NHS and Community Care Act | Critiques

“Community Care is really care by families which is really care by women; and it always will be!” Discuss

Introduction

When Margaret Thatcher came to power in the late 1970s one of her Government’s primary aims was to roll back the welfare state and cut spending on services. They argued that state services, and the health service in particular, were inefficient and costly. They further maintained that the introduction of market principles into welfare provision would increase efficiency, provide better services, and reduce costs. The Conservatives were anti-institutionalisation and began closing geriatric wards and psychiatric hospitals. The 1982 Government White Paper Growing Older emphasised the role of the family and that the role of Government was to enable, rather than replace that care. There was an implicit assumption here that much of this care would be provided by women. Twigg (1993) maintains that the 1988 Griffith Report which advised on more effective use of Government funds for community care also recognised that public services would only have a role where community and family support had broken down. Large numbers of the elderly and the disabled have always been cared for in the community, the state took over where this became a burden and the Tories were keen to discourage too much state provision. In 1990 the NHS and Community Care Act was introduced where the state was no longer the sole provider of care. Community care is the term used for both social and health care. Voluntary and Charitable organisations would also play a part and care packages would be organised by local authorities. This might include provision of services in a person’s home, residential care, respite care, day care and family placements, sheltered housing and group homes and hostels. This Act placed a much greater burden of care on those professions associated with healthcare e.g. social work, and at the same time resulted in further inequalities as care provision differed depending on what region of the country a person was in. It was argued that this kind of care would allow individuals to live with dignity and independence in their own communities. This paper therefore, aims to assess the statement that Community Care is really care by families which is really care by women and it always will be.

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Under the terms of the 1990 Act, responsibility for care in the community became the responsibility of local authority social services. Each authority has a duty to publish its care plans and has a duty to assess all those people who might need care. It is the authority’s responsibility to provide care and to promote the work of voluntary and charitable organisations by purchasing care from them. Local authorities are also bound to establish a complaints procedure and have the responsibility of checking out care packages.^[1] There have been a number of problems with the terms of the Act. Since 1993 the number of old people need support has continued to grow while NHS short and long term care has continued to shrink (Filinson, 1997). At the same time it is actually cheaper for social services departments to keep a person in residential care than to support them in their own home. New policies such as the Carers Representations and Services Act 1995 and the introduction of Direct payments which were intended to empower users and give them greater choice have been implemented without all the additional resources. Thus demands for service have increased while budgets have remained much the same. While there has been a lot of rhetoric about the needs of pensioners the focus has, necessarily been on the user, and carers needs are largely ignored. Unell (1996) points out that changes in community care:

…simultaneously raised the profile of carers and made their needs more difficult to meet in the short term (Unell, 1996:9).

Community Care and Familial Obligation

Since the 1970s there has been an increasing emphasis on care in the community and care within the family. This does not always work well and the greatest burden usually falls on those families with the least resources. Familial obligation is defined in law. In the UK it usually refers to the nuclear family of husband and wife, parents and children and benefits and taxes almost always recognise these relationships (Millar and Warman, 1996). The provision of services are intended to support, rather than take the place of the care and support that is expected of the family. Although Britain and most other European countries give some recognition to gender equality much policy making stems from post-war understandings within the welfare state, of the male breadwinner and the female housewife/carer. Community care and familial obligation are based on these hidden gendered assumptions. In Britain these obligations only extend downwards i.e. parental obligation to their children. In some countries adult children have familial obligation to their parents but this is not the case in the UK (Millar and Warman, 1996).

In spite of this the decreasing number of acute hospital beds means that there are more older people with chronic conditions in the community. They receive care from the local authority in their own homes but in many instances they rely heavily on informal carers, usually members of the family. Informal care involves a number of different activities and relationships and has been explained in the following way. Informal care:

…normally takes place in the context of family or marital relationships and is provided on an unpaid basis that draws on feelings of love, obligation and duty (Twigg, 1993:2).

Thus, this kind of care normally occurs within the family and Kirk (1998) states that data from the General Household Survey tends to suggest that the bulk of this kind of care is undertaken by women. Phillips and Bernard (1995) maintain that the kind of caring that many women give are the difficult tasks of physical and personal care. These carers may also have contact with a range of other community services and district nurses who might be involved in the caring process. The meaning of community care changes over time and during the 1970s and 1980s policy in this area brought changes to services for people with disabilities, people with learning disabilities, and people suffering from the frailties of old age (Kirk, 1998). Cost concerns meant that many institutions were closed and care was focussed on the community. Lewis and Glennerster (1996) maintain that during the 1990a community care was a policy shift to aid spending cuts. There was a change from residential care for older people to care in the community. How successful the shift from residential care to care at home has been is, Wistoe (1995) maintains still unclear. In the 1990s health policies in the UK have focussed on primary care, this has come about because of cost concerns, demographic shifts and changing patterns of illness. Many services that were provided in hospitals are now operating in the primary sector. This has resulted in complex nursing care being undertaken in a domicilary context. Which shifts the burden of care to informal carers, usually female family members with the help of district nurses. In some cases informal carers and the person themselves undertake some tasks such as intravenous injections (Conway, 1996). Costain and Warner (1992) maintain that if this continues then more dependent people with complex, intensive needs will be cared for at home thus increasing the burden on the family and on community care services. Manthorpe (1994) points out that informal carers are given little choice over their caring role and there is little respite as they are not often presented with an acceptable alternative. There has been little research into how this kind of caregiving affects family members although feminists (Abbott and Wallace, 1997) have expressed concern over the hidden assumptions underlying the concept of community care.

