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Special Articles

THE HANDICAPPED ADULTIN THE COMMUNITY *

J. B. M. DAVIESM.D. Lond., D.P.H.

DEPUTY MEDICAL OFFICER OF HEALTH FOR LIVERPOOL

* Based on a paper given to the Society of Medical Officersof Health on Nov. 5, 1954.

WHEN the handicapped child leaves the care of thelocal education authority his future is considered by theemployment officer, usually with sympathy but seldomin cooperation with the school medical officer. - Yetdecisions’must be made at this stage which will decidethe child’s whole life, and it would be logical for histeachers and the school medical officer, who have steeredhim through school life, and also the welfare officers whowill have to help him later, to be consulted.

Basically the problems of the handicapped are medical,capable of true understanding only by doctors, and thisis recognised while the child is at school. It is the schoolmedical officer, and not the educationalists, who decideswhether a residential or day school, a special class orhome teaching, is the answer to the child’s problems.It is the more surprising, then, that the handicappedadolescent does not always continue to be handled bydoctors. His handicap is unchanged, and his problemsare increased as he tries to adjust himself to his new wayof life. But at the time when there is greater need formedical control, that supervision is relaxed and oftenren oved.Under most large local authorities the medical officer

of health is also principal school medical officer, and thisensures that the preschool child’s welfare is integratedwith that of the school child. It is less usual for theM.O.H. to have charge of the welfare services ; but,where he does, he and his staff can continue to

supervise the handicapped child’s life after he leavesschool.Even where local administrative arrangements do not

favour this cohesion, I believe that each handicappedchild-particularly the physically handicapped anddelicate children-should be individually considered atthe age of 11, when he starts his secondary education,by a panel of his teachers, the school medical officer,the employment officer, and the welfare officer.

The Right Job

The chances of success in a job depend on the attitudeand character of the handicapped person, on the degreeof handicap, and on the energy and approach of thosewho have to help him. Often success is attained only byingenuity and improvisation. The seriously handicappedsometimes achieve great success, while others withminor handicaps fail. But, irrespective of the type ordegree of handicap, an individual assessment is necessary,and this can only be properly carried out by someonewho visits the handicapped person at his home to seethe conditions under which he must live.Who should do this assessment ? Usually in the case of

the blind, and the deaf and dumb, the visit is paid bysomeone with experience of dealing with the particularhandicap. With other handicaps the welfare visitor orhealth visitor carries out this work, often with the helpof a hospital almoner ; and I can see few drawbacksand many advantages in using general visitors for thispurpose, at any rate in the first instance. A’specialisedworker can be consulted later if need be. By usinggeneral welfare visitors, it should be easier to ensure thatthe handicapped are being treated as nearly as possible

as normal individuals, and more uniformity of treatmentbetween different groups of handicapped people could bemaintained.

Sheltered WorkshopsFor many of the handicapped-too many, in my view

- jobs will be found in sheltered workshops. Becausecosts are rising, many of these workshops are facing acrisis.The main reasons for rising costs are increased wages

and increased competition. This latter problem is veryinteresting, for it shows one of the fundamental weak-nesses of the present workshop system. The difficultiesof the workshops of the blind are typical of many shelteredworkshops today.The trades practised by the blind are traditional-

basket-making, mat-making, brush-making, and machine-knitting. Most of them were selected at the beginningof the century, and few have been added. Yet workingconditions in open industry during this period havechanged radically. For instance the cheapest brushesare now machine-made and their quality is as good as,and often better than, that of hand-made brushes. It isimpossible for any blind workshop to compete withmachine-made brushes, and to sell their products theymay have to do so at a loss.A new entrant into a workshop is patiently taught

his trade. Once he is fully trained, he is accepted as aworker in that trade for the rest of his working life,which may be for the next forty-five years. If, duringthat period, his trade becomes out of.date (as has hap-pened with hand brush-making) he has to continue inan out-of-date trade, or else try to learn a new one. Toa severely handicapped person, this may be difficult,and no public body likes to put him off work just becausehis trade is out of date. He usually carries on his trade,and through no fault of his own, continues to add to thefinancial burdens and difficulties of the workshop. Fewwould wish to disturb any blind worker who has beenworking satisfactorily for many years at brush-making,even if this is now unprofitable but it is wrong not toface the fact that the present system is at fault. A firststep should be to stop anyone else being taught theunprofitable trade ; but even this has not been acceptedthroughout the country.

No-one can say for certain whether or when an occupa-tion suitable for a handicapped person today will notbecome out of date. Where, then, is the answer to thisawkward question ?

It must be recognised that any sheltered workshop,however efficient, will run at an increasing loss. This

being so, an even smaller proportion of the disabledshould be sent to them-not only because of the expense(though it is no use pretending that expense can beignored) but because they will never provide the answerto the main problems. This in my view can be found onlyin open industry. At present the handicapped entrantinto industry, after an initial training, has to pull hisweight in competition with other workers. Each is placedwith great patience on the part of the placement officers ;naturally careful selection has to be ensured ; and thosewho are successful in open industry are the happiest ofhandicapped workers. The main difficulty in industrialplacing of a handicapped class is not so much that suitableoccupations are not available, as that initially the

employer cannot afford to employ them. The samedifficulty is met in sheltered workshops, and it is onlyby considerable augmentation that any workshop cancontinue. The obvious answer seems to be that augmen-tation should be introduced into open industry. Todayin Liverpool, for instance, each worker in one of our

workshops for the blind costs over :E5 a week. If wecould go to prospective employers in open industry, andoffer to augment up to, say, jE2 a week, I believe ourplacements would be numerous enough to solve a sub-stantial part of the problem. Of course there are difti-

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culties-the complaint of unfair competition, for example.But none of these are unsurmountable. Only a smallnumber of people are involved, and a few industrialfirms have already shown that severely disabled personscan do efficient work.Even if such a suggestion were accepted, there would

still be a place for sheltered workshops. But their num-bers should be kept to a minimum and they should catermainly for two groups :

.

