1272
A
BRITISH MEDICAL JOURNAL
4 NOVEMBER 1978
Modern Epidemic
What causes road accidents ? BY A SPECIAL CORRESPONDENT
British Medical3journal, 1978, 2, 1272-1273
The cost of treating victims of road accidents in England and Wales was estimated at between J50m and £55m in the financial year 1977-8; 1-4°,, of all hospital beds were taken up by these patients.1 In 1977 the total estimated cost of road accidents in Great Britain, including the "damage only" category and including an allowance for lost output, was £940m.2 To this the Department of Transport adds an allowance for "pain, grief, and suffering," amounting to C347m. This it calls a notional and minimum value. Accident trends
Alarming though these figures are, in the 1960s experts were predicting a much higher rate of accidents. Smeed forecast that in 1972 there would be about 745 000 casualties (more than twice the 1962 figure) on the basis of the expected increase in vehicles on the road or, more optimistically (if recent safety factors continued to operate), 472 000.3 As it turned out, there were only about 359 000.4 Certainly the increase in vehicles was less than expected: in 1972 there were 15-7 million4 rather than the 19-4 million predicted by Smeed. Even on this basis, however, his more optimistic figure would have been 382 000 casualties. What then happened to produce this reversal ? The year 1967 saw a White Paper5 followed by a new Road Safety Act. The most notable new measure, the "drinking and
driving" legislation, whereby it became illegal to drive with a blood alcohol concentration of over 80 mg/100 ml, had an immediate and striking effect on the statistics-an effect that began to wear off, however, after 1968 as the publicity lost its force. The declining efficacy of this measure has been monitored by surveys of blood alcohol concentrations in drivers killed in accidents, and one in five road deaths, it is estimated, would be prevented if drivers did not exceed the legal limit.6 Also as a result of the 1967 Act, separate licences were brought in for drivers of heavy goods vehicles, and there are now strict controls for these drivers; an especially noticeable improvement in accident rates followed the limitation of driving hours in April 1970, and other measures about the same time.7 The accident rates have declined more rapidly for this class of vehicle than for any other. In 1971 the Green Cross Code for pedestrians was introduced. The fall in pedestrian casualties did not start, however, until 19734; it is ascribed in part to the massive publicity campaigns that have been aimed at children and their parents, though some would give greater weight to other factors such as the fuel crisis of 1973-4. This indeed had a general effect on accident rates. The reduced volume of traffic certainly helped, but the fall in casualties, and in the proportion killed or seriously injured, was too great for that to be the sole reason. The higher speed limits were temporarily reduced to 50 mph (80 kpm); and the shortage of petrol and its suddenly increased cost are also thought to have made people heed the advice to drive more slowly and carefully to conserve fuel.8 Some trends in accidents suggest no simple solution. There
Factors contributing to the 2130 accidents in TRRL study* Contributory factor Lack of care Too fast. Looked but failed to see
No
Huma zn error-drivers (n = 3757) ..
..
..
..
Distraction Inexperience Failed to look. Wrong path Lack of attention Improper overtaking Incorrect interpretation Lack of judgment Misjudged speed and distance Following too close Difficult manoeuvre Irresponsible or reckless Wrong decision or action Lack of education or road craft Faulty signalling Lack of skill Frustration Bad habit In wrong position for manoeuvre
Aggressive
Total
905 450 367 337 215 183 175 152 146 125 116 109 75 70 61 50 48 47 33 15 12 7 6 3536
Contributory factor Human error-pedestrians (n = 147)
Lack of care .. Failed to look. In dangerous position Looked but failed to see .. Distracted .. Misjudged speed and distance Wrong decision
No 116 68 38 23 20 10 I
168 Total Factors in road environmentt . .316 (264) Adverse road design 157 (134) Inadequate signs, markings, lighting, etc 281 (231) Adverse road, weather, or traffic conditions . .129 (124) Obstructions
Vehicle defects (n = 3909)$ Tyre defects. Brake defects. Steering defects Light defects or inadequacy. . Mechanical failure Electrical failure Load defects. Windscreen defects or poor condition Total
*Based on tables 2, 4, and 5 in Sabey and Staughton's report1' by courtesy of the Transport and Road Research Laboratory. tNumber of accidents in parentheses. +Only defects thought to be main factors are included.
