I"
SUBNORMALITY HOSTELS- -Two Different Functions By
F. J. S. Esher, Consultant
Psychiatrist
seems
to
normal. A hospital's functions are: observation, special examination, treatment (including training) and nursing care. But subnormality hospitals now take well-behaved patients, whose immediate problem is solely that they have been left destitute, through the death or incapacity of parents or guardians. Neither their medical condition nor conduct really warrant hospital care.
Needing
a
home
Yet such patients do need a "home". It is this need which has led to the present local authority policy of providing residential accommodation in hostels for them. They are mostly admitted directly from their own homes, and tend to be ambulant, of fairly good behaviour, and not requiring nursing care or specialist medical attention. Their intelligence grade is of the imbecile or low feeble-minded level (I.Q. 30 to 60), for well-behaved dullards are normally to be found at home, working and caring for themselves. Those who are troublesome are not suitable for Local Authority Hostels and should be admitted to hospital for later social
rehabilitation.
I will refer to these local authority hostels as "custodial hostels", for their patients are really "welfare cases", who will generally need life-long care. But there is another type of hostel, for a different class of patient, which can be called the "rehabilitatory hostel". This is provided by a hospital, to act as a half-way house between the sheltered conditions of hospital life and the outside world. Experience has shown that unstable or anti-social subnormals re-socialise much better in a hostel than when discharged directly to the homes where their difficulties
began.
Patients selected for rehabilitation
through
such hostels
usually
have
long
maladjustment, and of problem families. Betwee"
histories of
be much misunderTHERE standing about hostels for the sub-
belong
to
third and
a
half of them find the c?r
parative freedom of hostel life # than they can manage, and have return to hospital for a time. Pattf" at this kind of hostel need cons'3 supervision from psychiatrists * senior nursing staff, with whom ^ develop relationships of a child-pafe type. Custodial hostels
can be looked modern replacement for insti. tional care, for patients who can some measure of freedom in the munity. They should be able to about outside, and to go to work"^ open employment or in a nearby tr^1 ing centre. Sexual problems should be a serious difficulty with st)l, patients and specialist care should unnecessary. They could well be looK after by the local authority Department, in co-operation with Health Department. The number suitable patients from any area W0' probably be up to 0-5 per 1,000 of population. Therefore, for a towfl 100 would bc 200,000 as
a
eflJj'
?
Wetf^
'j,
people,
places
good economic size for
hostel.
Sensible siting A custodial hostel should be
si^.
that lower-grade patients can * from it to a training centre, having to use a bus or cross busy roads. For the better, and employ*? " patients, there should be direct routes to the main industrial afet Both men and women could be modated on the same site, provid there were no patients with kn0* anti-social sexual tendencies. A P f pose-built hostel could be on the of a hospital type villa luxuries and costing up to ?1,500 bed. The cost of residence should the same as that laid down by : ( Ministry of Health for ^ patients in hospital, i.e. up to ?3 15s. per week. so
witb^ acco
-
1'^ witb0^
^
wofkjj
124 '
K:
a
v,
all.
Unless they
do domestic work in the should go out to during the day, either in industry a tfaining centres. In the evenings Would be games, radio, T.V. and Ij ^sits to relatives at weekend well as hoT sh?uld be encouraged, as ''days and coach outings in the sumer months. The warden need not be a Rental nurse, but should have exer'ence in hostel management.
^
^?stel,
all
0(?rk
patients
Aw
from supervision the other hand, rehabilitatory lj stels aim to take the patient away fr
of hosa hosatmosphere, these hostels should a sited in hospital grounds, and e l Ministry's plan for hostel wards in is quite indefensible (BuildNote No. 32). Their size should be ttyeen 12 and 20 places, and the site is *n a town area er slum nor suburbia?one enbad social contacts and the leaves residents socially isolated, should be in separat i?n anc* women hostels, as sexual problems loom in the lives of these patients. c'al contacts between the two hostels s. be discouraged, though heterofriendships and even marriage Possible with normal people, f?r the hostel, a normal house, or a p of semi-detached houses is best cheapest, in a street where there *lvvays people about. The aim for fur n'ture and food should be a good st ut not luxurious, f?r this liat^es ' discharge difficult and is no help patients. The aim Uld be to make the patient selfs usinS the general amenities tKlent' e district. Patients should pay for tjj keep, and should get the same ??s as other workers. Provided their Ct *s satisfactory, they could join sDo or social clubs, and go to swimtin
pj, al,
constant
supervision
get patients away from
*
jnsPitals
up
Co'
otLfages rjr
{j;e
5^.
