LIVING LONGER IN HARPENDEN - Report of a Study Group on the Care of the Elderly

The group formed to study the care of the elderly in and around Harpenden was born out of a widespread view that there were shortcomings in the present provision.

The group set out to inform themselves of the services which exist, to form conclusions and to make recommendations about what needed to be done. Its members, responsible only to themselves, contributed in a personal capacity, not as representatives of organisations.

In the year from March 1982 the study group met 15 times in full session and received evidence from 20 witnesses representing 14 official and voluntary organisations. Written views were also obtained from 31 other organisations, and several visits were made to accommodation for elderly people.

The warm thanks of the group are due to the individuals and organisations concerned, who without exception willingly gave their help, to Harpenden Memorial Hospital for providing a meeting place and to the former Old People's Welfare Association for paying for the printing of this report. The especial thanks of the group are due to Maude Oliver for her unstinting work as its Secretary.

It is our strong desire that all with a concern for the care of the elderly people of Harpenden will seriously consider our conclusions and recommendations. A conference at which we hope to learn of initial responses will be held shortly after the publication of this report.

1. Getting old is not merely a matter of advancing years. Some people are 'old' around 60, others are sprightly at 80. Yet broadly speaking the passage of the years means for most people some changes in body and mind which cannot be ignored.

2. More people are living longer. The average age of the older generation is rising. In the last 20 years the number of men and women living in the United Kingdom who are aged 65 or more has risen by one-third: they now represent about 15% of our total population, and this percentage is rising. By the end of the century the number of people in the United Kingdom who are aged 75 or more is expected to rise by one-fifth and the number aged 85 or more by one-half!

3. In this report we are especially interested in the figures for the district in which we live. In 1981, in approximate terms, the population of the St. Albans District was 125,000, of whom 17,000 were 65 and over, including 7,000 aged 75-plus. By 1991 it is estimated these numbers will be 19,000 and 8,000 respectively.

4. The Census figures for 1981 for Harpenden show that out of a total population of 28,000 there were 3,400 people over 65; of these, 1,400 were 75-plus. In Redbourn and Wheathampstead, the two largest villages associated with Harpenden for some aspects of medical care, the over 65s total 1,400, of whom nearly 500 are 75-plus. These figures will no doubt increase more or less in line with those for St. Albans District and the nation as a whole.

5. Behind these statistics lie some important questions. Are the official services available to our senior citizens right in emphasis and adequate in scope and character? Are the voluntary services adapting themselves to the problems and needs of an ageing population? Are families sufficiently aware of their crucial contribution?

6. These are some of the considerations which have led a group of Harpenden people to study what is being done in their "village," and what changes, if any, are needed to meet the problems the figures reveal. The many topics include the "geriatric" aspect, namely the medical condition associated with physical ageing, and the "psychogeriatric" which is particularly concerned with the confused and mentally infirm. If this report stimulates interest and action in response to a growing problem of significance to us all, the group will be well repaid for the work they have done.

7. The figures quoted in this introductory note are not just academic calculations of the statisticians. They are expressions of a profound change in the make-up of our population. Different ages, different needs, and we have tried to define those different needs and to express a view as to how they can be met. There is a growing problem of immense importance. The solution to that problem should above all enable the elderly to live their later lives with dignity and confidence.

8. Harpenden is singularly fortunate in the variety of voluntary services at the disposal of the elderly, and in the number of its citizens who provide them. Much of this activity is organised, but inevitably what is available reaches out and merges into a vast range of one-to-one relationships that epitomise the caring community to a notable extent. Why this should be specifically so in Harpenden is perhaps less important than what it actually adds up to.

9. It is impossible to categorise and quantify the whole of these services to our elderly neighbours. What follows is an attempt to describe the principal areas of help, i.e. accommodation, day care, meals, transport, companionship and advice. Reference is also made to other services and organisations peripheral but no less important.

10. In the voluntary sector the Anchor Housing Association (an offshoot of Help the Aged) has a new and imaginatively-designed sheltered housing unit, Martham Court. This consists of 36 flats (mainly single) which meet the requirements of people who can no longer cope with the problems of maintaining their own home though they are by no means infirm enough to require fully-residential old people's accommodation. There is a resident warden but no meals are provided.

11. The Abbeyfield (Harpenden) Society provides homes for 24 people in two houses of 12 people each. There is no nursing care, and the residents look after their own self-furnished rooms with two meals provided at an all-in cost. There is a resident housekeeper at each house who cooks the meals and provides a watchful eye on each resident twice a day, so that help can be obtained should the need arise.

12. Evidence has been given that in the voluntary housing sector there has been increasing need for nursing as residents age but cannot be moved to accommodation where nursing is a recognised part of the services available.

13. There are also private forms of accommodation such as the one registered Nursing Home in Harpenden, St. Gemma's, which has 16 beds although not specifically for the elderly.

14. Voluntary organisations support the elderly in statutory accommodation. The League of Friends of Harpenden Memorial Hospital have provided much of value to elderly patients, including a comfortable sitting-room for patients and a range of items such as nurse-call and physiotherapy equipment as well as transport. Similarly volunteers are active in caring for the elderly in local authority sheltered housing and in residential accommodation such as James Marshall House. In the latter case special mention must be made of regular visits by Toc H, by schoolchildren and by teachers who support such activities as art, painting on china, handicraft, etc.

