OU1t9ider penetrates hospit<l'l 
bound<l'r'ies and reports ·on the inaccuracyof the publi·c's stereotype. Thus, a sub-
editor of a national Sunday newspapereX'pressed his surprise 'in the headline of 
a story about a number ·df elderly women 
who were confined in a northern hospitalbecause they •once had had i.J'J.egitimatechildren: "Thousands of ' mental 
patients ' are sane "! 

ln hort, the White Paper represented a 
politi·cal compromise designed 'to protect 
the hospital service while encouragingcommuni·ty services to develop at their 
own p<l'ce over the longer term. Both 
Richard Crossman and Sir Keith Joseph,
successively Secretaries df State responsible 
for the mentally handicapped,
pursued seemingly contradictory policies 
during this period. T'hey increased expen· 
ditures upon the ho pita'ls while simu1taneously 
promising that the hospitals'role in the total range of services would 
be dimini hed. These strategies were in 
part a response to political pressure;
Peter Townsend has shown how in the 
period lbetween the publicaltion of the Elyreport and the White Paper the medical 
and hospital lobbies closed ranks in 
response to eX'ternal crit-icism (see "The 

political ociology of menta'! handicap," 
in The Social Minority, AHen Lane, 1973). 
It al'so was symbolic of the polit<ical divi· 
sion between cenltral and local government 
; a Secretary df State could not 
simply pronounce a renewed emphasis 
upon •community ca•re w'irhout grea'terimplementation of this policy by local 
authorities. But it is a<lso true lth'a1t local 
authorities could not enlarge •communityprovision without a redistribution of 
resources fl"om the hospita:l service. 

Absent 'from the White Paper was a 
recognition that the prdblems of 'the sub-
normality <hospitals were more than 
financial: they are political and soc'iological 
expressions a·s welt T'hey are 
political at rthe level ·Of representing the 
division of relatively scaflCe <heal1rh and 
welifare resources 1between competinggroups, such as local authority ~oci·al ser· 
vices department and <the NHS. 'Dhey are 
also pdliti•cal in rep·resent'ing 'the aufuority 
of some people ·over others. The segregative 
n<l'ture of the isolated men1tal hospital 
is a form of puhl<ic expression regarding 
mentally handica<pped people l(see for 
example DaV'id J. Rothman's The Discovery 
of the Asylum, Li~tle Brown, 
1971). 'Dhe prhys'ical separation of the 
hospitals' patients and medical and nursing 
staff !from members df 't'he genera·! 
community contributed to conditi<Jns in 
the subnormality hospitais in the 1960scondi
·tions which undoubtedly would not 
have ·been tolerated in sectors of the 
health and welfare esta'bl<ishment that 
receive more pub1ic eX'posure. One of the 
poignant aspects of rhe Nonnansfield 
affair wa,s the difficulty persons diose to 
the hospital experienced in attempting 
to cal1 attention to conditions there; it 
took an unpopular strike by members 
df the hospital's nursing staff to gainthe aHention of rhe general puiJiic and 
health administration. In addition 
<the cuStodial pat•tern of hospital care 
traditionally has accorded su'bs't'antial 
authority to professional staff members 
over merrtaUy handicapped people and 
~heir families. The medica·! concept of 
" clinical autonomy" for eX'ample ca'ffie 
under s'trong criticism from members of 
the Committee of Inquiry into conditions 
at South Ockendon Hospi't'al : "The 


history of •one of the villas which was 
intended fo'r medium •security revea-led 
a decline •to a w'ho!Iy una•cceptab1e and 
completely unjustifiable way af life. The 
inten·~ions of .the consulltant were good ; 
he made no ~ecret ·of what he was doing ; 
but he l•acked ~he experience to carry out 
the very difficult job r·equired ·of him. He 
needed clear gu'idance from the RegionalHospital 'Boa·rd, but did not receive it ; 
he required dose questioning about his 
actions and in'tentions when the ea-rlyfrJi•ts of the unjustifiable regime began to 
appear, but he seems to have 'Proceeded 
on his way wirhout ·cha:llenge. We have 
seen in the history of tlhis viHa ll!ll the 
stultifying effect·s {hat can fi'ow from an 
unimaginative subservice to the doctrine 
of the clin'ical autonomy of the consultant. 
The patients undoubtedly suffered because 
of it " (Report of the Committee of 
Inquiry into South Ockendon Hospital, 

HMSO, 197'4). 

The Sou:rh Ockendon Committee con· 
eluded that "mu1·Vi-disciplinary contra'! " 
of ·treatment st'anda·rds by professional 
teams would prevent reoccurrences. 
Simillarly, after the recent report by the 
Committee of Inquiry at Normansfield 
hosrpita1, improved monitoring procedures 
by healrfu authorities were offered 
as preventatives. But these prescriptions 
seem to miss the point. Publi•c 
scrutiny and demands for accountabili:ty 
seem at least as important in ensuring that 
handi•ca:pped people are able to enjoysimilar living standards as those enj·oyed'by non-'handrcapped members af the community 
and the question becomes ·one of 
whether thtis can be accompli&hed in an 
isolated institutional setting. 

'J1he nature of •the hospital organisarion 
and its administrative dhain •of command 
presents formida'ble social baTriers 'to 
meaningful reform of services. The White 
Paper encouraged hospita'l authorities to 
work toward the development of a community 
'based service, wifu ·the smal•ler, 
200-bed 1institu'ti•ons a-s the focal points. 
However an a:ssessmen't •of health authorities' 
progress five years later concluded: 
" . . . rhe great majority df the new 
developments . .. ei·Vher !built, building or 
being pl•a·nned are qui:te conventional 

mental hand~cap nosprtals, many of them 
in existing hospita'ls, some of them 
' tacked on' to other hospita:l premises." 
Even where rhe new, smaHer hospitals 
were being .built, they hardly represented 
community care : "The new ' small ' un•its 
of 180 'beds or so . . . are likewise essen-
tially hospitals and are s·rtuated on segregated 
'menta:! handicap ' carnpuses. It 
would be qu'ite wrong t:o see them a·s 
developmen'ts of 'community care ' in 
domestic-tY'pe accommodation . .. the 
overaH conception of ·Vhese developmentshas more in common wi•th the ' colonies ' 
of :the past than •it has with the communities 
and neighlbourhoods in w'hich non-
handicapped people live " •(Plans and 
Provisions for Mentally HandicappedPeople, Campaign for the MentailyHandicapped, Jully 1976). 

The White Paper also strongly encouraged 
health and soci•ai services dep·artments to 
collaborate in planning future services, 
and asked local and hospital authorities 
in each area 1to "fix a date aifter which 
the hospi1tals ·WiH not ·be expected ·ro admit 
from tha't loca'l authority's area, any more 
peop'le who need residential rather t!han 
hospital ca-re". The inquiry found after 
five years however t:hat : "T-he failure of 
central governmelllt policy to be interpreted 
•into aoti•on is nowhere more clearly 
seen than in relation to the 'loca~ dates ' 
to be determined for t'he cessation of 
' inarppropria'te' hospital admissions on 
purely ' socia·J ' grounds. Only one 
Authority had set such a daJte, and even 
that Autih•ority admitted that in1appmpriate 
admissions had nevertheless been 
made, where no alternatives were ava·ilable 
" (ibid). 

