Better community residential services for the mentally handicapped.

The sociological study of institutions has developed considerably in the past two decades. It has moved from the case studies of mental hospitals (e.g. Stanton & Schwartz, 1954; Belknap, 1956) and the graphic, speculative typology of Goffman (1961) to empirically based comparative studies of facilities for both the mentally ill and the mentally handicapped (Hewett et al. 1975; Wing & Brown, 1970; Ullman, 1967; Wing & Hailey, 1972; Morris, 1969; King et al. 1971; Raynes et al. 1977). All these studies have included among their goals the development of our understanding of the structure and functioning of these institutions so as to facilitate the planning, administration and evaluation of better residential services. Further, since the publication of Better Services for the Mentally Handicapped (DHSS, 1971), it is clear that in the United Kingdom the government supports the provision of a continuum of services for mentally handicapped persons. As part of that continuum there is a commitment to provide residential facilities in the community for those who need such services. It is now more than a decade since Tizard (1964) demonstrated that mentally handicapped persons can be cared for in either hostels or their own homes if adequate support services are made available for the handicapped individual and his or her family. The growth of residential services in the community has been slow. In 1974 there were 10496 places provided under the National Health Service in homes and hostels in the community (Hansard, 6 July 1976), but there were still 55150 beds in hospitals for the mentally handicapped. The Department of Health and Social Security currently encourages the development of community facilities and the reduction of hospital beds. At this juncture, however, we should ask two questions. First, where are those leaving hospital going ? Secondly, what is the quality of the residential services in which we are proposing to accommodate at least a part of this population ? In a thorough review of research on the handicapped child Pilling notes 'that hostels do not automatically mean that children will have the best type of care possible' (Pilling, 1973). We should still pay heed to her warning. What she says about the care of children equally applies to the care of adults. At this stage rational planning based on data and systematic evaluation is not only possible but essential if better services for the mentally handicapped are to materialize. It is necessary to know which aspects of organizational structure are related to which aspects of the quality of care if research is to be of assistance in the planning and development of residentoriented care facilities. The feasibility of such planning and evaluation is demonstrated by the findings of a number of research studies. First, there is considerable evidence that many mentally handicapped people can live in the community in small group facilities (Kushlick, 1967). Kushlick's recent work has shown that children in the Wessex hostels spend more time engaged in activity than do their peers in traditional settings. He has also demonstrated that the running cost of these experimental units is on 3 par with those of the traditional hospital (A. Kushlick, personal communication). Secondly, a systematic evaluation of the quality of care in a variety of residential settings for the mentally handicapped child has been undertaken by several workers (Raynes & King, 1968; King et al. 1971). These studies also showed the importance of aspects of the organizational structure, rather than its size or staffing ratios, in determining the quality of care provided in residential settings. The work of Clarke et al. (1975), who examined a wider range of facilities, also stresses the relative unimportance of size, as compared with organizational structure, in determining the quality of care. King et al. (1971) have also begun to delineate key variables in the organizational structure which promoted or inhibited resident centred care. They have already shown how delegation of authority and role diffusion were linked to child centred care.