15. Official services are, of course, also provided at the various forms of private or voluntary accommodation.

16. Adjoining James Marshall House (a local authority home) is the Harpenden Day Centre, a purpose-built building run by volunteer effort, apart from catering support. In many ways this was conceived as a sort of half-way house to day-care, filling the gap between people who are approaching the end of complete physical and social independence and those who need some kind of supporting services in order to preserve it. The main thrust of the Day Centre is therefore social, helping to counter loneliness. There are some 900 members, with facilities for morning coffee, mid-day meals at subsidised prices, chiropody, hairdressing, baths, whist, music-and-movement, library, etc. Holidays and day outings are also organised, as well as regular parties. The kitchens, paid for by Herts County Council, additionally service the meals-on-wheels organisation. An offshoot is the Workshop for the Elderly which is housed in a converted building nearby.

17. Meeting in the James Marshall House is the newly-formed Evergreen Club. Run by volunteers with close professional guidance and support, this provides on one day a week a meal and a programme of enjoyable activities for the elderly mentally infirm. It is restricted to 10 members but should help to meet an acknowledged therapeutic need as well as giving short respite to those who look after the mentally infirm at home.

18. For a frail old person living alone, a spell of ill-health or bad weather can make all the difference between being able to shop for food or going without. Meals-on-Wheels distributed by the Red Cross are a godsend. Cooked in the Day Centre and distributed to some 75 different homes five days a week throughout the year, these meals make a substantial contribution to independence and morale, not excluding the social contact and the "watchful eye" tactfully provided by each car-borne dinner lady.

19. On Christmas Day the Salvation Army and the Harpenden Trust serve a large number of dinners to those who may otherwise have to do without.

20. Twelve years ago the Harpenden Council of Churches initiated the setting-up of a good-neighbour scheme involving a volunteer in every road who would be unobtrusively vigilant for any neighbour's need of ad hoc or emergency help not fundamental enough to justify calling in the official services. This quickly came into being as the Harpenden Helping Hand and is remarkably effective, particularly in its concern for the elderly. It is widely recognised by the statutory and voluntary services as "eyes and ears," but its coverage is limited by the number of "Helping Hands" available to service every road in the town. It provides for collecting prescriptions, shopping for those temporarily incapacitated, form-filling for the slightly confused, occasional gardening, fire-lighting, and also an emergency transport service. A watch is kept, in collaboration with milkmen and postmen, for signals that help may be required by the housebound living alone.

21. In addition to Helping Hand many local voluntary organisations including the League of Friends of Harpenden Memorial Hospital, the Red Cross, the W.R.V.S., Toc H, Rotary, Ladies Circle and Rotaract provide transport for the elderly to hospital, to the Day Centre and James Marshall House, to doctors' surgeries and to public events. Churches and clubs provide transport for their own activities, and many lifts are given to the elderly by local Harpenden people simply as friends and neighbours.

22. The local Citizens Advice Bureau, open five mornings a week, gives advice to elderly folk, who so often become confused with aspects of contemporary life such as rent rebates, how to control hot-air central heating, computerised accounts, probate, etc. Organisations such as the British Legion and the Chest, Heart and Stroke Association also give specialised advice as well as practical help. Churches offer pastoral care; for example, within St. Nicholas parish there is a counselling group to help people recently bereaved, including the elderly.

23. To provide companionship, local churches arrange visits to members of their congregations at home and in hospital, as do other organisations. Clubs for the elderly abound and flourish, notably the Darby and Joan Club run by the W.R.V.S., the Salvation Army Silver Threads Club, and the Courage Club for the handicapped (65 of whose 67 members are over pension age). Regular morning coffee gatherings are provided by the Harpenden Trust and High Street Methodist Church. Meetings are held by the Hard of Hearing Club and by the self-help group The University of the Third Age. Outings and holidays are arranged by the Day Centre, the Salvation Army, Toc H, the Courage Club, the Chest, Heart and Stroke Association, and others.

24. Practical help ranges from fuel and grants from the Harpenden Trust to the fitting of special door-locks by the W.R.V.S. in association with the Rotary Club. "Talking books" are supplied to the blind, many of whom are elderly, from the Royal National Institute for the Blind. The Medical Loan section of the Red Cross, working from Park Hall, provides free loan service of wheelchairs, commodes and other aids.

25. The Trust was founded in 1948 as a general purpose charity, with wide terms of reference and strong emphasis on practical care. Some of its activities are provided almost exclusively for the elderly. For example, in the year 1981-82,188 pensioners were given fuel grants of £20 each, together with kindling for those still with open fires. The Trust deals with some 250 general cases of need every year, some 45% of which are for the elderly: help can range from the very simple, such as mending a fuse, to complicated matters concerning eligibility for statutory benefits or financial grants. The Trust's expenditure, derived wholly from voluntary sources, is some £10,000 a year. More general opportunities for help arise out of the personal visits that precede any grant.

26. The Trust was, at least in part, responsible for the formation of the League of Friends of Harpenden Memorial Hospital, Harpenden Helping Hand, the Courage Club and the Day Centre.

27. Most of the voluntary services owe their existence to open-handed financial support from the community. Name a good cause, and Harpenden so far has raised the funds to resource it, whether directly, through such charities as Help the Aged, or by donations from generously active bodies like Rotary, Round Table or the Lions. As an example, although the County Council gave the building for the Day Centre, it had to be equipped and furnished from local initiative; over £10,000 was raised for this within the three years 1974-76.

