These problems, and more, were the catalyst behind the rapid expansion of public expenditure on private residential care and the government wanted to put a stop to that. The government asked Sir Roy Griffiths to review community care and many of his findings in his 1988 report went onto be included in the 1989 White Paper, ‘Caring for People’. This was the official paper that spelt out the duties of local health authorities to assess people needing social care and/or support. It is based on the assumption that community care is the ‘best’ form of care available. The White Paper states that the proposed changes are intended to, first of all, enable people to live as normal a life as possible in their own homes or in a homely environment within the community. This is especially important in the long-term needs of the elderly, whom have long expressed their wish to be able to stay in their homes. Moreover, local authorities must provide the right amount of care and support to enable people to achieve maximum independence and finally to provide people with a greater say in their lives and the services they need. This is particularly significant with elderly people. Many older people are not in need of 24-hour care that a nursing home would provide. They just need a small amount of help, maybe for a couple of hours a day. They are mostly capable of taking care of themselves and they know what they want for themselves. They also feel more comfortable and relaxed in their own home, surrounded by people they know.
The White Paper suggests the key components of community care are services which respond sensitively and flexibly to the needs of individuals and their carers, allow a range of options for consumers, do not intervene more than is necessary and concentrate upon those with the greater needs.
The White Paper outlined 6 key objective and 7 key changes. Lets firstly deal with the objectives and the implicit issues covered.
The first objective was to provide services for people at home. To promote the development of domiciliary, day and respite care to enable people to live in their homes whenever feasible and sensible. This first objective includes the ideas of ‘targeting’. The government now aims to make the best use of the resources available by encouraging local authorities to ‘target’ people with the greatest needs. Unfortunately this means that people who only require housework to be done may no longer have this service. This particularly affects older people, as many only need a small amount of help.
The second objective is to provide support for informal carers. Most of the people who provide community care older members of society are the friends, family and neighbours of the individual needing help. Such people need recognition and support in order to continue caring. They may need financial help, and consideration of their own needs when assessments are being carried out. The White Paper first recognised the particular importance of informal carers in the role of caring for the elderly because of their long-term care needs. This is a central factor in assessing how the reforms have affected the long-term care needs of the elderly. Without family or friends or neighbours, many old people would find it impossible to stay in the community in their own homes and this is, after all, their main wish.
The third objective is to make proper assessments of care and need. The packages of care should then be designed in line with the individuals needs. One of the major concerns leading to the Griffiths report was the large amount of public money being spent on residential and nursing home care without any assessment of needs. It was argued that many people in homes need not be there if the proper services were available in the community. Again, this is particularly important for elderly people. Many do not need to be in homes and would feel more comfortable in the own house, with a little support. Another problem with assessment before the reforms was that many different people carried out the assessment itself. With the new reforms, one person was responsible for assessing one individuals needs.
The fourth objective was the development of private, public and voluntary sector cooperation. This was suggested to be important in order to ‘refocus’ the role of local authorities towards becoming enabling (or purchasing) agencies rather than direct providers of care. It is their responsibility to make maximum possible use of private and voluntary providers. The government believe that a variety of providers will increase choice for service users and that better services, and cheaper services, will result from the increased competition. This is significant when considering the elderly as many may not have family, and may not be able to afford some of the more expensive carers. Reduced costs, therefore, are a positive result for the elderly in both the short-term and the long-term.
The fifth objective is to have a clear demarcation of responsibilities, to hold agencies accountable for their performance through clarifying their responsibilities. Community care plans show who will be doing what. This is a key element of the reforms. There is an important area of confusion in this, however and that is the differentiation between health and social care for those with long-term care needs, such as the elderly. Although the white Paper very clearly states that the responsibilities for health authorities stay the same, local authorities took over responsibility for those who wished to enter publicly funded nursing. This had lead to considerable confusion as to where the responsibility for some groups with long-term care needs actually rests.
The sixth and final objective is to secure better value for the taxpayers’ money. With regard to community care, this is meant to remove the incentive to place people in care homes where they could claim benefit from the Department of Social Security through the transfer of the Departments money to local authorities.
The White Paper is full of references to the need to avoid unnecessary admission to institutions, especially in regards to old people.
To carry out these objectives, the White Paper proposed seven key changes. Many of these changes involved more responsibility being put on the local authorities. They would now be responsible, firstly, for assessing individual needs and securing their delivery within available resources. Secondly, they would be expected to produce and publish clear plans for the development of community care services and will also be expected to show that they are making maximum use of the independent sector. Local authorities are also responsible for financial support of people in private and voluntary homes. Furthermore, local authorities are to encourage independent sector care homes. The local authority pays more from it’s own funds for people cared in it’s own homes. Moreover, the responsibility for inspecting all residential homes rests with the local authority. Finally, local authorities were given a special grant to promote the development of social care for seriously ill mental people. This is especially important for older people with senile dementia, as social services expenditure for people with mental health problems was often only a very small part of a local authorities budget.
These reforms involved making some legal changes, and thus the National Health Service and Community Care Act 1990 was passed. Included in this act were objectives to be achieved by community care as well as by organisational arrangements by which these could be achieved. The main organisational changes are firstly, the separation of the social care sector into purchasers of care and providers of care. This was seen as the mechanism by which a market could be created resulting in competition.
Also, the delivery of services was to be achieved through the system of assessment and care management. People would be expected to ‘fit’ into services, but rather their needs to be assessed and a tailored package of care delivered.
Finally, social services departments had to demonstrate that the planning of services and outcomes had been achieved buy working collaboratively with various interested agencies such as health authorities, voluntary agencies and user-carer groups.
All of these changes are closely related to the reforms laid out in the White Paper.
In conclusion, the idea of community care is not new. Different ideals of community care have been around for more than 40 years. Themes of these years have included concern about quality and availability of care, coupled with a desire to get the ‘system’ right, to develop the roles of professional workers and to limit public spending. In relation to the elderly, a lot of the changes made in the early eighties and late nineties were for the good. The aim of developing community care for people at home have been rooted in the belief that people, especially the elderly, is preferred, desired and cheaper (believed, though not confirmed) than care in institutions. Whether or not all these changes succeed and continue to be a success depends pertly on the amount of money available to carry them out and on the availability of appropriate health care, housing and other factors. However, real success depends on the attitudes of the people involved. The changes are complex and are not always easy to understand. Community Care is constantly changing for all involved, including the elderly. For each individual person it is important to ensure that his or her community care jigsaw fits together as well as it possibly can. This means continuing to strive to make the practise of community care for each person match as closely as possible to the ideals. This, however, is an on going and never ending challenge.
BILIOGRAPHY
BALDOCK ET AL; SOCIAL POLICY; 1999; OXFORD UNIVERSITY PRESS
VICTOR, C R; COMMUNITY CARE AND OLDER PEOPLE; 1997; STANLEY THORNES PUBLISHERS
TESTER, S; COMMUNITY CARE FOR OLDER PEOPLE, A COMPARITVE PERSPECTIVE; 1996; MACMILLAN PRESS LTD
GROVES, T; COUNTDOWN TO COMMUNITY CARE; 1993; BMJ PUBLISHING GROUP
MEREDITH, B; THE COMMUNITY CARE HANDBOOK, THE REFORMED SYSTEM EXPLAINED; 1995; AGE CONCERN ENGLAND