Care in the community

Care in the Community was a policy of the Margaret Thatcher government in the 1980s. Its professed aim was a more liberal way of helping people with mental health problems, by removing them from impersonal, often Victorian, institutions, and caring for them in their own homes. Also, better psychotropic drugs became available and this meant that patients could be treated at home. It was, of course, also meant to be cheaper. Community Care, provision of health, education, welfare, and general care of individuals within their community. In practice, the term implies care outside of a hospital or other such institution.

The 1980s and 1990s have brought major changes in the ways in which people who are elderly, disabled, or mentally ill are given support by central and local government and by health services. As the number of vulnerable people who may need some support in the community rises rapidly in an increasingly long-lived population, this, coupled with an international recession, is a cause for major concern with regard to who should pay for such community care.

It is estimated that there are over 6 million identified disabled people in the United Kingdom, the majority of whom are elderly. Relatively few chronically sick or disabled people are under the age of 50. Although most people can still expect a considerably active and healthy period beyond retirement, the risk of disability increases with age. Disability does not only affect elderly people, however. There are 360,000 children with disabilities in the United Kingdom (3 per cent of the child population). The largest disability is learning disability, affecting 6 in every l,000 births. Learning disability is usually broken down into broad categories of moderate and severe learning disabilities, but in practice the distinction can be artificial.

Mental illness can take many forms, the most common of which is depression; it may also be age-related, as in dementia. Most public concern surrounds schizophrenia, which is difficult to treat and can be stressful for family and friends. Mental illness may be linked to other illnesses or disabilities: for example, depression may result following a disabling accident or serious illness. Contrary to public opinion, it can affect children as well as adults and in most cases is treatable. However, many families take professional advice too late for early diagnosis and treatment because of continuing stigma about mental illness.

Learning disability and mental illness have both seen the most significant patterns of change in terms of community provision. The closure of long-stay institutions has shifted responsibility to local authority social services departments, but there is a continuing debate about the care of those people with special health-care needs.

Although there has been general recognition of the importance of promoting a policy of social care for disabled people in the community, the debate about the provision of mental health services for those with mental illness has been more problematic. There is widespread and currently unresolved concern especially about policy and practice for people with mental health problems and a history of violence, and their early discharge from National Health Service (NHS) care. A series of widely reported murders by former patients (who had ceased to comply with their medication and treatment regimes on leaving hospital) has further highlighted concern about supervision and support for this small minority of mentally ill people.

The History Of Community Care
The history of community care is complex. In many countries the family was seen as having primary responsibility for members who were elderly, had a physical or learning disability, or were mentally ill. In the United Kingdom, elderly people without relatives to support them, or who were unable to support themselves in the labour market, entered workhouses, or poorhouses, until the Local Government Act 1929 reorganized the public care system. The best of the former Poor Law hospitals were redesignated as public health hospitals, and were transferred from the former Poor Law Boards to local authority public assistance committees.

The workhouses, vividly described by Charles Dickens and other Victorian writers, were deliberately uncomfortable in order to discourage those who were reluctant to take responsibility for themselves. Even the reforming 1929 Act did not remove the stigma of “pauperism”, as pension rights were relinquished after three months by any person entering care. Any assessment of a person's need for help had to take into account their relatives' ability to support them. In effect, the current debate about family or state responsibility for community care was already being developed. By the end of the 1940s, disagreements about the differences between “health” and “social” care were already manifest. Even in the 1940s, then, many of the problems of the 1990s were evident. Investigators of the time found children and adults, people with mental illness and learning disabilities, disabled and frail elderly people all grouped together without any consideration for individual care requirements. They discovered poor physical standards of care and clear evidence of what is sometimes seen as being only a recent problem, namely hospital beds “blocked” by elderly or disabled people who were there only because they had no community provision to move to.

The 1946 NHS Act had brought services for those with mental health problems or learning disabilities within mainstream health service provision. Local authorities acquired responsibilities for the assessment, supervision, and guardianship of vulnerable people in the community, but few exercised their powers on any regular basis. The 1948 National Assistance Act extended their responsibilities to provide both residential and domiciliary (that is, services and assistance, such as home helps, provided to families in their own home) care, but certain groups of people (in particular those with disabilities or mental health problems) remained almost wholly within the care of the NHS.

Towards the end of the 1950s attention became focused upon treatment and rehabilitation rather than “warehousing” of vulnerable people. However, the introduction of psychotropic drugs and the increasing use of electroconvulsive therapy were controversial and led to growing debate about civil rights and the nature of such treatments.

The 1950s and 1960s saw one significant change, the introduction of the concept of community care. The potential contribution of the voluntary sector was also acknowledged. During the 1960s, a number of organizations, some founded by parents or carers, began to publicly criticize standards of (mainly institutional) care and to ask for more support for families. They campaigned for better services and started to raise the profile of people with learning disabilities and mental illness as citizens first.