28. Voluntary services depend on people, and we have been told by a number of organisations that they are finding recruitment difficult. The St. Albans & District Council of Voluntary Services, which covers Harpenden, is busily updating its files of vacancies, and gladly gives informed advice to anyone wishing to use time and skills to help the elderly in Harpenden.

29. The official services provided for the care of the elderly in and around Harpenden are many, varied and complex. Most are provided by the National Health Service, through its local District Health Authority and Family Practitioner Committee; and through Local Government, notably the County and District Councils. The study group has been greatly impressed by the thought and service given by officers and staff engaged in meeting the needs of the elderly, often under very difficult conditions.

30. Although in recent years there has been an increased emphasis on community medicine, the hospitals remain of vital importance:

31. This unit, also known as the Red House, does not at present provide special services for the elderly. Its 23 general medical beds are used for patients of all ages whose treatment can be carried out by their own doctors. At any one time there may be several elderly patients in HMH, of whom a high proportion are admitted for the treatment of illnesses which afflict people of all ages. However, one or two of the elderly patients may be permanently incapacitated, requiring special nursing over a very long period. It is the HMH policy that such patients, often admitted to provide relief for families looking after them, should not be accommodated for more than a few weeks. Patients may be examined by consultants attached to District Hospitals, so that specialist advice is available for their treatment. Other services available at HMH to the elderly, as well as to those of other ages, include physiotherapy and outpatient treatment by consultant physicians, surgeons, opthalmologists, etc.

32. This hospital, together with the hospital at Hemel Hempstead, provides the District General Hospital (DGH) facilities for North West Herts. The provision of beds for geriatric patients is at the present time inadequate, consisting of 58 beds at the Mid-Herts Wing, Church Crescent. A geriatric ward in Normandy Road was closed recently, but 20 beds have been made available at Hill End Hospital. A new geriatric block is being built and is due to come into operation in April 1984. This will provide accommodation for 84 in-patients and a 30-bed day hospital.

33. There are also difficulties in staffing. For example, for a number of years there has been no consultant geriatrician in permanent post. The geriatric wards have been the responsibility of a number of short-term locums supplemented by general practitioners with duties in the hospital. Furthermore most if not all senior nursing staff, although well-experienced, have not undergone formal training in geriatric nursing.

34. To provide relief for families with chronically-incapacitated parents or other relatives, and to ensure that some beds are not "blocked" by one patient, SACH has operated a "floating bed" system for at least one bed in each female ward, whereby 8 families have access to a bed for two weeks in every four months or so. About 60% of families approached have been willing to take advantage of this arrangement.

35. Some difficulties regarding admission of elderly people to hospital have been brought to our attention. These probably arise from the differing functions of geriatric and acute wards. At present the geriatric wards in SACH do not normally cater for patients with acute, (i.e. short and severe) illness, the rapid alleviation or repair of which is the prime purpose of an acute ward, for patients of all age groups. But there is this difference in the case of old people, that recovery may be slow, and that considerable emphasis must be placed on rehabilitation. It is hoped that the opening of the new geriatric block with its attendant developments will provide a solution to present problems.

36. We understand that 28 of the new beds at SACH will be for assessment purposes. Assessment implies that each patient's medical history is reviewed and medical tests carried out, and that physiotherapists as well as speech-and occupational-therapists estimate the extent and timing of potential recovery.

37. The services of the geriatrician specialists are not confined to the hospital at which they are based. Domiciliary visits or visits to smaller hospitals such as the Red House are made for assessment purposes at the request of the patient's own doctor.

38. Rehabilitation, which follows the programme specified in the assessment, is undertaken in and from the Kimberley Unit, which also provides day-facilities. Once a week there is a meeting at which all the disciplines are represented, including community nursing and social work, to review individual cases.

39. A number of out-patient clinics, including one for the hard of hearing, are held regularly at SACH.

40. This hospital, near Leavesden, is for long-stay geriatric patients. Two 20-bed wards for females and one 10-bed ward for males are available for patients from the St. Albans sector of the Health District, which includes Harpenden. Some of the beds are for elderly people who are severely confused. Specialised geriatric nursing of a high standard is provided.

41. This hospital is the centre for psychiatric and psychogeriatric services within the District. Of particular importance for the elderly is Martinlea Ward, which is used for the joint assessment of patients who may have a psychogeriatric condition. The geriatrician specialist at SACH and four psychiatrists each have two beds available. Patients are admitted for a maximum of four weeks for assessment, then either return home or enter a SACH geriatric or Hill End ward, or go to residential accommodation. Day-facilities are also available, a particular ambulance and crew being allocated to transporting the patients to and from their homes; one beneficial result is that the ambulance officers in effect act as part of the psychogeriatric team.

42. To enable the elderly to live a normal life in the community for as long as possible, the community services have become of paramount importance. Much of the community health work is carried out by Health Visitors and District Nurses.

43. Health Visitors are qualified nurses with additional training. They work in the community making general assessments of needs, for example the social work and voluntary-body support that may be necessary, and mobilise the services required. Their work covers patients of all ages, but in Harpenden the proportion of their time spent with the elderly is quite small.

44. District or Community Nurses provide skilled nursing care in the patients' homes. Special training enables them to assess, prescribe and evaluate the nursing care required and if necessary mobilise statutory or voluntary services needed for the patient. In contrast to Health Visitors a high proportion of time is spent in caring for the elderly.

