Foster and Roberts (1998, p. i) indicate that there are deficiencies in … the ‘triangular’ relationship between user, carer an community”. They point out that there is a “…common tendency to establish a two-way relationship, and disregard the perspective of the third party …” which “…obstructs the healthy functioning of the care system” (Foster and Roberts, 1998, p.i). Booker and Repper (1998, p. 4) expound upon the preceding in adding that “… community living is particularly difficult for people who have serious mental illness, many of whom experience frequent re-admissions in times of crisis and survive inadequately: in poverty and isolation, without work, with poor social supports and networks, and at risk of victimisation, exploitation, homelessness and imprisonment”. They add that “Indeed the community tenure of this population is often dependent upon the support of informal carers who inevitably have problems and needs themselves” Booker and Repper, 1998, p. 4).
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The foregoing points to valid issues brought out regarding the community care system that indicate need further examination, and which represents the focus of this examination. Such asks the question, ‘to what extent is current community care policy and practice responsive to the needs and concerns of service users and carers? The preceding represents an expansive discussion. In order to formulate a balanced assessment of these aspects, this examination shall seek to break down the context into the three frameworks as indicated by Foster and Roberts (1998, p. i), and examine key policy frameworks, and practice developments representing the four specific areas of disability, health, mental health and older people in community care. In said examination, this study shall consider the extent to which policy and practice has been shaped by factors other than the needs and concerns of service users and carers. In a study conducted by the Hull Community Care Development Project over a three year period, it found that “… care and support issues have been largely neglected in area-based work” (Joseph Rowntree Foundation, 2004). The following shall seek to reach a determination if that assessment is true in terms of the four areas identified, disability, health, mental health and older people.
Community Care represents the help as well as support that is provided to individuals that aids them in being able to live either in their own homes, or in a home type setting in their community (careline.org.uk, 2007). The foregoing assistance can consist of representing help for the individual that needs the aid to live in the community as well as help and or assistance for the carer. The government’s policy on community care sets forth six key objectives (careline.org.uk, 2007). The first represents the providing of “… home care, day and respite services …” that enables individuals, wherever feasible as well as possible, to live in their own homes (careline.org.uk, 2007). Secondly, it entails the making of a proper assessment concerning “… need and good care management …” which represents “… cornerstone of high quality care” (careline.org.uk, 2007). The third area represents the promoting and “… the development of a flourishing independent sector alongside good quality services” (careline.org.uk, 2007). The fourth element consists of the clarification of responsibilities to thus make it easier to hold the various agencies accountable for their performance (careline.org.uk, 2007). The fifth aspect represents, “… to secure better value …” for expenditures as a result of the introduction of “… new funding structures for social care” (careline.org.uk, 2007). With the last area, sixth, representing the providing of “… additional help for carers …” as well as offering a choice for patients and the general public (careline.org.uk, 2007).
Community Care services are available to support older people, individual with physical disabilities, learning disabilities, mental health problems and chronic illness (careline.org.uk, 2007). The services that are available, which can differ slightly in some areas, basically consist of 1). Home care, that includes assistance with washing and dressing, 2) meals on wheels and frozen meals, 3) equipment as well as various adaptations to make living at home an easier prospect, 4) Day care centers that contain helpful activities, 5) respite services, 6) supported housing for individuals that with mental health and or disabilities. 7) intermediate care, 8) practical as well as financial assistance, 9) community nursing, 10) incontinence as well as NHS supplied nursing equipment (careline.org.uk, 2007).
Community Care Policy
The National Health Service and Community Care Act of 1990, that was phased into operation over a three year period, established a system whereby the needs of individuals were assessed entailing an agreed upon care plan, assigned worker and regular progress reviews (BBC News, 1998). Part of the procedural aspects of the foregoing was identifying those individuals whom might represent a significant risk, either to themselves and or others (BBC News, 1998). Those so identified where placed onto a ‘Supervision Register’ to prevent them from ‘slipping through the net’, which of course did not, and has not proven full proof (BBC News, 1998). The purpose of the National Health Service and Community Care Act of 1990 was to “… split health and social care provision between purchasers and providers to create an internal market” (Leathard, A., 2003, p. 16). This approach represented a means “To curb costs, purchasers were required to assess needs, while providers were intended to compete against each other to secure contracts from the purchasers” (Leathard, A., 2003, p. 16). The foregoing represented efficiency from the standpoint of governmental administration, however, it shortchanged the ends users, and the patients, in that it immersed them into a bidding supply system that did not place their needs and concerns upper most in the hierarchy. Leathard (2003, p. 16) states that the preceding “The split between purchasers and providers, as well as the competition between the providers themselves, led to fragmentation of services but a collaborative momentum began to build up between the purchasers”.
