There are a number of recent developments in policies relating to care, however, I am going to focus on just one of these policies which is the National Health Service And Community Care Act 1990. Community care has no single meaning, broadly, it means helping people who need care and support to live with dignity and as much independence as possible ‘in the community’. The ‘community’ is hard to define, it most often means ordinary homes, but for some people, it includes special forms of housing, residential or nursing homes.
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Community care involves provision which is largely pensions, benefits, income, transport, housing, the opportunity to work, policies for essential services such as fuel, telephone, recreation, education and leisure. Community care is part of our lives. It is the web of care and support provided for frail, people have sick, dependent people both by their families or others members of the community and by public or other services. This means helping some people remain in their homes or creating homelike places appropriate support.
Community care means a preference for home life over ‘institutional’ care. It means helping people to be integrated with their local community, rather than being separate from it, in a long stay hospital, where people do live with others in what are called ‘communal settings’ or ‘group homes’. There is a general reference for smaller homes close to where people have always lived.
New arrangements are being introduced for publicly provided social services. These are often referred to as the ‘community care changes’. They were first described in 1989 Government document called ‘Caring for people’, the NHS and Community Care Act 1990 made the necessary legal changes.
Firstly, When looking at the history behind the NHS and community Care Act 1990, In 1948 the new National Health Service (NHS) and local authorities inherited 500 old workhouses that catered for, or ‘warehoused’ a mixture of elderly people, some of whom were incapable of looking after themselves, some of whom needed medical or nursing care, and some of whom simply had nowhere else to go. The NHS, wanted to get rid of its embarrassing institutions, which contained hundreds of people confined to large wards with no privacy and receiving no significant medical treatment (Townsend 1962).
The Nuffield Foundation issued a report from a committee chaired by seebohm Rowntree in 1947 on the circumstances of old people living in these homes, in smaller residential accommodation and at home. It recommended the development of small units, of no more than thirty five people, sited in the community. Central Government issued guidance to local authorities encouraging them to develop such smaller residential homes, though its own expenditure restrictions made this difficult to achieve until the 1960’s when closure of the remaining workhouses became a major policy goal and local authorities began to build up services that supported elderly people in their homes, such as home helps and meals on wheels. In NHS terminology these alternatives to long stay care in the old hospitals and workhouses came to be called community care.
The same approach can be seen in the next social group to be considered for community care, which was the mentally ill. The Royal Commission on the Law relating to mental illness and mental deficiency in 1957 saw a decline in the number of people needing long-term compulsory detention in hospitals. Many were there and their civil liberties denied merely because no alternatives were available. The preparation for the closure of large long stay hospitals for the mentally ill began in the early 1960’s but it progressed very slowly at first. It was the scandals that hit the long stay institutions for the mentally handicapped in the late 1960s and early 1970s that began a large programme of hospital closure for that group too. (Martin 1984).
The term community care came to be applied to those facilities that were developed to replace long-stay hospital care. The expectation was that local authorities would take on the role of proving such alternative care. In the 1980’s, the emphasis changed again. In their very early statement of policy priorities for the elderly, ‘growing older’, the new conservative government emphasised the importance not of care in the community but of care ‘by the community’ (Department of Health and Social Security 1981).
This essentially meant care by the family and support by neighbours and local voluntary groups, not the local authority. Community care has been a concern to shift the responsibility for care from one agency to another, from the NHS to local authorities, from local authorities to families.
The NHS and Community Care Act 1990 was introduced for a number of reasons, it introduced new procedures for arranging and paying for state funded social care. The government stated that they aim to make the best use of public money to make sure that the services which are provided by local and health authorities meet their needs. They encouraged authorities to set priorities to decide how they will spend money if there is not enough to provide for everyone’s needs. They also ensure that local authorities check on the quality of care which is being provided through inspection units, complaints procedures, care management, setting of service specifications and monitoring contracts for care and they aimed to encourage local authorities to use other organisations to provide services, not just to provide themselves.
The Audit Commission 1986 carried out a report called ‘making a Reality of Community Care’, which was a highly cogent and critical document. It discussed the fragmented nature of the so-called spectrum of care that was supposed to be available, from hospital to domiciliary care. It pointed out that many agencies were involved and that many people were either getting the wrong kind of care or not getting care at all. It criticised funding arrangements that gave more central government support to hospital care than to local authorities, which were providing an alternative. What was new was the exposure of what was happening to the social security funding of residential care.
The Audit Commission documented the rise in spending and argued that the government was being wholly inconsistent. It was telling local authorities that it wanted old people to stay at home for as long as possible because that was the most cost-effective and desirable thing to do, but at the same time it was pushing large sums of public money into expensive residential and nursing home care.
Sir Roy Griffiths, Mrs Thatcher’s trusted advisor on the NHS, had already reported to her on the management of the NHS. He was called into service again. He established the Griffiths report in 1984 to review the way in which public funds are used to support community care policy and to advise the secretary of state on options which would improve the use of these funds. (Department of Health and Social Security 1988). His essential job was to sort the money problem. In his report he recommended that public finance for people, who require either residential home care or non-acute nursing home care, whether that is provided by the public sector or by private or voluntary organisations, should be provided in the same way. Public finance should only be provided following separate assessments of the financial means of the applicant and of the need of care. The assessments should be managed through social services authorities.