(1) Severely disabled, whose only hope of full-time employ-ment is in sheltered workshops. This should be a small groupand should not contain people unable to work full-time.

(2) A less severely disabled group who are training to enterindustry. A reasonable time-limit must be placed on theirstay and they should not be allowed to drift into - the first

group.

Those who are in charge of sheltered workshops -lament that they are unable to find suitable new skilledtrades. But there is another approach to this subject,which seems more promising. Most of their difficultiescome from competition, which may make a trade hithertolucrative to the handicapped no longer so attractive.The only way to avoid this is for workshops not to betied to skilled trades at all. The Tuberculosis Colony atGreat Barrow successfully employs handicapped personson any suitable unskilled work which is available at thetime. Packing components in tropical packs and dis-mantling out-of-date wireless equipment have providedwork for many years. They are prepared to do work forwhich there is demand at that time, and by not tyingthemselves to any fixed trades they avoid the snags anddifficulties of any occupation becoming obsolete.At first sight this may seem a retrograde step, for it

would deprive the handicapped of the opportunity tolearn a skilled trade. But this is not so. With a largerand larger proportion of the handicapped finding a placein open industry, all these would have a skilled tradein industry. Those doing the unskilled work would bethe few who are employed full-time in the workshops,and the real security of these workers is the shelteredworkshop itself rather than the occupation theyfollow.

Home WorkersThe schemes for home workers vary greatly, but since

new scales were agreed to two years ago there has beengreater uniformity in the system of augmentation. Theseschemes, which are only for full-time employment athome, are the only form of sheltered employment opento handicapped people living in rural areas or withinsmall communities where it is impossible to run a

workshop. ‘

The usual way of assessing full-time work in theseschemes is to prescribe a minimum amount of workwhich must be completed by each worker to qualifyfor augmentation. It was a real advance when thissystem was adopted nationally in preference to themethod of fixed augmentation, paid irrespective to

output. Many of the home-worker schemes are not

anything like so costly as sheltered workshops and theyare working satisfactorily in country areas.The arguments for preferring open industry, wherever

this is possible, still apply to this group, but undoubtedlyhome-worker schemes will always be needed. Perhapsthe greatest dangers of these schemes is that augmenta-tion may be offered to part-time workers which wouldupset the whole concept of augmentation. By ensuringa reasonable minimum output of high-quality goods, thisdifficulty can be avoided. -

Occupational TherapyPart-time work..comes really into the sphere of occupa-

tional therapy. Some authorities have set up a domiciliary

occupational-therapy service. The ideal system arrangesfor occupational therapy to be available to as large agroup as possible, including chronic sick and crippled athome, those rehabilitating at home after a long illnesssuch as pulmonary tuberculosis, and the aged living intheir own homes or in hostels.

Such a service to be successful must’have a satisfactoryoutlet for the sale of the goods made. This problem,common with all home-made products, is best solved byusing one central shop to cater for all of them.The advantages of an occupational service are great,

for not only does it help and encourage many who arebeginning to face the problem of overcoming their dis-abilities, but also it is a useful link with the hospitals. Toomany patients receive great help from occupationaltherapy while they are patients, but cease to do so ondischarge. The domiciliary occupational service shouldcome into action as soon as the patient leaves hospital.

Welfare Services

The young crippled adult without a home and in needof care and protection is one of the most pitiful objectstoday. There are a few outstanding voluntary homes,but, unless a place in one of these can be found, he mustbe put in part-in accommodation intended for agedpeople.

.’ If we are to provide a real welfare service for thisgroup, we must take over where the special school leavesoff. The special training colleges, such as St. Loyes atExeter, should be increased, but there should be onecoordinated policy for each handicapped person. Ifpossible, a decision should be made early in the child’slife. What is really needed is the kind of supervisorycontrol at present exercised over the handicapped childat school. The larger local authorities could providehostels, run in close association with the special schools,and special training colleges.

However their future is settled, the welfare serviceswill continue to play a large part in the lives of mosthandicapped people. At present these services are veryunevenly distributed. Thus the welfare services for theblind have dwarfed all other welfare provision for thehandicapped with the possible exception in some areasof provisions for the deaf and dumb. Though the needto extend our welfare services to other groups is nowadaysrecognised, the cost - of blind welfare has in fact risensince 1948 proportionately far more than the costs of anyof the new welfare services for the handicapped. In

Liverpool in 1949, £9397 was spent on the blind, againsti:6419 on the deaf and dumb, the physically handicapped,and the epileptic ; but in the year ending March 31,1955, i:25,156 was spent on the blind and £14,641 onthe deaf and dumb, the physically handicapped, and theepileptic-an increase of 168% for the blind comparedwith 128% for the other groups.

There is also considerable inequality in the standardof service available at different periods of the handicappedperson’s life. For the handicapped school-child, amenitiesare better than they are at any later time. To lavish allthe special care of a residential special school- on himand then to provide next to nothing when he leavesschool is surely to have failed to understand the meaningof education.

What is needed is a steady coordinated policy fromschool life into adolescent life and on into adult life.

Many of the severely crippled will not succeed unlessthey have help at every stage, and they will very seldomget it unless the same person, administratively, is

watching over them all the time. My own belief is thatuntil the welfare services are everywhere organised bythe medical officer of health, the provisions for the adulthandicapped will remain as disjointed and haphazardas they are in many parts of the country today.