Sincronía Fall 2001
The NHS and Community Care Act (1990) in the United Kingdom : A Critical Review
By Jason L. Powell, Centre for Social Science, Liverpool John Moores University, UK.
It is has been ten years since the inception of the NHS and Community Care Act (1990) in the United Kingdom. The legislation has in the past decade received scantily uncritical sociological acclaim. This community care policy based on the triumvirate of autonomy, empowerment and choice was endorsed by many commentators as the political and philosophical panacea for alleviating the deep and destructive problems confronting the community care system in the UK (Levick 1992). This paper deconstructs the hagiography surrounding the NHS and Community Care Act and provides a critical analysis of a number of the policies main areas. Before considering these criticisms, there will be a dissection of the failure of the government of both left and right persuasion to provide quality services which provides the sociological backdrop for the emergence of the NHS and Community Care Act and its care reforms in the UK.
A close and cogent examination of the emergence of the NHS and Community Care Act raises serious questions about its main intentions. Whose account was to count in the analysis leading up to its implementation in 1993 was based on a hierarchical vision of care truth in which the definition of reality articulated by older people was secondary to reality defined by experts/state servants such as policy advisors (Griffiths Report 1988). This is not the place to explore the epistemological and ontological debates concerning definitions of reality that have developed in social gerontology in recent years (Biggs and Powell 2000). However, it is important to note that care policy fails to convey in any strong sense alternative definitions of truth or different visions of care truth based on older peoples subjective experiences (Biggs and Powell 2000). Rather, the agism of the community care act directs its gaze downwards towards older people thus reinforcing an overall impression that these are the people who need to be researched, these are the ones who are out of step with social norms or who are causing the problems (Smart 1984: 150-1). Conversely, the Act rarely gazes upwards to look at the locally powerful (Smart: 1984) who in the case of older people would be care managers. The lack of any critical analysis of the role and daily practices of care managers constitutes a major weakness of the implementative process of the Act.
The ongoing disputes between the state and social workers before and after the introduction of the NHS and Community Care Act (1990) and the confusion and conflict between different state servants during the 1980s provide clear illustrations of the fractured dislocation within the state concerning community care policy. However, as with a number of official publications emanating from the Audit Commission (1986), the NHS and Community Care Act and its policy guidance has been seen as a significant and historical moment on the road to fundamental care reform for older people. In the next part of this paper we assess this contention through focusing on a number of major themes and issues contained in the Act: the political backdrop to its emerge; the specific reforms and reports which led to its formation; and an evaluation of whether care reforms worked out in practice or not with specific focus up until 1996.
The political backdrop to emergence of the NHS and Community Care Act (1990) in the UK
The N.H.S and Community Care Act (1990) emerged due to three significant factors during the dominance of the Conservative administration in the UK from 1979 onwards. Firstly, one of the central planks of UK government policy throughout the 1980's was the genesis of marketisation into the public sector. Government reforms in education and the health service, for example, constructed a quasi-market with internal commissioning and provider roles to stimulate the 'buying' and 'selling' of in-house services (Means and Smith 1997). Simultaneously, new legislation required local authorities to embark upon a phased programme, determined by central government, through which many of its services had to be subjected to compulsory competitive tendering, with the strategy of decreasing the role of local authorities and stimulating instead the private sector. The value which underpins all of these policy initiatives is a belief that a competitive market and a 'mixed economy of welfare' will inevitably provide better, cheaper services than a protected and bureaucratised public sector (Flynn 1992; Le Grand 1995; Clarke 1994; Walker 1993; Means and Smith 1997).
Social services is one of the highest revenue spending departments for most local authorities, and within social service budgets at the time, residential and domiciliary services for older people consumed the largest amount of revenue. Thus, community care for older people in particular presented itself to government, in both financial and policy terms, as an obvious area of provision into which market principles are introduced and implemented.