45. Luton Road Clinic provides a base for community health workers in Harpenden and from it are provided a number of services. The dental surgery, chiropody sessions and audiology clinic are of particular relevance to the elderly.

46. This is provided by a unit which covers the whole of Hertfordshire. Within the team there is one Health Education Officer whose responsibility is the St. Albans sector, including Harpenden. The Health Education service organises talks on various health topics and makes leaflets available to members of the public and to organisations. Some of these are particularly appropriate for the elderly and their relatives.

47. One of the services of most benefit to the elderly is that provided by their own general practitioners. Much of the success in maintaining the quality of life of people in their later years is due to the detailed knowledge that the general practitioner has acquired of each patient, knowledge not only of medical history and condition but of family, interests, housing and so on.

48. Providers of other family practitioner services include the dentist, optician, chiropodist and chemist. In connection with each of these services special problems arise for some elderly people, for example the high cost of dentures and spectacles, and the difficulty of travelling to the place where these services are offered.

49. One of the services provided by St. Albans District Council specifically for the elderly is sheltered housing. In Harpenden this is supplied at Breadcroft (which has the distinction of being the first sheltered housing in Hertfordshire built by a local authority), Leacroft, Masefield Court and Broom and Gorse Corner. Facilities vary, for example only a few of the units have a wheel-chair access or lift to an upper floor. Altogether the District Council provides 65 units of sheltered housing in Harpenden, of which 26 are bed-sitting rooms suitable for one person only and 39 are one-bedroom flats which can be used for two people. A warden appointed by the District Council lives on the premises in each case. These wardens often work beyond the call of duty, especially when residents whose condition has greatly deteriorated cannot be transferred elsewhere because of shortages in other accommodation.

50. It is difficult if not impossible for adequate care to be given in sheltered housing without support from the resident's family, from friends and by members of various bodies such as churches.

51. St. Albans District Council also provides a number of flats adapted to the needs of the elderly – for example by the fitting of alarm systems. There is no warden to look after the elderly residents, but as these flats are situated among flats occupied by more able-bodied tenants, help is available on a neighbourly basis. In Harpenden such accommodation for the elderly is in Beeching Close, Bowling Green Close and Sherwoods Rise.

52. Many services for the elderly are provided by Hertfordshire County Council. They reach Harpenden residents through a number of different channels:

53. James Marshall House is the only residential home for the elderly provided by the Social Services Department in Harpenden itself. While originally purpose-built for the able elderly, it now accommodates 36 residents with widely-varying degrees of disability or illness. There are two self-care groups, each of 8 residents, and two full-care groups of 10 people each. "Reality Orientation" sessions are conducted for residents who are confused or mentally infirm. As well as general support to the residents, nursing care is provided, although the staffing with trained nurses has not kept pace with the pressing needs resulting from a steady increase in the proportion of residents with serious health problems.

54. Residents can take part, if they wish, in a range of activities such as concerts, courses and outings. There is a homely atmosphere which is much appreciated by the residents as well as their relatives.

55. Up to ten elderly people are taken on a day-basis, providing an opportunity for being bathed, having hair washed, clothes laundered and receiving other kinds of personal attention including a medical check-up if appropriate. This can be regarded as a basic form of "health topping-up" which encourages and maintains independence. Being introduced to James Marshall House on a day-basis can also serve to allay the traditional fear of being "put in a home." Day-places are provided at the weekends but, because of staffing limitations, only to those requiring general rather than specialised support.

56. Some Harpenden elderly are provided with accommodation in County Council homes in St. Albans, particularly at Fosse House, Vesta Lodge and Jane Campbell House. There is a special unit at Jane Campbell House to enable elderly people who for one reason or another have lost some of the basic skills we take for granted – such as making a cup of tea – to retrieve them.

57. Social workers have a major role to play in caring for the elderly. For work in Harpenden they are available through the St. Albans Division of the Social Services Department of the County Council, which has an office at Harpenden Hall.

58. The proportion of time social workers spend on the problems of the elderly is small, but their assessment of needs following referral from medical, police and other agencies is particularly important. Two social service officers have specific responsibilities for the elderly in the Harpenden area, covering such aspects as allocating accommodation in residential homes and liaising with relatives. There is also one part-time occupational-therapist, dealing with the need for aids and adaptations for elderly people living at home.

59. Through the Adult Education Service some courses specifically for the elderly are provided in Harpenden. Thus 25 or so people regularly attend a Keeping Mobile class. There are also Keep Fit classes and Old Tyme Dancing sessions (at which the few males have a wide choice of females!). About 15% of those who attend ordinary classes are elderly and at the present time a person on State pension pays only 30% of the normal fee. These preferential arrangements are, however, likely to be discontinued or curtailed because Adult Education centres are now required to be as economically viable as possible.

60. Some elderly people in Harpenden take courses at St. Albans College, and for many subjects this is the most local provision. It is thought that there are not enough people in Harpenden retiring from small businesses or from self-employment to support a pre-retirement course.

61. About 90% of the work of the County Council's Home Help service is with the elderly. In Harpenden there are currently 31 Home Helps serving 225 clients. There are also 9 "Good Neighbours" and 3 night-sitters provided by the service.