67 65 7 10 22 4 10 13 474
BRITISH MEDICAL JOURNAL
4 NOVEMBER 1978
is a social class gradient, for example, that is not restricted to children-who clearly are more exposed to traffic in a workingclass environment. For men aged 15-64 deaths in motor vehicle accidents rise from social classes I to V, with a substantial increase between classes IV and V9 (exposure is not included in the calculations). An association between high accident rates and poor education, moreover, appeared in an American survey, even when drinking and distance travelled were taken into account.10 But from this study and many others lack of driving experience emerges as one of the main risk factors; "unsafe" characteristics of new drivers have been documented11 but we have not yet discovered effective ways of making the inexperienced more safe more quickly. Factors contributing to accidents Human error is generally agreed to play some part in a large proportion of road accidents. Often, however, there is a combination of factors, and accidents can be greatly reduced by purely external measures-for instance, improvements to the vehicle and the road environment. The most detailed evidence comes from a four-year "on-the-spot" investigation of accidents in south-east Berkshire by the Transport and Road Research Laboratory.12 The multidisciplinary team, on call 24 hours a day, gathered information on the site, and later studied some vehicles more closely and if possible interviewed drivers and pedestrians. The area was mainly rural and therefore had far fewer pedestrian accidents than the national average; but otherwise the findings are thought to provide a good introductory picture of accidents in Britain. In all, the team studied 2130 accidents, in which 1993 people (in 1316 accidents) were injured, 65 fatally. Fifty-nine per cent of drivers and 79% of pedestrians were primarily or partly at fault. Of the 2211 drivers at fault, 632 had been impaired in some way-463 by alcohol, 159 by fatigue, 87 by drugs, 33 by illness, and 26 by emotional distress. Human error (table) was the sole apparent explanation of no fewer than 650/O of the accidents. An adverse environment appeared to have contributed to 28% and vehicle defects to 8%. As apparently sole causes, however, these categories each accounted for only 2J% of accidents-human faults, particularly errors arising from care-
1273 lessness, misjudgment, and inexperience, contributing to nearly 95%. Clearly, impairment by alcohol and other conditions might well tip the balance between success and failure in coping with difficulties and hazards. Thus there may be several "layers" of causation, with complex interactions between contributory factors. Later articles in this series will look at particular factors in more detail. This interplay of factors-pointing to the varied scope for preventive measures-is illustrated by a collision that occurred on a rural trunk road on a wet night last November. This happened on a stretch of road where there had been several accidents over the years, at an unsigned sharp bend that restricted visibility. The driver of a camping wagon saw a saloon car coming round the bend on to his side of the road gnd so moved over himself to make room; but the other driver then attempted various ill-judged manoeuvres, skidded, and lost control. He was returning from a club where he had drunk several pints and said he was "laughing and joking," though a passenger thought he had not been impaired in his driving (for medical reasons, however, alcohol tests were never done). The result was a head-on collision in which the front parts of both vehicles were wrecked. None of the occupants was wearing a seat belt. The driver of the camping wagon was only slightly hurt but his passenger had severe head, leg, and internal injuries. The saloon car driver-who was later convicted of careless driving-received serious injuries to his head, face, and chest. His front-seat companion, a man of 31, had extensive injuries from which he died. I am grateful to the following for helpful discussion and comment: Professor R E Allsop, transport studies group, University College London; Dr D R Chambers, coroner of St Pancras Court, London (where I heard the inquest on the man referred to in the last paragraph); Dr J D J Havard, British Medical Association; Miss Barbara Sabey, Transport and Road Research Laboratory; and the Department of Transport.