The case aga'ins't institUJtiona.J care has an 
economic aspect as well. There can be 
little question tha.'t an effective ·community 
care system, providing •a compl~e range 
of service, can ·be developed on:ly at great 
expense. But this understanding Taises 
further questions with regard to the White 
Paper's emphasis on hospita-l expenditure. 
A study published 'by ~he Office •of HealVh 
Economics .a·rgued tha't continued investment 
in the subnormality hospitals was 
draining off funds that might be spent 
more economiooally on ·community pro



vision-the'!"eby postponing the time in 
which community care might be considered 
a practical rea·liity rather than a 
pious hope (Mental Handicap, 1973).
And evidence from the United States, 
generated in a rigorous coot-lbenefit 
analysis by a federal government economist 
of American sel'Vices fm mentally 
reta·rded peap!e, suggeSits ·~hat in the !eng 
term community 'based servi•ces may be 
less expensive than they ·appear: "a full-
scale programme ~o deal with mental 
retardation is, however, an expensiveundertaking 'that must 'be compa-red with 
other worthwhile u\Ses ·of resources-Thus, 
we are confronted wi·fh ·a prdblem rhat 
involves a large use of resources and ·one 
cannot await a ·scientific determination of 
the optimal use ·df these resources. However 
p·oor the data may be, we must make 
the 'best use of i1t. The mentally Tetarded 
Me human .beings, with as much capacity 
for love, hate, hope, fear, contentment, 
frustration, ·and anger as any •of us. 
Most of the retarded •can •live reasonably 
usefu1 and happy lives if provision is made 
for their specia'l needs " (Ronald Conleg, 

The Economics of Mental Retardation, 

Johns Hopkins University Press, 1973). 
Sheltered !iY.ing a·rra·ngements, his study 
found, could be provided Ies\S expensivelythan large scale •institution•a:l care. 
Expenditures on employment programmes 
and reha'bi'liatation servi•ces in the longte'l"ms generated greater incomes and less 
dependency. Comprehensive prevention 
programmes would reduce the incidence 
of men•tal ·reta-rda•~ion ·eventually as well 
as the need .for other types of services. 
Investment in servi·ces aiding famil·ies of 
handicapped people ·could be considered 
a form of economic redistribution and in 
economists' terms, be figured as ttansfer 
payments rather than socia:l costs. 
" Altruism need not a'lways be the motiva>
ting fa'ctor in providing •developmental 
and supportive services to the retarded," 
Conley 'Concluded (op cit). 

financing the future patternof care 

Notwithstanding ~he White Paper's continuing 
support for the hospital service, 
it also called upon local authorities to 
provide a social support servi·ce based 

upon ·the families of handicapped persons. 
It admitted for example that " only a 
smal1 start " had 'been ma'de in providing 
these services: " M·ost parents a-re devoted 
to their handicapped children and wish 
to care for them and help lthem to 
develop to t'hei·r full potential. About 80 
per cent ·of the severely handicapped 
children and 40 per cent Qlf the severely 
handicapped a'dults Iive at home. Their 
families need advice and many forms of 
help, most df which a't present are rarelyavai'lable .. . a handi•capped child needs 
the ·affection and Sltimula:ting companywhich ·a family n•ormally provides for its 
children." A'l·so, "Children living with 
their own f·amilies have been shown to be 
much less .bruckward in social development 
t'han chitdren ·o'f simil•a•r intel1•igence in 
institutional care." 

But when it came to con'Crete plans, •the 
White Paper failed 1to support this 
rhetoric ; its projections for !the future 
described a service strongly resembling 
tradition•al patterns of ·care. Over a 20 
year period, •the number ·df chi'ldren in 
hospital was expected to decrease by only 
13 per cent, from 7,400 'to 6,400 (assuming 
a stable 'birth rate see table on page 
11). Considering aH forms of residentia~ 
care, the W·hite Paper actual:ly forecast a 
15 per cent increase in the number of 
handicapped persons expected to need 
all forms of residential care including'lodgings and foster care. In 1969, 134 
mentally handicapped people were in res·idential 
care per 100,000 popul•ation ; the 
White Paper's projection\<> boosted this to 
!55 per 100,000 population by 1991. (Itshou1d be noted that the White Paper's 
figures on the numbers of handicappedpeople in residential care were in substantial 
disagreement between its table I, 
"Incapa•city associated with men·bal 
handicrup " and the planning pmjeotions 
in table 5). 

Examination ·of the White Paper's patterno'f expenditure de m o n s t rates the 
ambiguity -in 'the Government's policy.
While commifted 1to a g·reater shift toward 
'community care, the spending proposals 
were weighlted towards proppingup a hospital service t'hatt even 1he White 
Paper's authors found " intolerable ". And 


While 'local authorities were called upon 
to improve " domiciliary ·and other servi1ces 
to make ilt reasonably possib1e for 
fami'lies to keep men~aHy handicappedchildren and adul1ts in thei·r homes ", funds 
under ·central government control were 
planned :to be expended 'largely uponforms of residential care. 

The White Paper's financial estimates 
were presented obliquely and were incomp1ete 
in many respects, largely because 
ministers could not prediat local ·authority 
response to the policy statement or the 
pa'ttern of toea! expenditure. The estimates 
seemed to indicate t'hat the hospital 
service, beginning of cDurse with a 
much larger base, would receive up to 
£130 million in capital funds ·over the 20 
year period, at a rate of about £7.5 million 
per year. Local authorities were expected 
to make capi'ta1 eX'penditures rotaUing£154 mi:llion on mental handicap pmjects 
during this period. 

Revenue ·expenditure on 'the hospitals was 
expected to grow from £48 million in 
1969-70 to £65 million five years I·ater, 
and rema<in stable at this level over the 
l.ong term. However, revenue expenditure 
on community services wou'ld increase at 
a '!'ate of only £2 mi'llion anuual:ly from 
a base of £14 million, to an estimated 
peak of only £54 million a'fter 20 years. 

While the White Paper did not provide 
complete ·revenue !figures !for aU types of 
services for <:omparable periods, the fol


lowing statistics seem to best convey the 
Government's in'tentions (in 1971 prices) : 

(i) In the five year period 1969-70 to 197475, 
revenue expenditure on the subnorma'lity 
hospitals was to increase at a 
ra:te of £3.4 milhon eaCh year (ii) in the 
decade 1971-811, revenue expenditure split 
evenly between local authority homes and 
adult tra-ining centres was to increase a:t 
a rate of only £2 million annually from 
the same ten year period menta'l handicap's 
share of revenue expenditure on 
other Local authority services, including 
domici1iary, was to increase at a rate of 
£0.5 milhon ea'Ch year. 
This third category included the recruitment 
of ·social workers, home he~ps, other 
staff :for domiciliary servi·ces, increased 
use of foster homes, 'lodgings and sheltered 
housing, and day care f·or chi1dren 
under five years of a:ge. In other words, 
'the Government was forecasting increased 
expenditure on hospita:ls and communityresidential a<ccommoda:tion at a rate more 
than three times 1'arger than combined 
spending on a:11 other community services 
for mentally handicapped people-induding 
adult training centTes, rel'atively costly 
projects to build and operate. 

The rationale for the low planned investment 
in domiciliary and other communityservices was uncerta·inty over their availability 
and use by the mentally handicapped 
and their families. Ministers did 
not feel it was realistic to establish goals 
that local authorities would not-or could 

RESIDENTIAL CARE: NUMBER 0 F PLAOE'S PROVIDBD (1969) AND 
NUMBER REQUIRBD •C1991) IN ENGLAND AND WALES 

·children adults total 
type of (ages 0-15) (ages 16+)
residen'tial •care provided required provided •required provided required 

local authority, 

volun·ba.ry and 

privately owned 

accommodation 1,800 4,900 4,300 29,400 
foster homes, 

~odgings, other 100 1,000 550 7,400 
hospital

in-patients 7,400 6,400 52,000 27,000 

totals 9,300 12,300 56,850 63,800 

shortf'all 3,000 6,95 .:c..

O :::------;---;-;;~----:---~


source: Better Services for the Mentally Handicapped, Omnd 


not-meet. But the White Paper's chief 
fa:ilure was that it failed to propose a 
method ·of assisting local authorities in 
developing these services ; the broad 
separation between central governmentand local authority responsibilities remained 
unbridged. 