62. Other services provided by the County Council – often in conjunction with District Councils and other bodies – which are relevant but not restricted to the elderly, include road safety and home safety.

63. Although there is a wealth of services for the elderly in Harpenden, it became clear during our study that many of those working in this vital field desire changes. To some extent we have acted as their mouthpiece, but mostly we have combined strands from what we have been told into a wider framework within which we have made recommendations. In some areas proposed improvements could be made quite rapidly. Others however are of a more fundamental and long-term nature.

64. The study group constantly had in mind that those caring for the elderly should respect the views of the elderly people themselves. If, for example, a person does not wish to be visited, to become a member of a club, and so on, those wishes must be respected as an expression of the very independence which the services aim to foster.

65. Most people want to live, and even to die, at home. The best care for the elderly is that which enables them to spend their years of retirement at home or in conditions as near as possible to home. At best, old people are happiest living within their own family circle, loved and sustained by their relatives. But some have no families. There are others who find it difficult to live in harmony with their relatives in the same home. In practice one-third of all people over the age of 65 live alone.

66. To live at home, then, is what people want. For some, however, living at home supporting themselves or with the support of others becomes impracticable. The present system is based on an assumption that there will be an automatic progression through sheltered housing and residential home to hospital bed. Contrary to this, inevitable though some progression may be, we consider that the primary emphasis should be on helping people to live as long as possible in the accommodation which differs least from their original home, if not in that home itself. The number of changes, often traumatic, should be kept to an absolute minimum.

67. Such a policy would make sense, too, in the use of resources. Within this Region in 1981/2 the cost per in-patient in a District General Hospital acute ward was £450 per week. The comparable cost for a patient in a geriatric or psychogeriatric ward is about half that figure. Furthermore the cost per place in residential home accommodation such as James Marshall House is about half that for a geriatric or psychogeriatric ward, and the cost of local authority sheltered housing about a half again. Moreover, with a rising percentage of elderly in the population, the cost of providing even the existing level of services is greater every year, while the working population to pay that cost is decreasing.

68. So on both social and economic grounds it makes sense to help the individual to live at home for as long as possible, or failing that in sheltered housing, or failing that somewhere where there is full care, and only when none of those is possible, in hospital.

69. The paramount requirement is that the specialist services, such as nursing and social work, are available in the 'mix' most appropriate for the elderly in their home, whatever its type.

70. It is clear that while there is much co-ordination of the efforts of public authorities and with voluntary bodies, it could be more effective. The regular consultation between those providing the various services on problems affecting individuals does not necessarily lead to swift decision and early action because no-one has prime responsibility for implementation.

71. Most of the help needed by an elderly person increases only gradually, but there are also short-lived bouts of sickness or need requiring temporary additional help. The regular services of the various organisations concerned, voluntary or official, could perhaps be augmented – particularly for crisis situations – by engaging nurses from a commercial agency or giving financial support for a stay in a private nursing home, or providing payment for additional expenses incurred by a voluntary body.

72. There are indications that the current economic climate is producing an "organisational barricade" outlook which militates against links between some of the services necessary for the care of the elderly. Although there are at present a number of links of this nature there could be many more, yet the prevailing pressures are towards their disappearance. We consider this tendency should be reversed. Each authority should regularly consider whether more effective use could be made of its skilled staff by secondment fully or part-time to provide an integrated service under the auspices of another authority: for example, a nurse employed by the Health Authority could be attached to a residential home run by the Social Services Department.

73. As far as possible the facilities required by Harpenden people should be located within Harpenden itself. At the present time some elderly people normally living in Harpenden and requiring certain types of care which it would be feasible to provide in Harpenden can be accommodated only in St. Albans, or even further away. The residents or patients are then in unfamiliar surroundings and receive far fewer visitors than if the accommodation were provided in their home town.

74. Clearly it would be uneconomic if the more sophisticated services were to be available at Harpenden as well as at St. Albans, and in many cases provide a lower quality of service. There are however some services, especially for those requiring long-term nursing rather than diagnosis and therapy, whose location in Harpenden can be justified on both economic and social grounds. Harpenden should have its due share of these types of care.

75. Harpenden is rich in voluntary groups caring either specifically or among others for the elderly. Admirable though they are in their various ways, there is in some cases a need for existing organisations to review their present operations or extend their scope. For example the protective network of Harpenden Helping Hand, which seeks to ensure that in every area there are people available to assist their elderly neighbours, is incomplete. There are at present 45 streets in Harpenden without a Helping Hand. The Helping Hand organisation does immensely valuable work and it should be developed.

76. The excellent Meals on Wheels service is limited to five days a week. Deliveries are not made on Saturdays and Sundays, so often the loneliest and most depressing days of the week. The desirability of additional weekend and holiday coverage was brought to our attention. It might also be feasible to develop further the social role of the service, for example by arranging for volunteers to visit recipients more often and stay longer.

77. Official domiciliary services also have some gaps in their provision for Harpenden. For example many elderly people would benefit from physiotherapy at home.

78. Then there is the question of summoning help in an emergency. The local authority is considering 24-hour emergency communication by radio for warden-controlled flats. Is it possible that such a scheme could be introduced for private homes too?

79. There are people who could be enabled to remain longer in their own homes if "domiciliary care assistants" were provided by the County Council to help with dressing and undressing morning and evening.

80. Health Education and Adult Education are playing an important part in helping the elderly to live in their own homes, but we consider that their efforts could be enhanced if they were to draw up a joint programme aimed specifically at meeting the needs of old people.