jsxU^1
an'r ara
^habilitating
?
tyaIr
m-fts
hoiUses,^aths,
cinemas, theatres, public
etc. They should be encouraged regularly, but to pay for their n hobbies and entertainments. They huy all their own clothes, pay tlw hus-fares, and be able to invite "ds into the hostel.
t0
?tySaue fr:lr
125
The staff of such hostels need to be and it is wise to have a mentally-trained nurse as warden, with frequent visits from a psychiatrist. Well-settled patients who have no home may be discharged to a longterm hostel or to suitable lodgings.
experienced,
Lower salaries A problem which confronts hospitals is that their staff salaries are often much lower than those paid by local authorities for what appear to be similar duties. For example, local authorities are at present advertising for assistant hostel superintendents at ?775?905 per annum if unqualified, with an additional ?60 if suitably qualified. The Superintendent (Warden) is paid ?835?1,025 if with qualifications. On the Hospital side, a warden in charge is paid ?885 per annum and an assistant
?495.
To offset this difference, wardens are often appointed in the rank of charge nurses, at a top rate of ?1,080 per annum, the Assistant being paid as Staff Nurse at the top rate of ?800. Unqualified nurses would have to be paid as Nursing Assistants at the top rate of ?630 per annum. Even so, the unbalance makes it difficult to make suitable appointments in posts which are key ones in the rehabilitation of very difficult people. In my opinion, the responsibility for the difficult rehabilitatory patients is a greater one than in custodial hostels.
Local
authority
role
It is hoped that this article will help to form a clearer concept of the local authority role in providing residential care for subnormal patients?that of "homely care" and not one of "the final stage of a hospital's therapeutic responsibilities". Local authorities must plan for the care of the lower grades of subnormal patients (the unsatisfactory but well-behaved ones) and cannot expect to discharge them at all, let alone after a few months. It should also be realised that the building of small luxurious hostels is inappropriate, both for the type of patient concerned and for economic reasons.
SUBNORMALITY HOSTELS- -Two Different Functions By
F. J. S. Esher, Consultant
Psychiatrist
seems
to
normal. A hospital's functions are: observation, special examination, treatment (including training) and nursing care. But subnormality hospitals now take well-behaved patients, whose immediate problem is solely that they have been left destitute, through the death or incapacity of parents or guardians. Neither their medical condition nor conduct really warrant hospital care.
Needing
a
home
Yet such patients do need a "home". It is this need which has led to the present local authority policy of providing residential accommodation in hostels for them. They are mostly admitted directly from their own homes, and tend to be ambulant, of fairly good behaviour, and not requiring nursing care or specialist medical attention. Their intelligence grade is of the imbecile or low feeble-minded level (I.Q. 30 to 60), for well-behaved dullards are normally to be found at home, working and caring for themselves. Those who are troublesome are not suitable for Local Authority Hostels and should be admitted to hospital for later social
rehabilitation.
I will refer to these local authority hostels as "custodial hostels", for their patients are really "welfare cases", who will generally need life-long care. But there is another type of hostel, for a different class of patient, which can be called the "rehabilitatory hostel". This is provided by a hospital, to act as a half-way house between the sheltered conditions of hospital life and the outside world. Experience has shown that unstable or anti-social subnormals re-socialise much better in a hostel than when discharged directly to the homes where their difficulties
began.
Patients selected for rehabilitation
through
such hostels
usually
have
long
maladjustment, and of problem families. Betwee"
histories of
be much misunderTHERE standing about hostels for the sub-
belong
to
third and
a
half of them find the c?r
parative freedom of hostel life # than they can manage, and have return to hospital for a time. Pattf" at this kind of hostel need cons'3 supervision from psychiatrists * senior nursing staff, with whom ^ develop relationships of a child-pafe type. Custodial hostels
can be looked modern replacement for insti. tional care, for patients who can some measure of freedom in the munity. They should be able to about outside, and to go to work"^ open employment or in a nearby tr^1 ing centre. Sexual problems should be a serious difficulty with st)l, patients and specialist care should unnecessary. They could well be looK after by the local authority Department, in co-operation with Health Department. The number suitable patients from any area W0' probably be up to 0-5 per 1,000 of population. Therefore, for a towfl 100 would bc 200,000 as
a
eflJj'
?