It was also thought that because the services 
provided by social workers, home 
helps, play group organisers and similar 
staff benefit •other groups as well, it was 
not possible to estimate how many o.f 
these workers would be needeci by the 
mentally handicapped alone. Yet the lack 
of equivalent information about other 
services did not inhibit the Government's 
planners from making projections. Little 
consideration for example has been paid 
to the needs of mentally handicapped 
adults, either in applied m academic research. 
Parents o.f mentally handicapped 
children feel a growing insecurity as theywitness the gradual development of services 
for children, but the lack of corresponding 
development 1for adults. 

Even in commun1t1es with adult 
tra:ining centres there is a certain ambiguity 
regarding their role in the overall 
pattern o.f employment and education 
services, and their -objectives for the 
handicapped individual. Are they truly 
training centres, attempting to advance the 
indiv-idual's social a:nd occupational skills, 
preparing him fm greMer participation in 
community life? Are they sheltered workshops, 
with the emphasis upon obtainingand fulfilling manufacturing contracts 
with local industries? What are their links 
with community educati<on, rehabilitation 
and employment services? Or are theymerely centres for occupying handicapped 
people all day, providing them with a 
change of scene and rudimentary employment 
while offering relief to• their families? 
Though the answers to these and 
other questions are still to be determined, 
the Government planned ·a threefold increase 
in adult centre places (to 73,500 
places in the community). Later the DHSS 
contracted with an outside investigator to 
study the role of the adult training centre. 
Only recently with the pubJ<ication of the 
National Development Group'·s pamphlet 
on day servi·ces for the menta'i'ly handi


capped has the DHSS encouraged a discussion 
df the objectives of adult centres 
and moved towards issuing a revised 
model ot good practice for •local 
authorities to cons-ider. 

The White Paper not only forecast a 
greater number of people in some form of 
residential care ; it also provided the impetus 
{or the development of the 25 bed 
hostel for mentally handicapped people 
as the standard for measuring a !.ocal 
authority's progressiveness. 

homes, hostels and 
community care 

The Seebohm Committee first saw the 
hostel as the preferred .form of communityresidential care f.or the mentally handicapped. 
The Govemment in the 1960s 
was recommending foster homes or Iodgings 
as the alternative to hospital (orhostel) care. But the comprehensive experiments 
with hostel care in the Wessex 
region, and the apparent intermeruate 
qual-ity of the community hostel between 
the custodial regime of the subnormalityhospital and non-institutional care in the 
community seemed to appeal to the Committee 
as an appropriate compr-omise. 

The White Paper in fact recommended 
" residential accommodation according ·to 
individual need " and listed many possible 
forms of accommodation for handicapped 
people : foster homes, lodgings, 
ordinary housing •Or group homes with 
social work support, in children's homes, 
in local authority homes for the elderlymentally infirm, or in hostels. But it also 
stated that hostels with a maximum of 25 
beds (20 for children) "will supply much 

•Of the residential care needed·· and further 
called for the substitution of the 
word " home " for " hostel " bevause of 
hostel's " ring of impermanence and . .. 
certain austerity." 
Such pr-onouncements from the DHSS undoubtedly 
have a direct impact on local 
authority behaviour and thinking (seeNi•cholas Basanquet, New Deal for the 
Elderly, Fabian Tract 435, July 1975):
White Paper recommendations acquire 
greater strength when a local authority 


must .approach the DHSS for loan approval 
of capital pr·ojects. The hostel recommendation 
also possessed a power of 
its own, due to the fact that of more than 
92,500 people already in some form of 
local authority residential accommodation 
in 1972, more than 88 per cent were in 
institutions containing more than 31 beds 

(Health and Personal Social Services 
Statistics for England, DHSS, 1973). And 
a oloca'l authority building note (No. 8, 

RPsidential Accommodation for Mentally 
Handicapped Adults, pulbli~hed in 1973, 
encouraged local authorities to experiment 
with ho~tels with from 16 to 24 
places. However, the cost allowance table 
showed that •largest is cheapest, and this 
might a•ccount for the popul·ari:ty of the 
24 bed hostel as the primary form 
of commuruty residential[ provision ; 
of 32 approvals granted by the Government 
in 1974-75 for residential accommodation 
for mentally handicappedadu1ts, 24 were for p·rojects containing24 or 25 beds. As one observer commented: 
" Experience of a wide varietyof homes and hostels up ·and down 
the country suggests that the large hostel 
is becoming standard local autho•rity provision 
for mentally handicapped people " 
(Alan Tyne. " Residential provision for 
men•ta1ly handicapped adults," Social 
Work Today, 10 June 1976). 

Yet many questi·ons must be asked about 
the suitability of the standard hostel. As 
Professor Kathleen Jones has noted, 
" Somehow the magic .figure of 25 places 
has been arrived at as a suitable size. 
Yet very l·ittle research has been undertaken 
into the realities of hostel care, and 
I know of no study, empirical or theoretical, 
which suggests that homes for 25 
people have an automatic social viability"
(Annual Conference Report, Nafiona·l 
Association for Mental Health, 1973).
The social relationships of hostels of 
different size and social organisation must 
be examined very carefully. To what extent 
do they resemble the f.amily homes 
or other living arrangements of non 
handicapped people? How flexible and 
meaningful are staffI resident relationships 
and how much of an improvement are 
they over those found in traditional hospitals? 
(See Ann Shearer" No place like 

home, Campaign for the Mental'ly Handi: 
capped, undated, for an apt discussion of 
staffI resident relationship in different 
forms of ·accommodation f·or mentallyhand·icapped people.) What kind of personal 
relationships are hostel residents 
able to maintain with their friends and 
relatives? Equally important are questionsconcerned with the integration of hostel 
residents with their community: are their 
links with the n·eighbourhood, l·ocal services, 
recreational facilities, ·employmentservices and the social life of the community 
improved over other f.orms of in-
s~itutional and residential accommodati
·on? Before the hostel can be advanced 
as the all purpose solution to the residential 
care pr.oblem of mentally handicapped 
people, these and similar questions 
must be answered carefully and positively. 
But if hostels a.re found to be no 
more than mini institutions ·in the community, 
it already might be too late to 
change course. Clearly the momentum is 
running in favour of the yet unprovenhostel arrangement: " There is still t•oo 
the element of civic pride in buildings. 
A hostel can be named after a local personage 
and provides scope for the borough's 
architect, and the parks and gardens 
department. It can also be built on 
land already owned by the corporation, 
and it's surprising how of•ten this leads tn 
a site next to the sewage works or the 
hosoital, ·or in a complex of other ' deviant' 
institutions-reception •centres or 
homes for the mentaUy ill. Hostel's reflect 
·our passion for inv~tment of capital into 

property. rather than the less tangible 
revenue into people" •(Tyne, ibid). 

views on handicap and 
the family 

Domiciliary and other family supportservices are investments in people. But in 
spite of the White Paper's frequent admonishments 
that these services are 
crucial components of a community care 
system, the Government declined to set 
planning targets fm local authorities. With 
regard to financial projections for domiciliary 
services, which involve littl·e or no 
capital expenditure, the White Paper said : 
" ... it has been assumed that as these 
other services develop up to £1 million 


additi·onal ·expeniture may need to be incurred 
in any one year, and on averageexpenditure will rise over the whole 
period by at least £0.5 million a year. The 
rate o.f development will depend on the 
possibility of recruiting certain types of 
staff such as home helps, or of findingsuitable lodgings, the output of training 
progr·ammes, and other factors some of 
which will be outside individual authorities' 
control." 

This hardly was an inspiring charge to 
local authorities. But it was consistent 
with previous practice. Since the RoyalCommission pr·oposed a preventive community 
care system, no systematic evaluation 
has been made of the effects of 
different combinations of domiciliary services 
on families' capacities to cope with 
the problems of mental handicap. 

