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Randall Smith, University of Bristol
Randall Smith retired in 2001 as Reader in Policy Studies and now enjoys a University appointment as a Senior Research Fellow. In 2009, he was awarded the title of Honorary Professorial Research Fellow. Apart from his modest teaching load, he has concentrated in the early years after retirement on completing two co-authored books on community care and services for older people and two co-edited books based on an EU Fifth Framework Programme project on participatory governance.
Randall has also published a UACES monograph on Constitutionalising the European Union and has a jointly authored report on significant life events in old age, based on research financed by the Nuffield Foundation. In 2005, he worked on a project funded by the Office of the Deputy Prime Minister, the ensuing report influencing the Government's review of the disabled facilities grant. His current research, funded by the ESRC and conducted with two colleagues from the Open University, is revisiting Peter Townsend's study of residential care (published as The Last Refuge in 1962). Articles have been accepted by the International Journal of Social Research Methodology and the Journal of Social Policy. A book will be published by Palgrave Macmillan in 2010.
Randall is a member of the Editorial Board of the journal, Policy and Politics, having been its editor between 1996 and 1999. Outside the University, he is a member of the Executive Committee of the British Society of Gerontology and a Trustee of Age Concern Bristol.
Speech
In his 20s and 30s, the young Peter Townsend produced a raft of groundbreaking works on different aspects of old age. Alan, our third speaker in this session, referred to these publications recently as ‘the building blocks of social gerontology’. One of them was the book The Last Refuge and my remarks will be focussed round issues of residential institutional care. What Alan said in relation to that publication was that it was a massive indictment against institutional regimes. Of course, it is also an affront to human rights and an affront to issues of social justice. There were many reviews of this pathbreaking book and one was in the Times Literary Supplement in March 1963. It concluded as follows – “The Last Refuge will be read long after the conditions which provoked Peter Townsend to undertake his work have passed into the pages of history books to be gasped over by a more humane generation. How much more humane have we become, and are likely to be in the near and medium future?”
What is clear is that the profile of residents today in care homes is very different from that of the late 1950s. One quotation, from Jill Manthorpe: ‘Over one third of the people with dementia live in care homes, and two thirds of care home residents have dementia’ This is the theme of my remarks. Compared with 50 years ago, therefore, staffing levels have substantially increased in care homes as more personal care is required. I have been involved in a study, using the raw material from the University of Essex archive and revisiting The Last Refuge. Our conclusion is that residential care for older people is a radically different instrument of social policy, compared with the 1950s. Perhaps we need therefore to reflect a little and think about the policy recommendations made by Peter in the context of the demographics of the early 21st Century.
The personalisation thesis of recent policy debate is couched as we know only too well in terms of reducing the cost of residential care in order to underpin community based development, not least in the recent strategy document on dementia. I do acknowledge that objective 11 of that strategy does refer to ‘living well’ in care homes. There is to be little or no new money according to official statements. Let me just quote the Guidance to Local Authorities produced last month: ‘The most likely way that local authorities can release money for investment in the future is to reduce the proportion of spend on residential care.’ With respect to dementia, of course, there are many examples of good support for frail older people in their own homes but it is not 24/7 coverage unless other household members are present. This tends not to be the case in the context of extra care housing, which is the focus of much policy development and, if there are other household members, the burden can be extraordinary and heavy.
I wonder therefore whether residential care could actually offer more quality of life than so-called independent living in extra care housing. The BUPA and Alzheimer’s Society programme with over 130 homes with dementia champions and so forth is at least an interesting initiative in this respect. However, it all hinges on having experienced staff and this of course has implications for rates of pay, training and career development. As the chief executive of BUPA said, if you want 21st century care, it costs.
So what do we think about Peter’s advocacy for the abolition of institutional care? In a sense that is part of the theme that we are addressing from the policy level today. First, note the pejorative overtone of the word ‘institution’. It may well have been justified in the 1950s and the 1960s, but the terminology continues to this day. Take the July 2009 implementation of the National Dementia Strategy. It refers to a reduction in admissions to long term institutional care. There has been this persistent negative image of residential care and it seems to ignore research which had rather more nuanced findings in this respect. Take Amelia Harris’ work published in 1968, the overview by Ian Sinclair in 1988, work by Isobel Allen and her colleagues in 1990 and Sheila Peace and her colleagues in 1997. In the study we have undertaken, my colleagues and I found great diversity in the character and culture of homes. Compared with the late 1950s — half a century ago — circumstances are rather more complex. In commenting on the current policy emphasis on independence, re-ablement, improved wellbeing, self directed support — who can possibly object? But does that really relate to the reality of the life of so many in care homes? How can their human rights be best addressed? I would argue that personalisation for people with dementia is more about the daily experience of what I might describe as stimulation within stability whether talking treatments, sensitive and certainly not antipsychotic drugs therapy and, very important, experienced staff with time to relate to residents as individuals. This could well be more achievable in residential settings than in separate independent accommodation in the community. My remarks have been drawn in part from a forthcoming book to do with the study Revisiting The Last Refuge. I must acknowledge the key contributions — though but they are not responsible for what I have just been saying — of my co-authors, the principal investigator Julia Johnson who is in the audience today and Sheila Rolph, both from the Open University.
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