References IHansard, House of Commons, 6 June 1978, col 89. 2 Department of Transport, Roads to Safety. London, Department of Transport, 1978.
If preventable why not prevented? How many of these car owners, typical of others all over the country, had drunk too much for safe driving by closing time ? The risk of accident rises-more and more steeply-with the blood alcohol concentration, and drinking is the largest single factor in road accidents in the UK. At least 200 000 injuries and 5000 deaths, it is estimated,6 were prevented in the seven years after the drinking and driving legislation of 1967; but the effect of this has steadily declined. A higher proportion of drivers killed in accidents are now found to have exceeded the legal limit of 80 mg/100 ml than before the 1967 Act. Both Sweden and Finland have now effectively reduced drink/driving offences by enforcing the law: why don't we?
Kr
BRITISH MEDICAL JOURNAL
1274
Smeed, R J, International Road Safety and Traffic Review, 1964, 12, 5. Department of Transport, Scottish Development Department, and Welsh Office, Road Accidents Great Britain 1976. HMSO, 1977. 5 Department of Transport, Road Safety-A Fresh Approach, Cmnd 339. London, HMSO, 1967. 6 Sabey, B E, paper presented to joint conference of the American Association for Automotive Medicine and the International Association for Accident and Traffic Medicine, Ann Arbor, Michigan, 1978. Department of Transport, Road Accidents Great Britain 1971, p x. London, HMSO, 1972. 8 Scott, P P, and Barton, A J, The Effects on Road Accident Rates of the Fuel Shortage of November 1973 and Consequent Legislation, Supplementary
3 4
4 NOVEMBER 1978
Report 236. Crowthorne, Transport and Road Research Laboratory, 1976. 9 Office of Population Censuses and Surveys, Occupational Mortality: Decennial Supplement, England and Wales, 1970-1972, p 58. London, HMSO, 1978. 10 Borkenstein, R F, et al, The Role of the Drinking Driver in Traffic Accidents. Indiana University, Department of Police Administration, 1964. 11 Quenault, S W, and Parker, P M, Driver Behaviour-Newly Qualified Drivers, Report LR 567. Crowthorne, TRRL, 1973. 12 Sabey, B E, and Staughton, G C, paper presented to fifth international conference of the International Association for Accident and Traffic Medicine, London, 1975.
Contemporary Themes Changes in behavioural characteristics of elderly populations of local authority homes and long-stay hospital wards, 1976-7 D WILKIN, T MIASHIAH, D J JOLLEY British
MedicalyJournal,
1978, 2, 1274-1276
Summary and conclusions Behavioural characteristics of the elderly populations of seven local authority residential homes and three longstay hospital wards were assessed in 1976 and 1977 with the Crichton Royal behavioural rating scale. In 1977 the levels of behavioural problems had increased in the residential homes, but declined in the hospital wards. Differences between the homes had decreased as the overall level of problems increased. The findings suggested that the additional burden of caring for increasing numbers of severely disabled elderly people was affecting the balance of institutional care, and a radical reappraisal of present patterns of care may be necessary to meet their future needs.
Introduction The number of old people in England and Wales is expected to increase by about one million between 1971 and 1991, but the biggest increase will be among those aged 75 and over,' many of whom cannot care for themselves because of mental and physical illnesses. Most will be cared for at home,' but the concentration of severely disabled people in institutions is already posing problems of both policy and practice. At a time of economic constraint, and when expansion of institutional facilities is also unfashionable, existing establishments are coming under increasing pressure as the demand for care rises. Studies that have described the characteristics of the elderly populations of hospitals local authority homes, and other institutions3-5 have shown that allocation to different forms of
care varies with locality and is influenced by the services available and the way these respond to the demands made on them. Thus many people find their way into conditions not ideally suited to their needs,6-8 and present patterns of care are rarely
those described in "official guidelines."9 10 Changes in the demand for institutional care and the facilities available should be monitored regularly and there is a continuing need for upto-date surveys on current conditions.11 We describe changes in the behavioural characteristics of the elderly populations of local authority homes and long-stay hospital wards in south Manchester during one year.