No .government paper or circular has outlined 
the content or acppearance of a 
domiciliary service. Even t'he oHss's 
elaborate pr01ject on the " deve1opment 
and evaluation df modem :communitybased 
services " in SheffieJ.d ignored

1

·this important variable: the effect of 
domicilia-ry and other services on the 
" need " for residential care. The Depa-rtment 
of Hea'ith has steadfasVly refused 
to assume 'leadership on this .js·sue ; 
even its request for the submission of 
ten year development plans from the 
new soci.al services departments in 1972seemingly 
an excellent opportunity to 
·esta,blish standards •of care-neglected to 
outline the practical form of a domiciliary 
service (oHss Circular 35/72). 

the lack of information 

In a sense the DHSS misses this opportunity 
every year. Statistics collected by 
local authorities on their operation are 
determined largely ·by the information requested 
by the DHSS (M. Bone, B. Spain 
and F. M. Martin, Plans and Provisions 
for the Mentally Handicapped, GeorgeAllen & Unwin, 1972). Central departments 
therefore might construct more 
useful indices of the quantity and quality 
·of local provision through the annual 
mental health returns-equivalent to the 

revealing data •On the subnormality hospitals, 
their patients and services published 
by the DHSS in recent years. 

The present mental health returns are 
more remarkable for what they fail to 
tell us : they say how many sooi.al workers 
or home helps are employed by local 
authorities, but not how many lend 
assistance to mentally handica.pped people 
and their families. They tell us how manyhandicapped people attend adult training 
facilities or live in community hostels, but 
ndt the number benefiting fr·om the provision 
of housing aids or adaptations, incontinence 
services or going on holidays 
paid for by authorities. They pmvidecrude estimates of the numbers of handicapped 
people using various services, but 
not the extent of overlapping between serV'ices, 
the severity of hanilioap of the 
people served or, most important, the 
numbers not receiving these forms of 
help. The conclusion seems inescapablet:1at present returns are highly insensitive 
indicators ·of the quality of local authority 
services for mentally handicapped people. 

Evidence from other sources however 
suggests tha't community services have 
helped relatively few families since the 
R·oyal Commission's report. Only the provision 
of speci.al school places has approached 
demand for them, and the White 
Paper conceded that about 1,800 children 
were still on waiting lists in 1969 and that 
provision varied widely from one 
authority to another. In a sense, this 
policy of developing special school provision 
for mentally handicapped children 
is reaching fruition just as current thinking 
is abandoning it. The trend is toward 
providing education for handicappedchildren within conventional schools ; in 
April 1977 for example the American Department 
·of Health, Educat·ion and Welfare 
issued ·regulations stipulating that all 
handicapped children, regardless of the 
nature or severity of handicap, are entitled 
to a free public education appropriate 
to their needs, and these children 
" must be educated with the non-handicapped 
in regular classrooms to the maximum 
extent possible ". In 1969, only half 
·of the adult centre places required were 
provided (White Paper). A report in 1970 


said that less than one half of one per 
cent of cases served by the home helpservice were families of the mentallydisordered (which includes the mentallyill as well; ·see The Home Help Service in 
England and Wales, Government Social 
Survey, HMSO). The shortage of trained 
soci•al workers, <particularly those with 
knowledge of mental handicap, has been 
well documented. Studies -of families with 
handicapped members repeat this picture: 
the mentally handicapped apparently have 
been a low-priority gmup in the expansion 
of community health and welfare 
services (see for example M. J. Bayley,

Mental Handicap and Community Care, 

Routledge & Kegan Paul, 1973, or Olive 
Silver and Peter Moss, Mentally Handicapped 
School Children and Their Families, 
Liverpool Education DepartmentChild Guidance Clinic, 1972). 

One consequence o'f this 1ack of domiciliary 
provision is that gross disparities 
ex-ist across the country in terms 
of .the number of people fmm different 
J.ocal authorities who a·re resident in sub-
normality hospitals. The national average 
in 1970 was 131 patients in hospital per 
I 00,000 population, but English boroughshad an average of 153 patients, with a 
range of 24 to 294. Lincoln had about ten 
times as many handicapped patients in 
hospital as Tynemouth. The average for 
London boroughs was 129, with a range 
of 67 to 240 ; Tower Hamlets had four 
times as many patients as Bromley. English 
counties averaged 103, with a rangeof 36 (East Riding of Yorkshire) to 159 
(Devon) !(Census, op cit). Many exp'lanations 
could be offered for these disparities--<:
hanges in local authority boundaries 
or hospital catchment areas, the playof historical factors such .as the evacuation 
of handicapped children during the 
war years, or varying incidence of mental 
handicap itself. But there also is a suggestion 
here that these figures are representations 
of the quantity and quality of 
community services provided by the J.ocal 
authorities of these hospital patients. As 
recently as 1976-77, 33 local authorities 
and 19 London boroughs still bad no residential 
places of their own for mentallyhandicapped children and nine authorities 
had no place for handicapped adults 

(Nicholas Bosanquet, "Services for the 
mentally handicapped," Nursing Times, 
27 October 1977). 

The implication is that as long as mentally 
handicapped people are Living with their 
families-or elsewhere in the community-they are a low priority .group in the 
distribution of services. Considering that 
80 per cent of handicapped children and 
40 per cent of aduJts live in their familyhomes, the Government's balance of expenditure 
seems ill judged indeed. The 
White Paper's pattern ·of future services 
was based upon a number of DHSS-
sponsored epidemiological studies of mental 
handicap, including the numbers of 
handicapped people in institutional care. 
But these figures must be considered only 
as very provisional estimates. Changes in 
the birth rate and the rendering of effective 
support to families w.ill affect the 
number of reSJidential places needed in 
the future. 

lmpllicit in the White Paper\s patternof services-in spite of rhetoric to 
the contrary-was a familiar administrative 
a-ttitude expressing a lack of 
confidence in the family as an institution 
and its abiJ,ity to withstand the pressures 
wrought •by mental handicap. This 
attitude is represented by the developmentO'f a " minimum " level of serv'ice, one 
which emphasises residential accommodation 
as a substitute for the family and its 
own resources. It also is evident in the reliance 
placed upon casework that features 
interpretations of behaviour rather than 
the co-ordination of supplementary services 
by social services departments. This 
is due largely to the scarcity of resources 
available to provide direct assistance (see 
for example Michael Brill's account of 
the difficulties of the Seebohm worker in 
supplying maintenance services following 
re-organisation of the social services departmen'ts 
in '!'he Year Book of Social 
Policy in Britain, 1971). Where goods are 
in short supply, members of the familyseeking assistance too often find that they 
are subjected to an exercise in familypathology which is concerned not with 
how the family might be helped, but the 
essentially negative issue of the morbid 
effects of mental handicap on family or



ganisation. As Eugene Heimler described 
these effects: " . .. there is a grave risk 
that the parents' relationship with the 
child will be disturbed. If they become 
aware of their feeling of guilt, they veryoften over-protect the child. On .the one 
hand this often hinders his development 
by cultivating an unnecessary degree of 
dependency ; on the other hand they maymake quite exhorbitant sacrifices, often at 
the expense of their own mental health 
and sometimes that of the other children. 
If they are unable to face their guilt they 
may simply reject the child, withdrawing 
their affection from him. They feel guilty 
at having produced a subnormal child, 
and this sense of guilt is often the drivingforce behind their behaviour. It makes 
them over-critical and over-sensitive, 
sometimes to a pathological degree. These 
mothers are desperately in need of help,
attention and care. It is society's respon


ibility to help them by relieving them 
of the burden of their guilt, so that theydo not destroy either themselves or their 
mari'tal reiationships" •(Mental Illness and 
Social Work, Penguin, 1967). Tlhis passage 
is quoted at length because it illustrates 
the ease with which nearly any behaviour 
exhibited by the parents of handicappedchildren can be explained solely by the 
fact that they have a handicapped child. 
lf parents sacrifice to keep their child at 
home, they are endangering their mental 
stability of their non handicapped children. 
If they seek residential care, they are 
rejecting the child. If they try to stimulate 
him. they are not accepbing reality ; if 
they cater to his whims, they are contributing 
to his dependency. 