Important in the foregoing, is the understanding that the methodology provided the District Authorities with the power to purchase hospital care, and the family health service authorities had the responsibility “…for services provided by GPs, pharmacists, dentists and opticians, while local authorities covered the purchasing of all social services in the community” (Leathard, A., 2003, p. 18).
The Secretary of the Central Association for Mental Welfare, Evelyn Fox, in 1930 stated the pure view of community care was one that has seemingly gotten lost in the translation to practice, (Fox, 1930, p. 71):
“Community Care should vary from the giving of purely friendly advice and help to the various forms of state guardianship with compulsory power . . . It should include the power of affording every kind of assistance to the defective – boarding out, maintenance grants, the provision of tools, travelling expenses to and from work, of temporary care, change of air – in a word, all those things which will enable a defective to remain safely in his family . . . If the state has undertaken the duty and responsibility of active interference in the life of an individual by supervision, compulsory attention and so forth, it must undertake the corresponding duty of making his life as happy as possible.
The effective control of a defective at home does inevitably mean a restriction in his complete freedom to go in and out as he pleases, to make what friends he chooses, to select what type of employment he likes out of those that are open to him. To impose these limitations without at the same time giving compensating interests is to court disaster”.
Her statement, which has validity today, saw the family at the centre of community care. In fact, her view was that families should be co-opted to supply effective control (Fox, 1930, p. 73). The policy statements thus far put into action have tended to favour the carers more than the service users, which is shown by the following. The NHS and Community Care Act 1990 is based upon the “… triumvirate of autonomy, empowerment and choice (Levick, 1992, pp. 76-81). Smart, 2002, p. 102) as well as Biggs and Powell (2000, pp. 41-49) both state that the ‘Act’ has a major weaknesses in that it fails to account for any critical analysis concerning the role as well as daily practices of care managers. Clements (2000) provides a critical observation in stating that community care law bears the indelible stamp of its poor origins and that the present shape still resembles Beveridge’s vision of the welfare state. Care in the Community was a policy of the Margaret Thatcher government in the 1990’s whereby she questioned the existence of society and sought via the NHS as well as the Community Care Act 1990 to extend the privatisation agenda into health and community care through the creation of NHS trusts, the greater use of independent residential and nursing homes, and the general promotion of the mixed economy of care (reference.com, 2007). The preceding represented the second shift in the community care / health care approach. The third shift occurred under Section 6 of the Human Rights Act 1998 which casts the definition of a public authority as “to embrace any person some of whose functions are of a public nature” (Bacigalupo et al, 2002, p. 249). The preceding continues “The expansive nature of this concept was explained by the Lord Chancellor who stated that the key question is whether the body in question has ‘functions of a public nature … If it has any functions of a public nature, it qualifies as a public authority” (Bacigalupo et al, 2002, p. 249).
The foregoing means that “… private community care providers as represented by residential care home owners, and or voluntary sector service providers such as Age Concern, MIND or housing associations are ‘public authorities’ in relation to anyone for whom they provide publicly funded care” (Bacigalupo et al, 2002, p. 249). They continue that “Such providers now shoulder public responsibilities for their vulnerable clients and are accountable in public law for their actions” (Bacigalupo et al, 2002, p. 249). The Department of Health has accordingly emphasised the need for English social services departments to ‘ensure that contractors and independent providers are made aware of their new duties” (Bacigalupo et al, 2002, p. 249). Under Article number 2 of the Act, which relates to policy for the Community Care Act 1990, it requires that the government and local authorities take reasonable measures to protect life (Bacigalupo et al, 2002, p. 249). Studies conducted by the Times (1994) found that relocating institutionalised elderly people to a new residence may have a dramatic effect on their mental health and life. A study by the Journal of American Geriatric Society (1994) indicated that mortality rates run as high as 35% in such instances.
Service Users and Carer Perspectives
Both aspects point out the fact that the system was not geared to the well being of the users. Further evidence of the foregoing was also expressed by Hardy et al (1999, pp. 483-491) who pointed out that the changes as brought forth in policy by the 1989 white paper ‘Caring for People’ as well as the 1990 NHS and Community Care Act were to increase choices for users as well as carers. The preceding changes were as a result of the fact that service users had been subordinate to professional service providers (Hardy et al, 1999, pp. 483-491). In addition, their had also been an inherent bias of funding that was geared for residential and nursing care and that such had deprived service users of the choice of being cared for in their own homes (Hardy et al, 1999, pp. 483-491). This was expressed by Leathard (2003, p. 16) who stated, “The split between purchasers and providers, as well as the competition between the providers themselves, led to fragmentation of services but a collaborative momentum began to build up between the purchasers”. The preceding was a result of the efficiency the Act brought to community care which did not address the needs, wishes and concerns of the users as it put them into a bidding system that saved money, but resulted in poorer care.