Local authority social services departments were responsible for the funding of support and organisation in the community, which commenced when the establishment of the NHS and Community Care 1990 was made. The blurring of the boundaries involving health and social care came into effect at the same time as the development of this Act was made. Recent debates are concerned with equality in community care over the allocation of public resources involving various client groups, income groups, localities and generations.
Local authority services departments were in charge of funding and organising care and support in the community, this was carried out by the NHS and Community Care Act 1990 to allow individuals who are affected by disability or ageing to live independently as possible. Both the idea of responsibility and community care and for its organisation has been especially hard to identify. For example, in 1981 a study by the Department of Health and Social Security distinguished the inconsistent understanding of community care by health and social services authorities. For the NHS, community care typically referred to care offered outside the health service, for example, residential care from local authorities. Residential care was referred mainly by social services departments.
The central department of social security was handed the main responsibility for funding from means testing to local service departments. Providing and planning care and assessing people’s needs was the local authority’s responsibility. This included domiciliary care as well as the allowance of money for places in residential and nursing homes.
The Act included key objectives, which were, three different types of services available for people at their homes such as respite, day and domiciliary services which includes occupational therapy, bathing services, home care and home help, various types of daytime care outside a person’s home is associated with day services. Examples of day services are lunch clubs, day hospitals and day centres. Another key objective is respite care enables people who are being cared for and carers to get a break from another. Respite services include day centre attendance, family placement schemes, sitting services and also respite care provided in nursing and residential homes. Another objective from the Act was service for carers, when an individual’s needs assessment is being prepared, carers need to be considered.
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Another key objective was that a referral on behalf of a patient to social services can be made by any individual as well as any person who is a member of the primary health care team. Also, anyone who appears to need a community care service must be carried out by the local authorities. A written care plan should be then set out by the local authority which should address who, when and what will be achieved by providing services, to deal with issues with services there should be a contact point and if any circumstances change, there should be information on how the individual can ask for an evaluation of the services.
Another objective is that GP’s are expected to deliver helpful information on health to assist social services in the care assessment. There are a number of adult client groups that benefited from these objectives. The children Act 1989 introduced many changes relevant to provision for children and their protection, adult client groups include elderly people, people with physical disabilities, mental health problems, drug and alcohol problems, people with HIV or AIDS, homeless people and people who are terminally ill.
However, the National Health Service and Community Care Act 1990 have been criticisms. There is a tension between the idea of ‘user-led’ assessment and the ‘targeting’ of resources on people. Some social services departments are worried that the assessment process will raise expectations which cannot be met.
It is possible that some assessments will not reflect people’s ‘actual’ needs, but only the needs they are allowed to express in line with those the authority feels able to meet. Such a system would suppress only understandings of the true level of need, unless the unmet needs are carefully recorded and fed back into the system.
Also the community care reforms are rooted in the idea that people should have choice about how their care needs are met. Assessment should be user-led, but gives the ultimate responsibility for defining need and working out how or if it will be met to the local authority through the assessor or care manager
The Act has been also criticised for using the term ‘vulnerable adults’. They are defined as ‘at risk of abuse’. They are those meeting the criteria of the NHS and Community Care Act 1990, or being in need of community care services by reason of mental or other disability, age or illness and being unable to take care of themselves or to protect themselves against ‘significant harm or exploitation’. The term ‘vulnerability’ is being used in this Act to stress the differences between people in terms of their ability to protect themselves. However, these differences are not fixed and a disability perspective would argue that casting disabled or older people, or people with health problems, as vulnerable is a form of infantilization and further perpetuates their less than full adult status. They can be seen as helpless or dependent and unable to manage the risks of ordinary living. Examples of this are: people with learning disabilities may be over-protected by those who fear they will be exploited, in particular, sexually.
Another criticism of the Act is that Lewis and Glennerster (1996) have suggested that NHS officers regarded the 1990 Act as ‘good grounds for getting rid of their long-term care responsibilities as soon as possible’. Some health authorities stopped providing any continuing care beds at all (Richards 1996). Eventually, these developments forced the department of health publicly to accept that the 1990 Act had led to a reduction in the responsibility of hospitals for long term care, not withstanding its earlier claims to the contrary.
On a 1994 report by the Health Service Commissioner into the case of a seriously brain damaged patient, for whom the local health authority had refused to accept responsibility, The Commissioner found that, in refusing to spend resources on patients of this type, the health authority was failing to fulfil its duties. (Health Service Commissioner 1994).
Another criticism of the NHS and Community Care Act 1990 are that even though the reforms have stressed the significance of carers (primarily other family members), however, some of the individuals that need care do not have families and of the individuals who do have families do not have carers. Also the basic difference in individual’s family situation is not directly addressed by the current policy. The community care reforms, which were preceded by the white paper, found that ‘the government distinguishes that demographic movements will have repercussions for the potential availability of carers. However, it failed to explore what these repercussions might be; the reforms also persist to place the relatives at the middle of the care system. Another criticism is that there also may be no interpreting service to help people whose first language is not English, or who is death, People may not want their financial means to be assessed, disablement benefits have to be put towards services offered, when there is already difficulty making ends meet.
In conclusion the community care involves provision which is largely pensions, benefits, income, transport, housing, the opportunity to work, policies for essential services such as fuel, telephone, recreation, education and leisure. Community care is part of our lives.
The NHS and Community Care Act included key objectives, which were, three different types of services available for people at their homes such as respite, day and domiciliary services which includes occupational therapy. Criticisms of the policy include casting disabled or older people, or people with health problems, as vulnerable is a form of infantilization and further perpetuates their less than full adult status.
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