The emphasis upon family pathology is 
ymptomatic of contradictory attitudes 
toward mentally handicapped people and 
their families tha't find expression ·in profes 
ional ideologies in social work, medicine 
and nursing, phychiatry, and also in 
official policy. Traditional values uphold 
the sanctity of the family unit, perhap~ 
unfairly. and parent who eek residential 
care are chastised for " rejecting " their 
child. Yet we are aware also of the potent
·ial borne by the presence of handicapfor disrupting what are considered to be 
" normal " family relations : the popularand profe ional literature are littered 

with references to broken marriages,
guilty or inadequate parents, neglectedsiblings, overprotective families, and other 
stressful phen·omena that are said to occur 
when families attempt to accommodate 
their handicapped member. Many professionals 
advise parents to admit their 
child to institutional care with the hope of 
maintaining the integrity of the familyunit ; many parents refuse their offer for 
similar reasons. Yet the family is not a 
perfect institution, nor is it exempt from 
the pressures of change and modernizati.
on. What is needed is closer examination 
of the forms of family unit that can 
offer the affect,ion, protection and linkage 
to the surrounding community that are 
needed by handicapped people, and official 
recognition of the role of those families 
in pro·vision of services. 


4. labour and mental 
handicap 


When Labour ·returned in 1974 it had 
little room for manoeuvre: realignmentsof local government and welfare services 
had al•ready taken place, the NatJional 
Health Service reorganisation was only a 
month away and familiar pressures on 
public expenditure inhibited discussion of 
ambitious reforms. With rega·rd to mental 
handicap, ministers recognised that 
these reorganisations had not dealt with 
the clash between medical and social 
philosophies and were unlikely to engender 
the collaboration between health 
and social services authorities necessary .to 
make even the White ~aper's modest proposals 
work•able. As Barbara Castle 
noted: " But whilst ·there •is· ·rationalityabout the divisi·on of responsibilitiesgenerally between say the National Health 
Service and local authority soci·al services, 
I think we should be frank and 
admit that the boundaries appear the 
least rational, the most arbitra•ry where 
the mentally handicapped ·are concerned " 
(NSMHC •conference •speech, op cit). Mrs 
Castle and Dr David Owen, then her 
Minister of State, apparently gave cons.
ideration to radical recastings of services, 
such as by creating a national, centrally 
financed mental handicap service 
with a " social service and not a sickness 
service " orientation (by combj.ning the 
ho·spitals with l·ocal authority services, as 
proposed by the Labour Party's 1973 
Green Paper, Health Care) or by transferr.
ing the subnormality hospitals to local 
authority social services departmen-ts. 
However, feaTing the upheavals that 

might be caused by another juggling of 
services and responsibilities and pr·obablyinhibited by its costs as well, their eventual 
decision was to " reaffirm the phil·osophy 
and general approach of the White 
Paper " '(ibid) . 

Since then the Government's policy on 
mental handicap has had two J,imited elements 
: first, attempts to mlllinNllin mental 
handicap's share of reduced levels of pub1ic 
expenditure, .and second, efforts .to en-
cour·age greater efficiency and co-ordination 
in the development and delivery of 
services. In spite of the tepid nature of 
the Conservative Government's White 
Paper, there is· no indication that fundamental 
reforms of the mental handicap 

services have ·been given further considerati-
on. Moreover ·official statements 
have warned that reforms will be contingent 
upon br.ightening of the economic 
picture: " There is increasing public and 
professional recognition ·that the scale and 
qual·ity o.f the health and personal social 
serv•ices depends on our national economic 
performance, along with all the other 
main public services and so many other 
aspects of our nati·onal l·ife. We cannot 
insulate the financing of health care or 
the persorral social services from the economic 
facts .of life " (David Ennals, Medical 
JournaJ'is'ts' A~soci'ation ·speech, op cit). 

But the economic facts of life have not 
been much kinder to the mental handicap 
service under the Labour Government 
than under prev.ious administr-ations. 
Originally, the Government suggested !in 
the 1976 DHSS Consultative Document 

(Priorities for Health and Personal Social 
Services) that a numlber of services, including 
mental handicap, needed specialprotection f•rom the slowdown in publicexpenditure. Average g11owth rates ·in current 
expenditure for these priority or 
' cindereUa ' services were : services used 
mainly by the elderly and younger physic-
a'lly handicapped people 3.2 per cent, 
services for mentaUy handicapped 2.8 per 
per cent, services for children and fami'lies 
with ohi•ldren 2.2 per cent and servi-::es 
for the ment·ally ill 1.8 per cent. 

Gains in these services were ro be 
financed by cuts jn the growth rates of 
others-in particular, the acute, gener·al 
and maternity hospital services-and byreduced dispensa,t·ion of drugs. In .the 
words o'f the Consulta:t-ive Documen't : 
" Such a pattern of distJribution would 
broadly maintain the -rate of pr.ogress towards 
the targets set out jn the White 
Paper of 1971 on ·the Mentally Handicapped 
and the recent White Paper on 
Mental Illness." However it should be 
pointed out that these services for mentally 
handicapped people grew by 8 per 
cent per annum between 1970I 1 and 
1973 I4. That their growth rate could be 
cut by nearly two thirds yet maint<rin the 
White Paper's timetable further emphasizes 
the White Paper's .timidity. Minjsters 
responsible for mental handicap ser



vices m Wales took a more pessimisticview in their corresponding document : 
" . . . in v.iew of the difficulties which 
social services departments will be f.acing 
oin the next few years, Ministers have reluctantly 
concluded that .growth in these 
services will be considerably reduced,

although progress towards the realisation 
of the aims of the 1971 White Paper will 
be resumed in full as soon as resources 
become available " (emphasis added). 

Amid indications that the development of 
new facilities was faUing behind the White 
Paper's targets, the Government issued 
another statement on health and social 
sefV'i·ces priori>ties }ate in 1977 (The WayForward, DHSS, HMSO). In spite •of further 
cuts .in public expendtture, the Government's 
aims, the document said, remain 
broadly the same : " . . . to •remedy 
past neglect of services, particularly those 
for the mentally ,jJJ and the mentally handicapped." 
But it was apparent that this 
strategy was running .into difficulty ; the 
expected transfers from the ·acute and 
general hospitals were not -occurring and 
in some circumstances, expenditure on 
these services might need to be increased. 

The best indication however that the 
White Paper strategy was bein-g compromised 
by the needs of the hospital service 
was prov•ided in an appendix in 
which regional health authority strategic 
plans were reviewed : " All regions foresaw 
slow progress in providing district 
·based services for the mentally ·ill and 
handicapped and in closing J.a•rge psychi
·atJ1ic hospitals. There were widespread 
doubts about the abil-ity of l·ocal author.ities, 
despite joint financing, to prov.ide 
-residential and day care serv•ices for those 
groups. Most regions still had Large institutionalised 
populations. Several commented 
on the increased revenue cost of 
providing treatment in smaller centres. 
But the main problem appeared to be a 
conflict, at least in the shorter term, between 
the priority for serv-ices for the 
mentally ill and mentally handicapped 
proposed in the consultative document, 
and the pressures on regions to invest ~n 
acute services " (Appendix II). 