Services Social service provision to the resident elderly population of Manchester (roughly 90 000 of retirement age) is among the best in Britain. Domiciliary services are well developed, and include 700 home helps, who visit almost 10 000 households, and a system of neighbourhood wardens and neighbourhood visitors in contact with over 5000 households. Almost 900 000 meals-on-wheels are delivered every year, and in addition 40 luncheon clubs are well attended. There are five day centres, and most residential homes accept up to four day attenders. Residential care is provided in purpose-built or converted homes, with an average capacity of 40 residents and a total of 25 places for every 1000 aged 65 or more. There are six administrative areas in the City of Manchester, and each area provides a team of social workers and assistants and has various facilities, such as residential homes, for caring for elderly clients. Hospital facilities for the elderly are less ample. The geriatric services continue to carry the burden of providing for those who live in the commuter suburbs outside Manchester itself. Thus, although there is an academic department of geriatric medicine at Withington hospital and a total of four geriatric firms working from the hospitals of south Manchester, the ratio of beds available is roughly 0 7 per 1000 elderly, with 40 day places in a catchment population of 54 000 elderly. Psychiatric beds for demented people are in the ratio 15 for every 1000 elderly, with no designated day care at all. The level of provision of facilities did not change during the study.
University Hospital of South Manchester, West Didsbury, Manchester M20 8LR D WILKIN, PHD, research fellow, psychogeriatric unit T MASHIAH, MD, visiting postgraduate student D J JOLLEY, BSC, MRCPSYCH, consultant psychogeriatrician
Methods The Crichton Royal behavioural rating scale (CRBRS)12 was used to assess behavioural characteristics in residents in seven local autho-
A
BRITISH MEDICAL JOURNAL
4 NOVEMBER 1978
Modern Epidemic
What causes road accidents ? BY A SPECIAL CORRESPONDENT
British Medical3journal, 1978, 2, 1272-1273
The cost of treating victims of road accidents in England and Wales was estimated at between J50m and £55m in the financial year 1977-8; 1-4°,, of all hospital beds were taken up by these patients.1 In 1977 the total estimated cost of road accidents in Great Britain, including the "damage only" category and including an allowance for lost output, was £940m.2 To this the Department of Transport adds an allowance for "pain, grief, and suffering," amounting to C347m. This it calls a notional and minimum value. Accident trends
Alarming though these figures are, in the 1960s experts were predicting a much higher rate of accidents. Smeed forecast that in 1972 there would be about 745 000 casualties (more than twice the 1962 figure) on the basis of the expected increase in vehicles on the road or, more optimistically (if recent safety factors continued to operate), 472 000.3 As it turned out, there were only about 359 000.4 Certainly the increase in vehicles was less than expected: in 1972 there were 15-7 million4 rather than the 19-4 million predicted by Smeed. Even on this basis, however, his more optimistic figure would have been 382 000 casualties. What then happened to produce this reversal ? The year 1967 saw a White Paper5 followed by a new Road Safety Act. The most notable new measure, the "drinking and
driving" legislation, whereby it became illegal to drive with a blood alcohol concentration of over 80 mg/100 ml, had an immediate and striking effect on the statistics-an effect that began to wear off, however, after 1968 as the publicity lost its force. The declining efficacy of this measure has been monitored by surveys of blood alcohol concentrations in drivers killed in accidents, and one in five road deaths, it is estimated, would be prevented if drivers did not exceed the legal limit.6 Also as a result of the 1967 Act, separate licences were brought in for drivers of heavy goods vehicles, and there are now strict controls for these drivers; an especially noticeable improvement in accident rates followed the limitation of driving hours in April 1970, and other measures about the same time.7 The accident rates have declined more rapidly for this class of vehicle than for any other. In 1971 the Green Cross Code for pedestrians was introduced. The fall in pedestrian casualties did not start, however, until 19734; it is ascribed in part to the massive publicity campaigns that have been aimed at children and their parents, though some would give greater weight to other factors such as the fuel crisis of 1973-4. This indeed had a general effect on accident rates. The reduced volume of traffic certainly helped, but the fall in casualties, and in the proportion killed or seriously injured, was too great for that to be the sole reason. The higher speed limits were temporarily reduced to 50 mph (80 kpm); and the shortage of petrol and its suddenly increased cost are also thought to have made people heed the advice to drive more slowly and carefully to conserve fuel.8 Some trends in accidents suggest no simple solution. There
Factors contributing to the 2130 accidents in TRRL study* Contributory factor Lack of care Too fast. Looked but failed to see
No
Huma zn error-drivers (n = 3757) ..