81. Many frail or ill elderly people are enabled to remain at home by the devoted help and care of their families. The responsibility is willingly undertaken but can become overpowering on the basis of a 24-hour day 365 days a year. There is urgent need for short-stay provision for the elderly infirm in residential home or hospital to cover the needs of relatives in domestic emergencies, sickness or for a holiday. We warmly commend the "floating bed" arrangement which has been used at St. Albans City Hospital and suggest this could be applied to residential homes as well as to the geriatric wing we are recommending for Harpenden Memorial Hospital. (See para. 97)

82. Those looking after elderly relatives at home can also benefit from mutual support. The National Council for Carers and their elderly dependants has some Harpenden members but its local base is St. Albans. The recently-formed Association of Carers covers all those with family-caring responsibilities (not only the elderly) and we suggest an existing local organisation might be willing to try out the scope for a branch in Harpenden.

83. To live at home does not necessarily mean to spend all one's days at home. Harpenden's Day Centre, with its Club atmosphere and its five-day-a-week facilities is warmly appreciated by its members. But its membership has declined. The reason for this is far from obvious and its causes are worth study.

84. For those whose needs for skilled assistance are becoming greater, the use of the day places available at James Marshall House is at present hampered by insufficient accommodation, uncertain transport, and reduced staffing at weekends. The new one-day "Evergreen Club" for elderly people who are mentally infirm still needs funds and volunteers.

85. Associated with the recommended geriatric wing at Harpenden Memorial Hospital, we consider that there should be a Day Hospital catering for the needs of the old. The Day Hospital is a relatively new concept, the first purpose-built unit having been established in Oxford in 1958. It is distinct from the Day Centre concept, for whereas the Day Hospital provides a therapeutic environment with most of the capabilities of the in-patient ward but without the need for care at night, the Day Centre is primarily a place for social activities. The Day Hospital is staffed by doctors and nurses: the Day Centre is not. Historically, the Day Hospital has evolved from a place at the end of a ward to a separate unit, sometimes, but not always, associated with a hospital. It is in the Day Hospital that old people, including those suffering from psychiatric conditions, would attend daily, returning home at night. Advice would be available on problems of medication, physiotherapy, aids for the management of incontinence, and on the maintenance of health generally. There would be a few beds for resting during the day. An essential element in Day Hospital organisation is the provision of transport adapted to the needs of those attending. Such a Day Hospital would not only have an economic advantage but would do much to enable old people to continue to live in their own homes, to live longer and to live more happily.

86. It is worth noting, too, that relief and day care facilities can be of great benefit to the elderly living in sheltered housing, residential homes and other kinds of accommodation.

87. Sheltered housing and residential homes, official and voluntary, exist in Harpenden in several forms. We are reasonably sure that the present places are too few for Harpenden's needs, though we cannot quantify the shortage. This is partly because these types of housing are now occupied to a considerable extent by residents whose physical or mental condition is beyond that for which they were planned, equipped or staffed. Furthermore the full provision of such accommodation available to Harpenden people is not known, because some is available only to members of specific groupings such as churches and professions, and national information on that kind of provision is not generally available. We consider that a survey should be made to establish the extent of provision of accommodation of the various kinds in Harpenden and the actual services provided within them, whatever the sponsoring organisation.

88. Furthermore if extra provision is made anywhere in the chain of accommodation for the elderly, this will ease the pressure all along the line. It is not possible for us to be definite just where the increase should be, but we know that at present the needs of some Harpenden elderly are having to be met in accommodation outside Harpenden.

89. Alternatively or in addition to the provision of extra accommodation, we repeat that an improvement can be brought about by increasing in every type of home occupied by the elderly the support from medical, nursing, therapeutic and other official services as well as from volunteers. This is the basis of our recommended principle that there should be more, and more creative cooperation between all kinds of the services involved.

90. Sheltered housing is usually provided on the assumption that no nursing care is needed by the tenants. The reality is different. With increased calls for care, due to the deterioration in physical and mental condition of many of the tenants far beyond what was originally envisaged, nursing services of a rudimentary kind are, of necessity, being provided by the wardens, families and voluntary workers. This should be acknowledged and enhanced. In particular, the ineligibility of sheltered housing for the "night-sitting" service because a warden is in residence, and the absence of paid non-nursing care assistance, should be the subject of scrutiny.

91. In small units of sheltered housing the only full-time member of staff is the warden. The arrangement of providing off-duty cover through the kindness of a few of the slightly younger tenants is no longer justifiable.

92. In residential homes the allocation of nursing hours should be adjusted to take account of the greater age to which many of the residents are living, and consideration should be given to the attachment of community nurses part-time or full-time as members of the care team within the home rather than as "visiting nurses." The possibility of providing extra-care units in residential homes and sheltered housing should be examined.

93. Transfers between Harpenden local government homes and corresponding accommodation elsewhere in the county, if not the country, should be facilitated, so that family support can be provided where it is needed.

94. Other improvements which should be urgently studied are the provision of wheelchair access and lifts.

95. Possibly other forms of residence, for example nursing homes specifically for older people, together with extra-care units in sheltered housing, could be brought into being in Harpenden. This would increase the variety of degree of support available and may enable elderly people to 'stay put' for a longer period in familiar surroundings.