Within loca'l authorities as well t'here 

a:re ·conflicts between social services ex· 
penditures on domicil-iary and com-
munity-care services, on Ca!pi>tal investments 
on residenti•al fa,cili:~ies for t'he 
mentaiJly handicapped and menta•lqy ill, 
the elderly and physica1ly handicapped 
people. Rather than promoting an expansion 
o•f community care services, the 
term of the current l.;a:bour Government 
has seen the balance shift somewhat 
toward spending on residential accommodation 
; between 1974-5 and 1976-7, 
the net share ·of personal social servi·ces 
expenditures devoted to res·identia.J care 
by Qoca'l authorities has grown from 44.8 
to 46.2 per cent, while community care 
spending has dropped from 24.6 to 22.9 
per cent (The Government's Expenditure 
Plans, 1978-79 to 1981-82, Omnd 7049-11, 
HMSO, 1975). 

the joint financing scheme 

In this context, the Government's jointfinancing scheme, announced .in 1976 and 

•rev.ised the foUowing year, must be 
watched carefully. Joint financing is 
meant to provide a financial incentive for 
health and social serVJices authorities to 
collaborate in planning and deliveringassistance to groups such as .the mentallyill and mentally handica·pped, the physically 
handicapped and the elderly. There 
akeady ·is a statutory obligation uponthese authorities to co-operate in this 
manner under the NHS Re-organisabionAct 1973, but this linkage has failed to· 
develop. As Mrs Castle said .in her 
NSMHC speech in 1975, " . .. we must be 
disappointed that there has not been that 
dramatic change in attitudes nor, as a 
consequence, that improvement in collaboration 
and joint planning between 
health and local authorities which was, 
and is, central t·o the full success of the 
White Paper's strategy ". 
The Government's strategy has been to 
foster the creation of a bewjlder.ing aHayof consultative and planning teams to develop 
'these impoved aott'itudes and better 
co-ordination : the National Development 
Group for the mental'ly handicapped 
(NDG) and Development Team (oT) at the 
DHSS level, joint ca•re planning teams 


(JCPTS) and sub-groups in appropriatespecialities-such as mental handi•capon 
the Area Health Authority (AHA)
'level, and district planning teams (OPTS) 
to assist the di•strict mana:gement (DMTS) 
in hea'ith autho6ties. These are in addition 
to the joint consulta:tive committees 
(Jccs) estab1ished in 1974 to advise Area 
Health Authoribes and local authorities 
on their performance. To give aU this 
collaboration an edge, the Government 
has announced that funds would be 
available-up to £43 mil~ion in 1980/81 
in capita'! and current financing for joint 
p1lanned projects. 

Under this plan, health authorities are 
permitted to provide, fr.om their own resources, 
capital funding for selected soci-al 
services projects, funds to underwrite the 
operating costs of these or other social 
services projects, or speoial arrangements 
giving local authorities the use of National 
Health Service land or property. The 
criteri•on to be used by health authorities 
in making the decision to provide this 
assistance is that the authority js satisfied 
that the " spending is in the interests of 
the NHS as well as the local authority, and 
can be expected to make a better oontr.ihution 
in terms .of t•otal ca·re than if 
direct'ly applied to health services" (oHss). 

The jo·int financing plan provides a 
method of transferring centra1 government 
funds to local authority social 
services departments. It a~so pl-aces the 
onus upon local authorities to deve'lopservices and assume ·the future costs 
of their operation. The joint financing circular 
recognised that in the current economic 
situation many l•ocal authorities 
wou'ld be reluctant to make heavy capita1 
investments without assurance that theycould bear the operating costs in the 
future. Therefore, " . .. it will be appropriate 
for a signi'ficant proportion of 
these funds to be directed to supportof revenue activities not requiring capital 
investment. In these circumstances, joint 
financing assistance may 'be used to 
maintain existing personal social services 
which might otherwise be at risk, o·r to 
support capital projects already begunby LAS ". So if used imaginati-vely, the 
joint finan:cing scheme coutd be used to 

develop non capital domi•cihary services 
to prevent or postpone fhe need for 
insti1tutiona1 admi·ssions. 

It remains to be seen how the joint-
financing plan wi'll work in practice. An 
early assessment of ~he scheme published 
by the Disability AHi·ance, found that 
while some heal-th authorities and social 
services departments were taking advantage 
of it in deve'loping innovative domicil
·iary and non-institutional services, in 
other area·s, " the joint financing scheme 
seems to be adding to the pressures to 
insti·tutional-ise •la:rger sections df the population, 
or, at least, provide an a~ternative 
form of institution for those who would 
previoiJIS!y have been cared for within the 
'hospital system" (The Choice Between 
Family Support in the Community and 
Segregation of Client Groups in Residential 
Institutions, 1978). It might be 
questioned whether local authorities 
possess the imagination -or means to take 
full advantage of the pian, or whether 
the health authorities wii'l concede that 
it is in the publ·ic interest to develop nonmedica1, 
non traditional services in the 
community ru; a matter of high priority. 

FinaUy one of Vhe reasons Why jointpLanning has not taken place in the past 
can be traced to differences •in philosophies 
and professional approaches between 
the medical -and social services 
establishments toward the care of groupssuch as the mentally handicapped. Also 
it might be questioned whether the recurrent 
cuts in publ-ic expenditure might 
dampen these collabopative efforts, leading 
health officials to protect the hospi-tals 
and the rest ·of thei•r tePritory. These questions 
will be answered only as the jointfinancing scheme develops and future expenditures 
on health and the personalsocial services might be compared. 


5. beyond community care 
When pl·an is latid upon plan, reorganisation 
upon .reorganisation, one sees that the 
weakening of the " community care " 
ideal has been the distinguishing feature 
of social policy for mentally handicapped 
people in the 1960s and 1970s_ There have 
been improvements in t•raditional services, 
to lbe sure, and uneven development 
of some community services_ This is not 
surprising: the succession of Elys, Farleighs, 
South Ockendons, Whi-ttinghamsand Normansifields was bound to stimulate 
changes of some magnitude in a 
clearly out moded system oif care_ Yet 
these marginal deveJiopments should not 
be over estimated: they cannot be mis


taken for the radical transforma·tion of 
pohcy that conditions demanded and 
optimistic rhetori•c promised_ And few 
would argue that they 'have been a 
'liberating influence on those traditionaNy 
shunted from the communi•ty for disa'
bi'lity df mind. 

A curious footnote to the per.iod has been 
the performance of Labour with regard to 
the mentally handicapped_ The 1964-70 
Government not only presided over the 
storm of publicity regarding conditions in 
the subnormality hospitals, but in the late 
1960s actually cut local author,ity loan 
approvals for tra.ining cent•res .and residential 
provisi·on for the mentally handicapped 
(Nicholas Bosanquet, " Inequalities 
'in heal'th," -in Labour and Inequality, 
Fabian Society, 1972)_ Despite Richa·rd 
Crossman's tireless campaigning in demonstrating 
the need to .improve conditions 
for mentally handicapped people 
and his implementation of stop gap 
measures to reduce the •inequalities between 
the subnormality hospitals and 
other instituti·ons, the Labour Government's 
long term pol·icy on mental handicap 
failed to emerge before -its defeat ,in 
the 1970 general election_ In view of these 
past performances 1it is peculiar that the 
·present Government would be satisfied 
with a reaffirmation of the Conservatives' 
conception of ref·orm. 