..
..
..
Distraction Inexperience Failed to look. Wrong path Lack of attention Improper overtaking Incorrect interpretation Lack of judgment Misjudged speed and distance Following too close Difficult manoeuvre Irresponsible or reckless Wrong decision or action Lack of education or road craft Faulty signalling Lack of skill Frustration Bad habit In wrong position for manoeuvre
Aggressive
Total
905 450 367 337 215 183 175 152 146 125 116 109 75 70 61 50 48 47 33 15 12 7 6 3536
Contributory factor Human error-pedestrians (n = 147)
Lack of care .. Failed to look. In dangerous position Looked but failed to see .. Distracted .. Misjudged speed and distance Wrong decision
No 116 68 38 23 20 10 I
168 Total Factors in road environmentt . .316 (264) Adverse road design 157 (134) Inadequate signs, markings, lighting, etc 281 (231) Adverse road, weather, or traffic conditions . .129 (124) Obstructions
Vehicle defects (n = 3909)$ Tyre defects. Brake defects. Steering defects Light defects or inadequacy. . Mechanical failure Electrical failure Load defects. Windscreen defects or poor condition Total
*Based on tables 2, 4, and 5 in Sabey and Staughton's report1' by courtesy of the Transport and Road Research Laboratory. tNumber of accidents in parentheses. +Only defects thought to be main factors are included.
67 65 7 10 22 4 10 13 474
BRITISH MEDICAL JOURNAL
4 NOVEMBER 1978
is a social class gradient, for example, that is not restricted to children-who clearly are more exposed to traffic in a workingclass environment. For men aged 15-64 deaths in motor vehicle accidents rise from social classes I to V, with a substantial increase between classes IV and V9 (exposure is not included in the calculations). An association between high accident rates and poor education, moreover, appeared in an American survey, even when drinking and distance travelled were taken into account.10 But from this study and many others lack of driving experience emerges as one of the main risk factors; "unsafe" characteristics of new drivers have been documented11 but we have not yet discovered effective ways of making the inexperienced more safe more quickly. Factors contributing to accidents Human error is generally agreed to play some part in a large proportion of road accidents. Often, however, there is a combination of factors, and accidents can be greatly reduced by purely external measures-for instance, improvements to the vehicle and the road environment. The most detailed evidence comes from a four-year "on-the-spot" investigation of accidents in south-east Berkshire by the Transport and Road Research Laboratory.12 The multidisciplinary team, on call 24 hours a day, gathered information on the site, and later studied some vehicles more closely and if possible interviewed drivers and pedestrians. The area was mainly rural and therefore had far fewer pedestrian accidents than the national average; but otherwise the findings are thought to provide a good introductory picture of accidents in Britain. In all, the team studied 2130 accidents, in which 1993 people (in 1316 accidents) were injured, 65 fatally. Fifty-nine per cent of drivers and 79% of pedestrians were primarily or partly at fault. Of the 2211 drivers at fault, 632 had been impaired in some way-463 by alcohol, 159 by fatigue, 87 by drugs, 33 by illness, and 26 by emotional distress. Human error (table) was the sole apparent explanation of no fewer than 650/O of the accidents. An adverse environment appeared to have contributed to 28% and vehicle defects to 8%. As apparently sole causes, however, these categories each accounted for only 2J% of accidents-human faults, particularly errors arising from care-