The foregoing included all four areas, disability patients, health patients, as well as mental health, and elderly patients who were caught in policy and practice developments. The Kings Fund Rehabilitation Programme (Hanford et al, 1999) addresses the foregoing deficiencies through policy initiatives based upon three themes, 1) working in partnership, 2) joint planning, and 3) commissioning. The preceding has been further developed through the King’s Fund updated statements on health and social care, in community based settings (King’s Fund, 2003). The combined initiatives have been devised to loosen governmental control and provide more accountability to patients and the local community (King’s Fund, 2003). Such a shift in policy will also affect hospitals as well as other what is termed as frontline providers to thus be more responsive to local needs and potentially improved performance (King’s Fund, 2003). The King’s Fund (1999) pointed out that the primary responsibility for the improvement in health programmes, specifically with regard to community care, lies with the health authorities, The King’s Fund (1999) also pointed out the however it is the local authorities that are expected to work out the objectives in improving the health and well being of their local communities. The initiatives put forth by the King’s Fund (1999) (2003) have been designed and crafted to achieve these lends through streamlining of the policy and operational facets.
An important aspect of the 1999 King’s Fund initiative entailed calling for improved preventive services that called upon local authorities to aid users to take on as many tasks as they could for themselves for as long as they could, along with living in their own homes for as long as possible. The preceding was borne out of fiscal realities, in order to better conserve funds. However, in light of the findings of studies conducted by the London Times (1994) as well as the Journal of American Geriatric Society (1994) that found that elderly patients that were institutionalized had morality rates that ran as high as 35% in many instances, means that this approach had definitive merits beyond the saving of funds. The foregoing approach was based upon older policy documents by the government that reinforced the methodology of fostering greater independence. Such was put forth by the Department of Health that stated the promotion of independence would “… have a positive effect on informal or unpaid carers … (King’s Fund, 1999). The King’s Fund (1999) also pointed out under ‘Best Value Initiatives’ “… local authorities should reduce delays in providing housing adaptations as part of the general move towards increased accountability to local people”.
The above recognizes the need as well as better care that users would and do receive from home based care that Evelyn Fox brought forth back in 1930. Her statement “If the state has undertaken the duty and responsibility of active interference in the life of an individual by supervision, compulsory attention and so forth, it must undertake the corresponding duty of making his life as happy as possible” (Fox, 1930, p. 71). The initiatives of the King’s Fund helped to remove the stigma as indicated by Clements (2000), that community care law bears the indelible stamp of its poor origins and that the present shape still resembles Beveridge’s vision of the welfare state. The initiative also addressed the observations of Smart, 2002, p. 102) as well as Biggs and Powell (2000, pp. 41-49) who both stated that the ‘Act’ had a major weaknesses in that it failed to account for any critical analysis concerning the role as well as daily practices of care managers. Through promoting more in home care for as long as possible, signaled a change in direction.
Policy changes as brought forth in 1997 resulted in the United Kingdom government issuing in June of each year a policy document informing the Health Authorities of their purchasing intentions for the following year (NHS Executive, 1996). Resulting there from were three sets of objectives: long-term objectives and policies; medium-term priorities and objectives for the 1997/98 year; and baseline requirements and objectives for 1997/98 year (NHS Executive, 1996). In the longer term, performance will be assessed under three headings: equity, efficiency, and responsiveness (NHS Executive, 1996, pp. 11-21). Under the 1997 New Labour reforms, Health Authorities are to be responsible for drawing up three-year Health Improvement Programmes, which are to be the framework within which all purchasers and providers operate (NHS Executive, 1996, pp. 11-21). Under Section 17 of the Health Act 1999 it accords wide powers to the Secretary of State to give directions to Health Authorities, Primary Care Trusts, and NHS Trusts. Prior to the 1997 New Labour proposals, monitoring efforts in the UK’s internal market concentrated on a small set of dimensions of output: annual growth in activity, waiting times, and targets for improvements in the health of certain groups of the population (Propper, 1995, pp. 1685). The foregoing is why the Health Authorities had focused on performance being monitored, but not the needs, desires and wishes of patients and carers.