The victims of this failure ,in pol,icy are 
of course mentally handicapped people_ 
What is not clearly understood is that a 
policy can be successful ·in improvingJ.iving conditions of handicapped people, 

yet fail to forge the desired l.inks with 
non-handicapped members of the community_ 
Segregative aspects of life in the 
long-stay hospitals are familiar, and no 
one has yet demonstrated how the expensive 
upgrading programmes will lessen the 
social isolation of hospital patients' lives_ 

Whi'le the recent report of the National 
Development Group for the MentallyHandicapped made many impor.tantrecommendat•ions to the Government 
regarding the mental handi•cap hospitals 
(among others, that an independentinspectorate be establis'hed to inspect all 
ser.vices for mentaHy handicapped peoP'Ie; 
that a more radi•cal shift be made from 
hospital to community services ; that a 
method be found to earmark centra'! 
government funds for loca1 authorities 
for mental handicap serv-ices ; and that 
the role of the mental handi•caip hosp<i·tal 
should be reappra-ised by the Royal Commission 
on the NaJtional Heallth Service), 
it failed to explain how a hospita·l can 
be "first and foremost a home " for 
people who .Jive there (Helping Mentally 
Handicapped People in Hospital ", DHSS, 
1978)_ No amount of domestic Ulpgrading, 
staff tra-ining and attention to minimum 
standards wiN crea<te the pattern of personal 
relationships, continuity and familiarity 
that characterise real homel·ife_ 
Mentally handicapping conditions are not 
medical conditions, and no one has explained 
yet why hospitals, whether theyhave 200 beds or 2,000, are appropriateplaces for mentally handicapped people 
to live out their lives_ But in addition a 
gr.owing body of ·research is describing 
how deprivation and handicap restrict 
persons al·ready living in the oommunityfrom full participation in commuruty ].ife_ 

With mentally handicapped people and 
thei·r families this means sharp restrictions 
of choices in living, working, education, 
economic and domestic decisions 
that not only isolate ·the handicapped person, 
but restrain those living around him. 

An effective policy must not only provideaccommodation and occupation ; -it must 
go beyond present conceptions of "commun•
ity care" to deal as well with the 
wider issue •of 'the enhancement and pro



tection of the handicapped person's place 
in the community. 

The principles underlying an authentic 
community care policy are, ironically,
familiar: they were formulated and 
elaborated upon in the report of the 
Royal Commis~ion, and many were incorporated 
in the ·• general principles " 
neCllr the beginning of the White Paper.
They can be summarised as follows. 

principles of community care 

Community care is a social, not a medical 
concept. Tradiuional patterns of medical 
care, with their suggestions of ~ickness, ill 
health and abnormality, are inappropl1iate 
models for the care of mentally handicapped 
people because mental handicap 
itself is a disability, not an illness. Supporting 
services therefore should concentrate 
upon the effects of this disability, 
seeking to contribute to the ~ndivjdual's 
social development and ability to participa:
te in rhe life of the community. This 
concern with the functional consequences 
df mental handicap suggests that opportunities 
for sharing domiciliary and community 
occupational, transport, and 
domestic services by elderly, physicaiJ!y 
handicapped, mentaily il'l and m_entall_yhandicapped people should be mv~st;gated 
and implemented wherever poSSible. 
This new emphasis upon the severity of 
a person's disablemen_t as the crite~ion 
to be used in a!'locatmg serv1•ces mightrationa'lise demands for rhe creation and 
expansion of services. _and lessen the 
likelihood of competitiOn for scarce 
resources 'between representatives of 
various populations jn need of assistance. 
medical needs of mentally handicapped 
people should be met by the same medical 
resources used by non-handicappedpeople, and should not be used . as a 
rationale for the long-term separatiOn of 
the handicapped person from the community. 


Community care aims to integrate handicapped 
and non-handicapped people.

Specialised, segregated services. f.or mentally 
handicapped people have m the past 
meant inadequate, under-financed ser


vices. They have been stigmati~ing also, 
emphasizing differences between handicapped 
people and other people rather 
than thei-r similal'ities. Services should 
therefore be based in the local community 
and seek to preserve the handicapped per-
son's links with his family, neighbourhood 
and community. Whenever possible, handicapped 
people should use the same services 
and community resources as ordinary 
people. Community serv·ices should 
be pr-ovided regardless of severity of handicap. 
Inequalities between handicappedpeople should not be created by the pr.ovision 
of community facilities for the most 
Cllble and institutional care f.or the most 
handicapped. 

Community care is preventive and regularly 
applied, and it not crisis oriented. 

Traditional services have served as an 
alternative to the fam~ly: the State 
assumed responsibility for the handicapped 
person when the burden of care 
became too great for the family to bear 
alone. Communi·ty care recognises family 
units as the keystones of the care systemand offers regular assistance, guidance and 
specialised skills that reinforce the 
family's own efforts. Residential accom


modation jn small, domestic units or 
ordina,ry housing ·in the local community 
also is an important element of community 
care. Residential assistance can be 
used as short term care, to provide relief ; 
as accommodation while the handicap 
person receives speciaLised . trainin~ or 
medical treatment ; as a family substitute 
for handicapped people without families 
of their own, or as an aid to the natural 
progression of the fam~y cycle when t~e 
handicapped person WIShes to leave rus 
home to 'lead an independent or semi-
independent 'lilfe. 

proposals for 
community care 

A new community care policy must begin 
with the abandonment of the 1971 White 
Paper. Its replacement should contain a 
cogent statement on the needs ?f m~tally 
handicapped people and dls~uss1on 
of the ways in which these needs rrught be 
met. This would take the form of a 
national development plan for the men



tally handica,pped, setting objectives for 
family support, assessment and education, 
residential accommodation, income ma·intenance 
and the long-term issue of vocational 
rehabilitation and training. It 
should outline responsibilities of central 
government departments concerned not 
only with health and the personal social 

ervices, but housing, education and employment 
·as weU. The development plan 
should contain a,n analysis of the causes 
of past failll!fes in this area of publicpolicy ; a discussion of views on the r·ole 
of mentally handjcapped people in 
modern , industnial societies ; consideration 
of the rights of handicapped people : 
an elaboration of the philosophy underlying 
its objectives and pla,ns, and an expression 
of renewed commitment on the 
part of central and local government to 
community care. 

The national development plan would be 
only an initial step however. Other actions 
must be co-ordinated with it to create an 
effective community care service: 

I. The DHSS should commission or carry 
out a national census of mentally handicapped 
people in the community to supplement 
corresponding data in earlier 
censuses of handicapped people in hospital 
and residential care. The census should 
collect detailed information on the livingand family circumstances of handicapped 
people, the nature and everity of their 
disabilities, their instrumental needs, and 
their use of and experience with the 
health, social, education, training and employment 
service in their communities. 
Such census data would be useful in ma,ny 
respects, furnishing estimates of the extent 
of unmet need, an assessment of present 
community services and reliable information 
on the disparitie in services 
between communities and regions. 
2. A an urgent matter, the Government 
hould publi h a target date for the 
do ure of all pecialised hospital for the 
mentally handicapped. Becau e of the size 
f the investment involved, health 
authorities should be given lengthy notice 
that in the future all handicapped people. 
even the most everely handicapped needing 
medical supervision, will be cared for 

in their own communities. Proposals such 
as the ten year plan prepared by the 
Northumberland Health Care PlanningTeam to replace all hospital care with 
domiciliary ervices and housing in small 
residential clusters deserve every encouragement. 
Further expenditure in the longstay hospitals should be .restricted to fillingstaff needs and developing training and 
occupation services. 

3. As a step toward (2), the Government 
should announce that all mentally 
handicapped children aged 15 and under 
wi-ll be transferred from qong stay hospitals 
within four years, and no further permanent 
admissions should take place from 
this group. Where conditions permit, 
children should be given the opportun1ty 
to return to their family homes, aided by 
fuU social support services. The remainingchildren should be placed in foster homes, 
local authority children's homes or in 
small residential units in their own communities. 
4. Any programme that phases out the 
long stay hospitals must also find methods 
of redeploymg present hospital staff in the 
community to take advantage of their 
particular skills in caring for mentallyhandicapped people. Training. occupational 
and rehabilitation staff might be 
attached to community-based training 
centres or workshop . Nursing staff with 
appropriate retraining could staff small 
community homes, short term care facilit•
ies or act as an in-home con ulting service 
for familie with handicapped members. 
A system ·of positive benefits should 
be developed to encourage hospital staff 
to transfer to community services without 
loss of eniority and employment status. 
TITaining programmes will have to be remodelled 
to prepare staff to work jn the 
community rather than residential situations. 
The recent proposal by the Secretary 
of State for Social services for 
more child-care training for hospital staff 
hould be questioned on the grounds that 
their specialised skills should be applied 
in the community; child-care training for 
hospitaq staff presumes that handicappedchildren will continue to be admitted to 
institutional accommodation in the future 
-and wi11 make attempts to reform 


present services for the menta'lly handicapped 
even more difficult. 