1273 lessness, misjudgment, and inexperience, contributing to nearly 95%. Clearly, impairment by alcohol and other conditions might well tip the balance between success and failure in coping with difficulties and hazards. Thus there may be several "layers" of causation, with complex interactions between contributory factors. Later articles in this series will look at particular factors in more detail. This interplay of factors-pointing to the varied scope for preventive measures-is illustrated by a collision that occurred on a rural trunk road on a wet night last November. This happened on a stretch of road where there had been several accidents over the years, at an unsigned sharp bend that restricted visibility. The driver of a camping wagon saw a saloon car coming round the bend on to his side of the road gnd so moved over himself to make room; but the other driver then attempted various ill-judged manoeuvres, skidded, and lost control. He was returning from a club where he had drunk several pints and said he was "laughing and joking," though a passenger thought he had not been impaired in his driving (for medical reasons, however, alcohol tests were never done). The result was a head-on collision in which the front parts of both vehicles were wrecked. None of the occupants was wearing a seat belt. The driver of the camping wagon was only slightly hurt but his passenger had severe head, leg, and internal injuries. The saloon car driver-who was later convicted of careless driving-received serious injuries to his head, face, and chest. His front-seat companion, a man of 31, had extensive injuries from which he died. I am grateful to the following for helpful discussion and comment: Professor R E Allsop, transport studies group, University College London; Dr D R Chambers, coroner of St Pancras Court, London (where I heard the inquest on the man referred to in the last paragraph); Dr J D J Havard, British Medical Association; Miss Barbara Sabey, Transport and Road Research Laboratory; and the Department of Transport.
References IHansard, House of Commons, 6 June 1978, col 89. 2 Department of Transport, Roads to Safety. London, Department of Transport, 1978.
If preventable why not prevented? How many of these car owners, typical of others all over the country, had drunk too much for safe driving by closing time ? The risk of accident rises-more and more steeply-with the blood alcohol concentration, and drinking is the largest single factor in road accidents in the UK. At least 200 000 injuries and 5000 deaths, it is estimated,6 were prevented in the seven years after the drinking and driving legislation of 1967; but the effect of this has steadily declined. A higher proportion of drivers killed in accidents are now found to have exceeded the legal limit of 80 mg/100 ml than before the 1967 Act. Both Sweden and Finland have now effectively reduced drink/driving offences by enforcing the law: why don't we?
Kr
BRITISH MEDICAL JOURNAL
1274
Smeed, R J, International Road Safety and Traffic Review, 1964, 12, 5. Department of Transport, Scottish Development Department, and Welsh Office, Road Accidents Great Britain 1976. HMSO, 1977. 5 Department of Transport, Road Safety-A Fresh Approach, Cmnd 339. London, HMSO, 1967. 6 Sabey, B E, paper presented to joint conference of the American Association for Automotive Medicine and the International Association for Accident and Traffic Medicine, Ann Arbor, Michigan, 1978. Department of Transport, Road Accidents Great Britain 1971, p x. London, HMSO, 1972. 8 Scott, P P, and Barton, A J, The Effects on Road Accident Rates of the Fuel Shortage of November 1973 and Consequent Legislation, Supplementary
3 4
4 NOVEMBER 1978
Report 236. Crowthorne, Transport and Road Research Laboratory, 1976. 9 Office of Population Censuses and Surveys, Occupational Mortality: Decennial Supplement, England and Wales, 1970-1972, p 58. London, HMSO, 1978. 10 Borkenstein, R F, et al, The Role of the Drinking Driver in Traffic Accidents. Indiana University, Department of Police Administration, 1964. 11 Quenault, S W, and Parker, P M, Driver Behaviour-Newly Qualified Drivers, Report LR 567. Crowthorne, TRRL, 1973. 12 Sabey, B E, and Staughton, G C, paper presented to fifth international conference of the International Association for Accident and Traffic Medicine, London, 1975.