96. We have no doubt that more hospital beds for the elderly should be provided in Harpenden for the people in and around Harpenden. When the old are suffering from major medical or surgical conditions liable to affect people of any age, they should of course be treated in medical or surgical wards of District Hospitals like everyone else. But when their infirmities stem primarily from the ravages of age there is need for two kinds of professional care, each rendered by doctors and nurses with the appropriate outlook, training, experience and skill. The first kind is that of diagnosis, assessment and intensive therapy, which can best be provided by specialists in a unit such as that now being built in St. Albans. The second type is one in which the care needed is mainly that of skilled nursing. The latter type of geriatric unit is best located in or near the community in which the patients have had their homes, and where their G.P.s and friends and relatives can have ready access.

97. We believe, then, that Harpenden needs its own G.P./Nursing geriatric hospital unit. In our view it would best be established in a geriatric wing attached to the Harpenden Memorial Hospital, and we warmly recommend the construction of such a wing together with associated day hospital facilities. For administrative purposes the wing would be part of the main hospital, though its day-to-day running would be undertaken by nurses with a special interest in and experience of the care of old people. Medical care could be provided by the patients' own general practitioners, with a consultant geriatrician attending regularly or as necessary. Alternatively this care could be the responsibility of the geriatricians in association with the general practitioners. We envisage such a wing as also providing short-stay beds to enable those caring for their elderly at home to be relieved for a short while for, say, a much-needed holiday.

98. Using the 1981 Census figures for the elderly in Harpenden, Redbourn and Wheathampstead we have estimated the need for beds in the proposed geriatric wing to be 10 male and 20 female by the 1990's. These figures indicate the number of residents from Harpenden and around who do not need the specialised services of a major hospital, yet who are at present accommodated in St. Albans or Abbots Langley hospitals. Since the number of beds proposed is of crucial importance we give the basis of our estimates in Appendix A. The calculated numbers of beds do not include provision for the elderly suffering from severe senile dementia and other conditions covered by the psychogeriatric services. The bed requirements for this last category of patient are not as well established as for geriatric patients in general, especially as medical research may significantly affect the numbers requiring in-patient care. Possibly another 10 beds will be needed for this type of patient.

99. Terminal care is usually of a short-term nature and is at present provided when necessary in the general medical wards of the hospital. We recommend that so far as ward care is concerned this practice should continue rather than be transferred to the geriatric ward, should this be built.

100. In the case of the specialist services provided by St. Albans City Hospital we are concerned to note that for some years there has been no consultant geriatrician permanently in post at St. Albans Hospital. We understand that consideration has been given to making such an appointment soon, together with supporting medical staff. Similarly we understand that greater attention will be given to training and qualification in geriatric nursing.

101. Incontinence affects a proportion of old people and is often associated with a feeling of embarrassment as well as discomfort. It would be greatly appreciated if there could be made available to the incontinent, or the relatives and others looking after them, a reliable laundry service. Such a service should be centred locally and eventually operate from the proposed geriatric wing of Harpenden Memorial Hospital. The service would bring relief and enhance the quality of life of many people out of all proportion to the cost involved.

102. Of the other helpful suggestions made and matters raised mention will be made of only a few:

(a) Many elderly people or their relatives appear unaware of the range of support and activities specifically for the elderly in Harpenden. We consider more information should be provided. In particular a well-designed booklet outlining benefits and services, which they could study in their own homes, would prove a boon.

(b) Most voluntary services seek additional volunteers, but we wonder whether sufficient use is being made of the St. Albans Council of Voluntary Services in supplementing their own efforts.

(c) More people might be encouraged to volunteer, and the value of their contribution greatly enhanced, by the provision of a course on some of the specific aspects of working with the elderly. Such a course would include talks on the physical and psychological aspects of ageing, the official and voluntary services available, etc.

(d) Consideration might well be given to "granny-sitting" and "granny-fostering," of which there is now experience in other parts of the country.

(e) The care of the dying is becoming a speciality in its own right. No Harpenden-based service of this type is planned but a hospice being established at Berkhamsted covers Harpenden, as does a St. Albans group of doctors, nurses and volunteers. Both are at an early stage of development and provide at present only domiciliary terminal care. We welcome these important developments.

(f) There is some reason to think that the multiple prescribing of medicine, usually in tablet form, can lead to confusion and even discomfort to some old people. This seems to us a subject worth study by those competent to undertake it.

103. More than anything else, perhaps old people need to feel that they still belong, and can contribute, to the community, and that the other members of that community appreciate their ambitions and problems and will help them to enjoy as full a life as possible. Many young people's organisations make a determined effort to narrow the gap between young and old. It often seems easier, however, to establish an effective relationship between the very young and the old than it is for those who have become preoccupied with making a success of their career or bringing up a family. The need is not just for the provision of a service such as shopping for the housebound, but to establish regular contact, which can lead to understanding, friendship and the relief of loneliness. The family has the facilities to best achieve this result. They often have at their disposal a home, car and hobbies or pastimes which can be used to enrich the lives of old people who may otherwise be confined to their own homes for long periods.

104. Is it not possible for organisations for the young, and not so young, to take upon themselves the responsibility of helping their members and others in the community to develop a more practical understanding of the way in which they can help this growing proportion of the population?

105. Finally, a matter brought to our attention time and time again was the need for each type of service to understand the aims, motivation and limitations of the others with which they are associated in the common task of caring for the elderly. If this report of a study helps with such mutual understanding our efforts will be amply repaid.

