Some mention should be made of the important role of local government after the Beveridge reforms were introduced. The National Health Service Act 1946 required local government to establish Local Health Authorities (LHA’s) to carry out the health centre programme, which itself was expected to play a crucial part in the development of services for the elderly. LHA’s were also given a statutory responsibility to provide a health visitor and home nursing service, and enabled to make arrangements for preventive measures, care and after-care services, and home helps. This provided an important range of social and health services, while leaving the main responsibility to central government.
In implementation terms it seems that the first few decades of local authority health visitor activity were preoccupied with maternity and child welfare rather than elderly care delivery, but by 1960 the elderly were known to form a growing percentage of that activity, by which time the bedridden elderly were in grateful receipt of laundry services.383
382
Webster, Ibid, p. 175.
383
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These July 1948 innovations are historically incomplete without analysis of the enacting of the ‘sister’ legislation, the National Assistance Act 1948.384 Although
receiving the Royal Assent on 13 May 1948, its timing for implementation on 5 July 1948385 with the National Health Service Act was well co-ordinated.
Elderly care is mentioned as the 1948 Act that had formally repealed and replaced the poor law, but set out the terms of the new reform:
“An Act to terminate the existing law and to provide in lieu thereof for the assistance of persons in need by the National Assistance Board and by local authorities; to make further provision for the welfare of disabled, sick, aged and other persons and for regulating homes for disabled and aged persons and charities for disabled persons.”
This came into statutory effect as a state funded ‘safety net’ to support any person in need, as well as the elderly who still rely on part of the Act still in force now being Section 21(1)(a) which provides that “a local authority may with the approval of the Secretary of State, and to such extent as he may direct shall make arrangements for providing residential accommodation for persons aged eighteen or over who by reason of age, illness, disability or other circumstances are in need of care and attention which is not otherwise available to them.”
The continuing effect in conjunction with this provision of Section 26 which provides “...arrangements under section 21 of this Act may include arrangements made with a voluntary organisation386 managing any premises.”387
384
(11 & 12 Geo.6, c.29).
385 National Assistance Act 1946 (Appointed Day) Order 1948 (1948 No.1218) (signed by Aneurin Bevan as
Health Minister).
386
For example, a charity such as the Leonard Cheshire Foundation primarily focussed on the elderly.
387 Thus private contractual provision for profit was significantly not permitted until this section was amended
to that effect by Section 26 of the National Health Service and Community Care Act 1990 (1990, c.19) brought about by need, and from which point private provision for profit then developed triggering many other issues.
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Central government’s role in long-term care was narrowly defined to finance disability benefits and through grants and aid in the 1980s to reimburse care homes for the board and care of the elderly frail in private care homes. Local government greatly expanded its provision for social services for the elderly and this became one of it largest sectors of activities as social service departments expanded to meet the demand and deliver elderly care services. State provision rapidly gained acceptance and recognition. There were restraints on funding. Local government soon realised that it had to act cautiously as it did not want to put at risk acute hospital beds for the elderly with no choice in the matter. There was no uniform set of delivery targets and in many cases different local authorities would fund what other local authorities expected to be charged to the patient. In many ways the rise of a private sector for elderly care was seen as a welcome development that took away costs and expenses from local authorities388.
Commercial sector involvement in care homes was remarkably limited throughout the 1960s and 1970s. This was soon to change after November 1980, when social assistance schemes reimbursed private homes for the care of the elderly and frail. This was to have a transformative impact on care delivery for the elderly.
388
An authoritative report in 2010 describes a remarkably parallel French care delivery system for Long Term Care (LTC), said to be philosophically modelled on a mixture of Bismarck and Beveridge and its family and neighbour participation, whereby since the 1980’s central government as policy setters incentivised local government at Department level (les Conseils generaux) to engage in care delivery, and its challenging complexities. “Departmental authorities readily accepted this new responsibility....satisfying increasing demand, but also a big opportunity in terms of employment.” Since 2004 legal changes local departmental authorities are considered as ‘leaders’ in the field of dependency, and define policy for disabled elderly people, “planning and co-ordination, and financing a major part of the personalised autonomy allowance (APA)”.S Departments grant approval for care services and even set care home fee levels, with general but mixed levels of success across the 96 mainland France structure of Departments. Joined-up care delivery issues and even how to define “care” also trouble the French:- European Network of Economic Policy Research Institutes (ENEPRI) – Long Term Care in France (Report No.77 -June 2010)- Marie-Eve Joel and others- Pages 1 to 9.
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4.4 Conclusions
The birth of the welfare state was clearly a complicated and time-consuming process. The 1908 pension provision was a major landmark decision. This recognised the elderly in a way that proved significant.389 The Beveridge reforms
brought elderly patients into medical treatment often for the first time.
However, whilst the Beveridge Report is clearly fundamental to the creation and subsequent development of the welfare state, embracing Beveridge’s universalism philosophy it is notable that elderly care does not come high up the agenda, although medical care of the elderly does. In its first couple of decades from 1948 amongst the shortcomings in the new welfare state is a connection between the elderly not being regarded as a priority by senior Ministry of Health civil servants and the issue of incomplete universalism.
The post-1948 NHS brought to the elderly the availability of hospital consultants, desperately needed free dentistry hearing aids and spectacles, and then general practitioners (GP’s), but domiciliary care services were slow to catch up and because of the inferior status of the elderly in the eyes of many services for the elderly were always disproportionately affected by charges and cuts. These cover the medical treatment for dementia in its various forms, other mental health disorders, convalescent and respite care, frail disabled care, palliative/end of life care and residential care.
One significant post 1948 NHS hospital improvement was that the presence of many elderly in hospitals triggered the growth in a specialist geriatric
389
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profession.390 Hospital modernisation programme, and a framework domiciliary care
delivery system were also undertaken but this was patchy as resources were limited. Resources continued to pour into inefficient long term hospital, and even new care home construction, in each using models, often repeated the defects of old workhouses. Always present were the complexities of continued finance along with continuing increases in elderly longevity.
The growth in the state’s provision for health care had implications for the charitable sector. Voluntary action was to be encouraged as part of health care delivery and the Charity Commission received continued government support. Elderly care continued to be delivered by families and charitable/ religious organisations that contributed to the general well-being of many elderly patients. Health care visitors and supportive nursing and palliative care provided an important support – bridging different elements of the public and private sectors.
As we have seen local government was given important responsibilities for the elderly notwithstanding the creation of a nationalised health service. These included residential and domiciliary care. This made local government a pivotal part of elderly care through home care provision or also enabling local authorities to establish and run care homes and play by far the major role across various elderly care delivery services.
This was a defining period for elderly care and by 1968 local government was given a general power to promote the welfare of the elderly. A large proportion of elderly lived in their own homes supported by their families but also supported through home care systems. Local authority delivery of elderly care services reached
390
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a peak in the 1980s. It was set to change with the private sector market developing a market in private care homes.
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