The Feminist Critique of Community Care

Feminists have focused on the informal caring that women do and which is often ignored by the professionals. Caring for an ageing or disabled relative for twenty four hours a day is bound to have an effect on women and yet there is little available help for respite.. Furthermore, the Community Care Act of 1990 has imposed further responsibilities on women in the role of informal carers (Abbott and Wallace, 1997). Based on the gender roles that existed in the welfare state, the discourses of health take it for granted that when members of their family are sick a woman will care for them. It assumes that women will put the needs of their children before their own. Health care is defined as care that is given by doctors, nurses, and other health professionals and the caring that women do in the home is recognised only as a part of the role that a woman plays in the home. Not only is her caring role invisible but the impact of shouldering the burden of caring is also ignored (Graham, 1993). The Office for National Statistics reports that in 1995 there were three times the number of female informal carers to male carers. Watson et al (1999) maintain women, who are the primary care givers in the family actually negate the view that the responsibility of care should primarily be in institutional structures. This is because as wives and mothers, even if they are employed full time, they still give care to other family members. Walby (1990) contends that women have been oppressed because of their biology and this is evident in the healthcare system. However, patriarchal control of women operates through an inter-related set of structures and practices through which women are oppressed by men, the state is patriarchal in its policies and practices and its interests are biased towards men. Thus it is not surprising that implicit in discourses of care in the community is the view that women will shoulder the burden of care. Abbott and Wallace state that:

While it is rarely given official recognition, and the tendency is to see paid health workers as the primary providers of health care, women provide most health care, within the confines of the family (Abbott and Wallace, 1997:170).

Conclusion

Care in the community is care in the home and feminists are right to suggest that this largely means care by women. The gendered nature of care giving needs to be re-examined if policy continues to shift the greater burden of care to the community. While there are such things as carer’s allowances these are very low and means tested, therefore many people do not claim them. There seems to be a stigma attached to the idea that people should claim allowances for long term care within the family. Perhaps a better option, once a person was assessed as needing long term community care would be an automatic payment for informal carers. It might also be useful if Government debate on care in the community lauded the work undertaken by informal carers and promoted a positive image of care within the family. Those families where men are the informal carers could, perhaps, be promoted as positive models for other men to follow. This might not only bring a shift in the implicit assumption that women will do the caring, but might give a broader and less stigmatised view of caring within the family. Assessment packages for long term informal carers should have regular respite care built into them so that carers get a regular break. Free community nursing care and domicilary care should be provided so that informal carers can go on holiday without having to worry about what was happening at home. Government may be keen to establish policies that shift even more care into the community but should also recognise that truly cost effective care takes account of all eventualities. At present it seems as though the notion that problems may arise in informal care settings is ignored, so that when these problems do occur it actually costs more to rectify than if an allowance for such eventualities was made in the first place. Too much strain is placed on many women because of the expectation that they will be informal carers, community care, it would seem needs much more careful planning than is presently the case.

References

Abbott and Wallace, 1997 An Introduction to Sociology: Feminist Perspectives. London, Routledge

Conway A.1996 Home intravenous therapy for bronchiectasis patients. Nursing Times 92(45), 34 35

Costain D. & Warner M.1992From Hospital to Home Care: The Potential for Acute Service Provision in the Home. King’s Fund Centre, London

Filinson, R. (1997) ‘Legislating community care: the British experience, with U.S.

comparisons’, The Gerontologist, 37,3: 333-140.

Giddens, 2001. 4^th ed. Sociology. Cambridge, Polity Press

Graham, H. 1993 Hardship and Health in Women’s Lives Hemel Hempstead, Harvester

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State for Social Services, London: HMSO.

Kirk, S. 1998 “Trends in community care and patient participation: Implications for the roles of informal carers and community nurses in the United Kingdom” Journal of Advanced Nursing Vol 28 August 1998 Issue 2 p.370

Lewis J. & Glennerster H.1996Implementing the New Community Care. Open University Press, Milton Keynes.

Manthorpe J.1994 The family and informal care. In Implementing Community Care (Malin N. ed.), Open University Press, Milton Keynes Millar, J. and Warman A. 1996 Family Obligations in Europe Family Policies Centre in association with Joseph Rowntree Foundation

Moore, S. Scourfield, P. Sinclair, S. Burch, S. and Wendon, B. 3^rd ed. 2002 Social Welfare Alive Cheltenham, Nelson Thornes.

Phillips J. & Bernard M.1995 Perspectives on caring. In Working Carers (Phillips J. ed.), Avebury, Aldershot.

Twigg, J. (1993) ‘Integrating carers in to the service system: six strategic

responses’, Ageing and Society, 13: 141-170.

Unell, J. (1996) The Carers Impact Experiment, London: King’s Fund Publishing.

. Walby,S. 1990. Theorising Patriarchy. Blackwell, Oxford.

Walsh, I ed. 2000 Sociology: Making Sense of Society. Edinburgh, Prentice Hall.

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^[1] http://www.infosci.org/MS-UK-MSSoc/pubcca.html