In the 1960s and 1970s there was also growing concern about the cost of providing community care through the NHS and a belief that services could be provided more economically and more appropriately within the community. Additionally, the vulnerability of residents living in large and isolated institutions, with minimal contact with family or external services, was highlighted.

Community Care Reform
During the 1970s and 1980s there was a major shift in national policy in the United Kingdom with regard to providing care for vulnerable people. Growing disillusionment with hospitals as the providers of long-term care prompted the beginnings of a new approach that envisaged the closure of long-stay hospitals, to be replaced by a range of community-based services run jointly by health and local authorities. In 1988 the government published the Griffiths Report, Community Care: An Agenda for Action, which led to the NHS and Community Care Act 1990.

At this point, organizations such as MIND, MENCAP, and Age Concern were arguing strongly for a rights-based approach to community services, which would treat recipients of services as citizens and consumers and not as problems to be resolved by placement in large institutional settings.

There was also massive growth in the private sector (in particular, in the development of residential homes for elderly people), parallelling developments in the United States. This was seen as one way of providing more choice and better-quality services, and the Griffiths Report acknowledged these changes.

In effect, the new community care arrangements were made on the assumption that there would be a shift from institutional care to community care. New assessment arrangements would be introduced that would identify need. They would take account of carers' views and ensure that packages of care were designed in line with users' needs and preferences (but also offered “value for money”).

Carers
The debate about community care in the 1990s is widespread. Western Europe, the United States, and Britain have the same challenges (and opportunities) in reviewing social welfare policies. They need to acknowledge the huge potential cost of community care and address both the financial and personal consequences of increasing the number of frail and vulnerable people living in the community. Across the developed countries, the roles of families (in particular, women) are changing. Families themselves are smaller. They are more mobile and, with divorce and separation commonplace, may be less able to take on any significant caring role. It is estimated that around 6 million people in the United Kingdom are currently caring for disabled, sick, or elderly relatives, friends, or neighbours in their own homes. Over half these people will provide care without any support and a quarter of them will do so for at least 20 hours a week. However, it was not until 1996, with a new government act, that it was acknowledged that the needs and wishes of carers could be different to those of the family members they were caring for. It enables carers to request a separate assessment of their needs in their own rights. While it does not guarantee the provision of resources, such as aids or equipment, it is a first step in recognizing and supporting the role of carers.

Financing Community Care
The British government, as part of its community care reforms, has changed the funding basis of community care. Payments for residential care are no longer made through the social security system direct to applicants who meet the eligibility criteria. Instead, funding goes to new assessment and care management systems co-ordinated by local authority social services departments. Many local authorities have chosen to exercise their powers to make charges for certain services. Some may expect individuals or their families to “top up” the costs of services. Others have gone further and required a person to sell his or her house to contribute to the direct costs of community care.

During the 1980s and 1990s, some of the most radical changes ever in the provision of care and support for vulnerable people have taken place. There is general endorsement of the closure of the large institutions and recognition of the miserable quality of life and neglect that many provided. However, there are also concerns about a too-rapid closure of some of the good-quality residential provision (especially small residential homes provided by local or health authorities) in the community. With a rapidly ageing population and with the associated increase in dementia (such as Alzheimer's disease) and significant disability, there is a recognition that good-quality residential care is a serious option for some people. The Government is currently considering a range of financial options for future generations to fund their own health and social care in old age through a variety of pre-payment plans. Some Western European countries have already moved to additional taxation to fund community care provision. There are also current discussions about how to ensure that elderly or disabled people who have savings and/or own their own home will not have to sell their home and/or give all their assets to the local authority if they need additional care. However, the vast majority of disabled or elderly people can expect to live in the community and to lead their usual lives, albeit with some additional support.

There have been major changes in expectations of disabled children, with a new framework for seeing disabled children as “children first” and providing them with access, as far as possible, to ordinary services in their community.

further reading These sources provide additional information on Community Care.

In general, the traditional concept of community care as a rescue service for vulnerable and “inadequate” people has changed. A strong disability rights movement has emerged, and there is a strong belief among disabled people that they should have the right to live in the community, to have access to community facilities, and to have control over their own lives (as stated by the Joseph Rowntree Foundation, a long-established Quaker charity). The major challenge for the 21st century comes from the fact that society expects more for all its citizens. However, good-quality community care will be both expensive and labour-intensive if it is to meet everyone's needs.

The policy has been beset by problems, not the least of which has been a number of killings by mentally-ill people being cared for in their own homes.

An inquiry was set up, and this led to the National Health Service and Community Care Act of 1990. Patients were to be individually assessed, and assigned a specific care worker; if they presented a risk they were to be placed on a Supervision Register. But there have been further problems with patients "slipping through the net" and ending up homeless on the street. There have also been arguments between Health and Social Services departments on who should pay.

In January 1998, the Labour Health Secretary, Frank Dobson, said the care in the community programme launched by the Conservatives had failed.