Changes in Direction
The preceding facets were thus corrected under the indicated 1997 New Labour proposals promise to broaden performance measures to “things that count for patients, including the costs and results of treatment and care” (Department of Health, 2007). This represented the backbone of the indicated King’s Fund (2003) initiatives that have resulted in better patient and carer involvement. The Human Rights Act has had implications both for service users as well as carers in terms of re-focusing upon rights afforded them. It provides for them to have the right to life, the right to be free from inhuman and or degrading treatment, as well as the right to respect for private and family life (Carers UK, 2005). These aspects might seem as being basic rights that carers should have had all along. However, governmental surveys have shown that all too often the rights of carers are ignored and need to be balanced against the people they care for (Carers UK, 2005).
The United Kingdom’s National Strategy for Carers (Carers.UK, 2005) revealed, “carers’ rights are not adequately considered”. The preceding represents that under the Human Rights Act the rights of patients is balanced against the rights of the carer to mean that their views are considered by social services in the rendering of decisions. In addition, the research uncovered that all too frequently “carers’ rights are not real” (Carers.UK, 2005). The foregoing refers to assessments of carers regarding either their opinions and or rights as well as those expressed on behalf of their patients. Research conducted uncovered that carers’ all to frequently feel that their views and opinions are not considered in assessments and or decisions (Carers.UK, 2005). The third aspect of this facet represents the fact that carers’ as well as patients feel that “resources are inadequate to allow rights to be protected” (Carers.UK, 2005). The foregoing refers to the services needed are in all too many instances not available as a result of resources that are inadequate in terms of the cost and or staff time (Carers.UK, 2005). The last aspects refer to “good practice need not be expensive” (Carers.UK, 2005). The research conducted indicated that there are instances whereby imaginative good practice helped to safeguard the human rights of carers. One such example that was provided referred to the utilization of a 24-hour hotline that enabled carers as well as patients to arrange for support in cases of emergency thus referring to the ‘right to life’ aspect of human rights (Carers.UK, 2005). However, unfortunately, there are too few such examples.
The King’s Fund has been most progressive in being circumspect as well as balanced in their review and analysis of legislation, policy, procedures and rights as contained in documentation and as provided by carers and patients. Steps to shore up the human rights of carers as well as patients have been implemented under the Carers Recognition and Services Act 1995 (opsi.gov.uk, 1995) that calls for a separate assessment of carers at the same time one is carried out for patients. The vagueness is being addressed to clear up ambiguities in terms of words and phrases such as ‘substantial care’ services are a result of assessment, autonomy, health and safety, management of daily care routine and involvement (opsi, 2000). The preceding represents four key criteria under the Carers and Disabled Children Act 2000 (opsi, 2000). It corrects the loopholes found under the Carers Recognition and Services Act 1995 in that anyone over the age of 16 years of age who are or intend to provide substantial care that will be on a regular basis for another individual over the age of 18 years of age is entitled to an assessment (opsi, 2000). The preceding occurs regardless of whether the individual for whom they provide care and or support to has refused community care services (opsi, 2000). Additionally, social workers are advised to provide potential carers of their rights through the hand out of a special booklet that sets forth the benefits in receiving a carers assessment (Carers.UK, 2005). All of the foregoing represent policy and practice developments that are and have addressed a number of carer and patients concerns and issues under community care for disability, health, mental health and the elderly, yet there is still room for improvement.
As shown and evidenced throughout this examination, governmental policies in terms of community care policies and practice for the areas of disability, health, mental health and the elderly has been one of evolution. Sometimes however, representing backward steps before moving forward. Evelyn Fox (1930, p. 71) represents an example of progressive thinking and understanding that was not put into practice initially, but was gradually recognized as the approach later in the process. Her statement that placed the family at the center of community care was initially usurped by the efficiency of the National Health Service and Community Care Act of 1990 was devised to curb costs, but shortchanged patients and carers (Leathard, 2003, p. 16). As the system evolved, through its triumvirate of autonomy, empowerment and choice (Levick, 1992, pp. 76-81), it was impacted by the Human Rights Act 1998 and more recently by the combined initiatives of the King’s Fund (2003). These initiatives helped to reshape the inadequacies as presented by the efficient governmental system and adding more humanity, understanding and caring. Through addressing the observations of Smart, 2002, p. 102) along with Biggs and Powell (2000, pp. 41-49) who commented that the Act’s major weaknesses represented its failure to account for a critical analysis of the roles and daily care practices of carers and the importance of maintaining home care for as long as possible. Additionally, the King’s Fund (2003) initiatives brought forth the importance of the carer, patient voice in their affairs as a part of the overall community based care programmes. Thus, after 80 years, the system as swung back to Evelyn Fox (1930. p. 71). Family, after all, is the basis for the community, and as such is the foundation of community care.
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