5. At the earliest possible date the Government 
should enact a comprehensivedisablement income and allowance system, 
paid to mentally handicapped persons 
(as well as other disabled people) as 
a matter of right on the basis of severity 
of handicap. Such a programme would 
provide recognition of the substantial 
costs •incur:red by families in maintaining 
a handicapped person in thei·r home, and 
the restricted Iife chances and employment 
opportunities of the handicappedadult. 
6. To replace the hospital system, the 
Government should in.itiate a pro-
gramme for channelling the financial 
means to local authorities to develop community 
residential, training and supportservices for the mentally handicapped. 
The programme must be gene.mus enoughin scope to emphasize the predominantrole of the social services depa·rtment in 
co-ordinating and deliverin.g services. Departments 
might be encouraged to establish 
case r·egisters of mentally handicapped 
people and their needs. Direct 
grant payments might be made to local 
authorities in proportion to the size of 
thei:r case registers, or by increasing the 
rate support grant. 
7. The DHSS should prepare and publish 
a long-overdue circular outlining the 
standards and speoifications of a domiciliary 
care service for handicapped people. 
This should emphasize the importance of 
regular social work support when it is 
backed up by instrumental assistance. 
This assistance would include a comprehensive 
assessment and reassessment pro-
gramme that is connected to ·appropriatemedical, educational and tra·ining services 
; places in ordinary day care or day 
nursery facilities ; a crisis-help service, 
perhaps based in a cluster of .residential 
accommodati·on on the Northumberland 
model ; a respite or short .term care service 
provided either in the home or in 
community residential facilities ; better 
use of the home help serv.ice ; housing 
aids and adaptations under the Chronically 
Sick and Disabled Persons Act, and 
transportation assistance where needed. 
The DHSS might fund demonstration projects 
on. the creation and use of pa·rticular 
serv1ces, such as different combinations 
of domiciliary serv.ices, methods of 
organising voluntary groups in the neighbourhood 
and community to assist handicapped 
people and their families, fostering 
of handicapped children, the use of 
local authority children's homes by handicapped 
·children, and similar community 
support programmes. 

8. Cabinet Ministers responsible for 
housing and the s-ocial services should 
prepare jointly a blueprint for future community 
residential provision for mentally 
handicapped people. This housing pro-
gramme, in accordance with the community 
ca•re principles described earlier, 
should be l·ocally based and flex•ible. Its 
emphasis should be on small domestic 
units. Lodgings, ordinary flats and houses, 
and converted sheltered housing should be 
used whenever possible. Central .government 
departments should use their loan 
sanction authority to disapprove large, 
purpose built developments that stigmatise 
their residents. 
9. To underscore the importance of 
domiciliary support, the DHSS should revi.
se its current mental heaiJ.th returns, 
seeking informaticm from local authorities 
on the basis of the individual handicapped 
person (a client based reporting 
system) rather than on the basis of the 
services provided (serv.ice based, aggregated 
returns). These returns, which 
could be collected ev·ery second or third 
year rather than on an annual basis, 
would provide more sensitive data on the 
numbers of handicapped people served 
by each authority, their disabilities, their 
family circumstances, their needs and 
services received. 
10. Joint consultations between the central 
government depa·rt1nents .of health, 
education and science, and employment 
should be initiated w:ith the aim of developing 
occupational, training and employment 
goals for mentally handicapped 
people. Consideration should be given to 
such issues as which department should 
bear ·responsibility for the local authority 

adult training centre and what should be 
accomplished there, the appropriateschool-leaving age f.or mentally handicapped 
children, whether an employment 
assistance service should be established to 
a·id mentally handicapped people, and the 
best method of developing opportunities 
in orctinary employment situations for 
handicapped people. 

11. Efforts should be made at all levels 
of government, in all departments, to enlist 
the participation of mentally handicapped 
people and their families in the 
making of policy decisions rega·rding their 
lives and futures. Past decisi·ons have been 
made in a patronising manner, with little 
consideration of their desires. In addition 
administrative re-organisat·ions of 
the health and sooial servioes left relatively 
little latitude for democratic consultation 
and consumer e-xpression. The 
experiences of Campaign f.ar the MentallyHandicapped in conducting participation 
conferences with mentally handicapped 
reople suggest that they a:re able to speakfm themselves ; it is tJime to g.ive them a 
voice in matters that determine the course 
of their lives (see the 'Our Life' 'Listen ' 
conference reports, Campaign for the 
Mentally Handicapped, 1972 and 1973). 
Oertainly implementation of these or 
other proposals leading toward a radical 
transformation of policy on mental handicap 
will requi.re substantial public investment. 
But the additional costs may not be 
as great as one might imagine. Mentally 
handicapped people constitute a relatively 
small group in terms ·of the total society. 
And the central element of such a policywould enta.il a reaUocation of funds, staff 
and other rewurces from the hospital services 
to local authorities, from increasingly 
expensive and out-moded institutional 
provision to forms of public expenditure 
with lower capital costs and 
debt interest. Also, evidence from other 
countr·ies such as the United States and 
Sweden, indicates that current investments 
in occupational and rehabilitation pro-
grammes and housing services for handicapped 
people have long-term returns in 
productivity and decreased social costs. 

But investments in mentally handicapped 
people should not be justified solely on 

grounds of economic costs and productivity. 
This is a question of equity as well. 
Expenditure on services for the mentallyhandicapped traditionally has lagged behind 
the spending on services enjoyed by 
non-handicapped members of the community. 
A compassionate polricy must recognise 
that years of neglect -of these services 
eventually must be paid off. In the 
end it becomes a question of the strengthof our moral commitment to restore mentally 
handicapped people to the general 
pattern of life in the community. Richard 
Titmuss's warning is as appropriate today 
as it was rin 1961 when he wrote "We 
may pontificate about the philosophy of 
community care ; we may feel righteous 
·because we have a civilized Mental Health 
Act on the statute book ; but unless we 
arre prepared to examine at this level of 
concrete reality what we mean by community 
care we are simply indulging in 

wishfurl thinking" (Community Care : 
Fact or Fiction?) . 


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a family service for the mentally handicappedA series of shocking reports on Britain's mental hospitals (such as that on 
Ely !Hospital in 1969) have shown that the system of care of the mentally 
handicapped condemned by the 1Royal Commission which reported in 1957 
has not fundamentally changed. 'Walter Jaehnig looks at how the ideals of 
the Royal Commission have been frustrated and how the preventative, community 
based system it urged has not arisen out of the custodial. medically 
and hospital based system then 1extent. He points out that the bulk of 
expenditure in this field has been allocated to hospitals for improvements 
rather than local authorities who should implement the recommendations 
and ascribes the reasons to the system of finance and lack of political will. 
The author also questions the strategy favoured by the IOHSS of building 25 
bed hostels and sugg·ests this may be a form of small scale institutional care 
rather than genuine community care. Finally a number of proposals are put 
forward which would make community care a .reality rather than a myth 
including a target date for the closure of mental hand~cap hospitals, a comprehensive 
disablement income and allowance system and an effective 
means of channelling funds to local authorities. 

fabian society 

The Fabian Society eXIsts to further socialist education and fesearch. It is 
affiliated to the tabour Party, both nationally and locally and embraces all 
shades of socialist opinion within its ranks -left, right and centre. 
Since 1884 the Fabian Society has enrolled thoughtful socialists who are 
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Beyond this the Society has no collective policy. It puts forward no resolutions 
of a political character. The Society's members are active in their 
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problems that matter. 

The Society is organised nationally and locally. The national Society, 
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