Contemporary Themes Changes in behavioural characteristics of elderly populations of local authority homes and long-stay hospital wards, 1976-7 D WILKIN, T MIASHIAH, D J JOLLEY British
MedicalyJournal,
1978, 2, 1274-1276
Summary and conclusions Behavioural characteristics of the elderly populations of seven local authority residential homes and three longstay hospital wards were assessed in 1976 and 1977 with the Crichton Royal behavioural rating scale. In 1977 the levels of behavioural problems had increased in the residential homes, but declined in the hospital wards. Differences between the homes had decreased as the overall level of problems increased. The findings suggested that the additional burden of caring for increasing numbers of severely disabled elderly people was affecting the balance of institutional care, and a radical reappraisal of present patterns of care may be necessary to meet their future needs.
Introduction The number of old people in England and Wales is expected to increase by about one million between 1971 and 1991, but the biggest increase will be among those aged 75 and over,' many of whom cannot care for themselves because of mental and physical illnesses. Most will be cared for at home,' but the concentration of severely disabled people in institutions is already posing problems of both policy and practice. At a time of economic constraint, and when expansion of institutional facilities is also unfashionable, existing establishments are coming under increasing pressure as the demand for care rises. Studies that have described the characteristics of the elderly populations of hospitals local authority homes, and other institutions3-5 have shown that allocation to different forms of
care varies with locality and is influenced by the services available and the way these respond to the demands made on them. Thus many people find their way into conditions not ideally suited to their needs,6-8 and present patterns of care are rarely
those described in "official guidelines."9 10 Changes in the demand for institutional care and the facilities available should be monitored regularly and there is a continuing need for upto-date surveys on current conditions.11 We describe changes in the behavioural characteristics of the elderly populations of local authority homes and long-stay hospital wards in south Manchester during one year.
Services Social service provision to the resident elderly population of Manchester (roughly 90 000 of retirement age) is among the best in Britain. Domiciliary services are well developed, and include 700 home helps, who visit almost 10 000 households, and a system of neighbourhood wardens and neighbourhood visitors in contact with over 5000 households. Almost 900 000 meals-on-wheels are delivered every year, and in addition 40 luncheon clubs are well attended. There are five day centres, and most residential homes accept up to four day attenders. Residential care is provided in purpose-built or converted homes, with an average capacity of 40 residents and a total of 25 places for every 1000 aged 65 or more. There are six administrative areas in the City of Manchester, and each area provides a team of social workers and assistants and has various facilities, such as residential homes, for caring for elderly clients. Hospital facilities for the elderly are less ample. The geriatric services continue to carry the burden of providing for those who live in the commuter suburbs outside Manchester itself. Thus, although there is an academic department of geriatric medicine at Withington hospital and a total of four geriatric firms working from the hospitals of south Manchester, the ratio of beds available is roughly 0 7 per 1000 elderly, with 40 day places in a catchment population of 54 000 elderly. Psychiatric beds for demented people are in the ratio 15 for every 1000 elderly, with no designated day care at all. The level of provision of facilities did not change during the study.
University Hospital of South Manchester, West Didsbury, Manchester M20 8LR D WILKIN, PHD, research fellow, psychogeriatric unit T MASHIAH, MD, visiting postgraduate student D J JOLLEY, BSC, MRCPSYCH, consultant psychogeriatrician
Methods The Crichton Royal behavioural rating scale (CRBRS)12 was used to assess behavioural characteristics in residents in seven local autho-