106. The group has not made recommendations for actions which, to the best of our knowledge, can only be taken nationally; it has confined its consideration to those developments which may be determined locally. In making our recommendations we recognise that the arrangements best fitted to implement some of them may not at present be in existence. In these cases it is very much hoped that new initiatives will be taken so that the proposals may be carried out.

The overriding aim should be to enable the elderly to live as long as possible in accommodation which differs least from their own homes, if not in those homes themselves. (paragraphs 65-68)

Wherever possible the care required in each home or type of home should be provided by a team drawn from the various sources, with one person or authority taking overall responsibility in each case. For this purpose secondment of staff from one authority to another should become normal practice. (paragraphs 69-72)

Although it would be uneconomic and detrimental to quality for the more sophisticated services to be available at Harpenden as well as at St. Albans, facilities required by Harpenden people should in all possible cases be located in Harpenden itself. (paragraphs 73-74)

(a) Voluntary organisations providing services in Harpenden should take stock of their operations in relation to the elderly with particular regard to meeting the increasing needs of a greater number of people. (para. 75)

(b) Harpenden Helping Hand should set out to cover the 45 or so streets in Harpenden which do not at present have the benefit of a Helping Hand. (para. 75)

(c) Urgent consideration should be given to the delivery of meals at weekends and over holiday periods to those who need them. (para. 76)

(d) Every effort should be made to fill the gaps in the official services available in the home, e.g. physiotherapy, domiciliary care assistants, emergency alarm cover. (paras. 77-79)

(e) Health and Adult Education services should together study ways of providing a joint programme to meet the needs of the elderly, particularly in the promotion of health and the prevention of accidents. (para. 80)

(a) A "floating bed" scheme and short-stay bed arrangements should be operated in the residential homes and hospital in Harpenden to meet the needs of relatives in domestic emergencies, sickness or holidays. (para. 81)

(b) The formation of a Harpenden association through which relatives may support each other in the care of the elderly should be sponsored by the Harpenden Trust. (para. 82)

(c) The Committee of Management of the Day Centre should sponsor a detailed survey of the pattern of membership. (para. 83)

(d) There should be established in Harpenden a Day Hospital for old people, including those suffering from psychogeriatric conditions, providing most of the facilities of the in-patient ward but without overnight facilities. (para. 85)

(a) A detailed survey of all types of homes provided for Harpenden's elderly people and the patterns of movement between them, and the care actually provided within them, should be sponsored by the Town Council. The survey should aim at establishing the need for increased accommodation of the various types at present existing in Harpenden as well as those not at present available, such as public sector nursing homes, other nursing homes specifically for older people, or an extra-care unit attached to a voluntary-sector sheltered home. Supporting day-facilities should also be considered. The results of the survey should be made known to all organisations interested in the care of the elderly. (paras. 84 and 87-95)

(b) Staffing arrangements should be modified to take account of the increased age and frailty of residents in sheltered housing and residential homes, especially where there is only one full-time member of staff. (paras. 90-91)

(c) In residential homes the number of hours allocated for nursing staff should be increased to take account of residents' greater infirmity. (para. 92)

(d) Arrangements to facilitate the movement of elderly people between accommodation in Harpenden and elsewhere should be reviewed. (para. 93)

(e) Improvement in wheelchair access in sheltered housing should be provided urgently, and the need for lifts should be the subject of study. (para. 94)

(a) A geriatric and psychogeriatric unit with up to 40 beds, together with associated day facilities, should be constructed in Harpenden, preferably as a wing of Harpenden Memorial Hospital. (paras. 97-98)

(b) Top priority should be given to the appointment of the full range of specialist and support staff to provide a high quality geriatric service in and from St. Albans City Hospital. (para 100)

(c) A reliable incontinence laundry service should be provided in Harpenden together with an advisory centre. (para. 101)

(a) More publicity should be given to the sources of help, official and voluntary, available for old people in Harpenden. This should include a well-designed booklet for use by the elderly themselves and their relatives. (para. 102a)

(b) The St. Albans and District Council of Voluntary Service should embark upon a recruitment drive to provide volunteer support for the many services involved in the care of the elderly. (para. 102b)

(c) The Harpenden Trust should sponsor courses or seminars for those considering voluntary work with elderly people. (para. 102c)

(d) A study should be made of the possible benefits of "granny-sitting" and "granny-fostering" schemes in Harpenden. (para. 102d)

(e) The Harpenden community should strongly support the development of skilled terminal care services. (para. 102e)

(f) Doctors caring for the elderly in Harpenden are asked to consider the implications of multiple-prescribing of drugs. (para. 102f)

	MALES		FEMALES		TOTAL
AREA	AGE 65-74	AGE 75 +	AGE 65-74	AGE 75 +	AGE 65-74	AGE 75 +
Harpenden MB	875	437	1110	970	1985	1407
Redbourn ward	211	84	251	155	462	239
Wheathampstead ward	198	87	239	151	437	238

— we have assumed that there will be a 25% increase on the 1981 Census figures

— we have followed the DHSS advice that 30% of the elderly requiring geriatric beds

► Mrs. D. Overall, Community Nursing Officer with geriatric liaison responsibility

Harpenden Council of Churches held a meeting on 10th February 1983 to discuss the role of the Churches in the care of the elderly.