Wetf^
'j,
people,
places
good economic size for
hostel.
Sensible siting A custodial hostel should be
si^.
that lower-grade patients can * from it to a training centre, having to use a bus or cross busy roads. For the better, and employ*? " patients, there should be direct routes to the main industrial afet Both men and women could be modated on the same site, provid there were no patients with kn0* anti-social sexual tendencies. A P f pose-built hostel could be on the of a hospital type villa luxuries and costing up to ?1,500 bed. The cost of residence should the same as that laid down by : ( Ministry of Health for ^ patients in hospital, i.e. up to ?3 15s. per week. so
witb^ acco
-
1'^ witb0^
^
wofkjj
124 '
K:
a
v,
all.
Unless they
do domestic work in the should go out to during the day, either in industry a tfaining centres. In the evenings Would be games, radio, T.V. and Ij ^sits to relatives at weekend well as hoT sh?uld be encouraged, as ''days and coach outings in the sumer months. The warden need not be a Rental nurse, but should have exer'ence in hostel management.
^
^?stel,
all
0(?rk
patients
Aw
from supervision the other hand, rehabilitatory lj stels aim to take the patient away fr
of hosa hosatmosphere, these hostels should a sited in hospital grounds, and e l Ministry's plan for hostel wards in is quite indefensible (BuildNote No. 32). Their size should be ttyeen 12 and 20 places, and the site is *n a town area er slum nor suburbia?one enbad social contacts and the leaves residents socially isolated, should be in separat i?n anc* women hostels, as sexual problems loom in the lives of these patients. c'al contacts between the two hostels s. be discouraged, though heterofriendships and even marriage Possible with normal people, f?r the hostel, a normal house, or a p of semi-detached houses is best cheapest, in a street where there *lvvays people about. The aim for fur n'ture and food should be a good st ut not luxurious, f?r this liat^es ' discharge difficult and is no help patients. The aim Uld be to make the patient selfs usinS the general amenities tKlent' e district. Patients should pay for tjj keep, and should get the same ??s as other workers. Provided their Ct *s satisfactory, they could join sDo or social clubs, and go to swimtin
pj, al,
constant
supervision
get patients away from
*
jnsPitals
up
Co'
otLfages rjr
{j;e
5^.
jsxU^1
an'r ara
^habilitating
?
tyaIr
m-fts
hoiUses,^aths,
cinemas, theatres, public
etc. They should be encouraged regularly, but to pay for their n hobbies and entertainments. They huy all their own clothes, pay tlw hus-fares, and be able to invite "ds into the hostel.
t0
?tySaue fr:lr
125
The staff of such hostels need to be and it is wise to have a mentally-trained nurse as warden, with frequent visits from a psychiatrist. Well-settled patients who have no home may be discharged to a longterm hostel or to suitable lodgings.
experienced,
Lower salaries A problem which confronts hospitals is that their staff salaries are often much lower than those paid by local authorities for what appear to be similar duties. For example, local authorities are at present advertising for assistant hostel superintendents at ?775?905 per annum if unqualified, with an additional ?60 if suitably qualified. The Superintendent (Warden) is paid ?835?1,025 if with qualifications. On the Hospital side, a warden in charge is paid ?885 per annum and an assistant
?495.
To offset this difference, wardens are often appointed in the rank of charge nurses, at a top rate of ?1,080 per annum, the Assistant being paid as Staff Nurse at the top rate of ?800. Unqualified nurses would have to be paid as Nursing Assistants at the top rate of ?630 per annum. Even so, the unbalance makes it difficult to make suitable appointments in posts which are key ones in the rehabilitation of very difficult people. In my opinion, the responsibility for the difficult rehabilitatory patients is a greater one than in custodial hostels.
Local
authority
role
It is hoped that this article will help to form a clearer concept of the local authority role in providing residential care for subnormal patients?that of "homely care" and not one of "the final stage of a hospital's therapeutic responsibilities". Local authorities must plan for the care of the lower grades of subnormal patients (the unsatisfactory but well-behaved ones) and cannot expect to discharge them at all, let alone after a few months. It should also be realised that the building of small luxurious hostels is inappropriate, both for the type of patient concerned and for economic reasons.