Second, at local levels throughout the 1960's and 1970's, social service departments and health authorities were responsible for joint planning and service development and charged with the need to provide community-based services as alternatives to institutional care (Wistow et al. 1994). In rhetoric, joint planning between health and social services promoted integrated and multidisciplinary community services. In practice, such arrangements failed to realise such services and were criticised as pedestrian and 'patchy' (Working Party on Joint Planning 1985). Community care services were indeterminate, with many users unable to obtain the services they require. In the context of demographic apocalyptic projections about older people likely to need support, the perceived 'social problem' of older people became a general theme in government discourse and the need to improve joint planning as an essential prerequisite to improve services was recognised (Audit Commission 1986).
Third, however, in the early 1980's the Conservative government had instigated its long-term policy of privatising public services. One strand within its programme was the decision to enable people to enter private residential homes through a system of social security financing differentiated from that of local and health authorities. In the absence of a diverse array of community-based services to support people at home, vast numbers of older people took the only option available to them and, for many, entered private residential care at the expense of the public sector (Mooney 1997). This policy essentially channelled public sector funds into the private institutional sector while leaving the domiciliary sector chronically under-resourced. According to Wistow et al. (1994: 4) this led to a 'perverse incentive' that undermined the commitment to community-based care. Private residential homes flourished and in the absence of community services, older people as 'consumers' had little 'choice' other than the decision about which institution they might enter in the 'residential private sector plc'.
Fervent criticism manifested from the Audit Commission (1986) initiating a process which led to the establishment of the Griffiths committee. Griffiths (1988) proposed that local authorities were strategically placed to oversee the delivery of community care within the matrix of policy, professional practice and older people themselves involved in the process.
On the Road to Care Reform: Community Care PLC?
There are a number of milestones that led to the NHS and Community Care Act which appeared in the middle of the 1980's:
1981 Working Party on Joint Planning, Progress in Partnership
1985 House of Commons Social Services Select Committee Report,
1986 Audit Commission, Making a Reality of Community Care
1988 Griffiths Report, Community Care, Agenda for Action
1989 White Paper, Caring for People
The Audit Commission (1986) in particular was critically important in the developments which were to follow. The authorship of the commission derived from its 'independence': it stood as an objective and non-political discourse on the state of community care arrangements. The commission was not restricted to examine of how to make policy work better, but also to analyse the efficacy of policy itself and it was the critique of policy which central government could not ignore.
The commission located a number of key problems of policy and its consequence on community care development and practice: the 'perverse financial incentive' which supported the development of private institutional care at the expense of community care, through the income support system. Indeed, social security expenditure on income support for recipients in private residential care was £10 million in 1979 rising to £2, 575 million in 1993 and dropping to £1, 754 million in 1995 (Laing and Buisson 1996: 110). Numbers of people receiving income support did increase from 11, 000 in 1979 to a peak of 281, 200 in 1993 then a decrease to 181, 000 in 1995 (Laing and Buisson 1996: 111).
The Audit Commission (1986) also identified a lack of incentives for local authorities to develop community care options; the absence of clear financial arrangements to facilitate the re-settlement in the community of long-stay hospital patients colloquially known as 'bed blocking' (Tozer 1996); the deficiency of a systematic approach to assessment. formulating care arrangements and fundamentally, costing.
The UK government responded with the appointment of Sir Roy Griffiths. His remit focused upon the way resources could be used 'as a contribution to more effective community care' (DHSS 1986). Griffiths (1988: 17) identified three key objectives for a new community care policy: a focus upon the individual user and carer - meeting need, improving choice, promoting self-determination. The prolific intensification towards consumerism entered the discourse of community care; promotion of non-institutional support services - to be delivered in the domestic environment and community settings to allow people to remain in their own homes; effective targeting of resources - to ensure those most in need received services and to avoid inefficiency and waste of resources.
The responsibility for, and oversight of, community care vested in local authorities was indulged with the recommendation that the role of local authorities should change. Rather than provide services directly, local authorities should become planners, commissioners and enablers, ensuring services are provided but largely by other agents in the mixed economy of welfare:
'The primary function of the public services is to design and arrange the provision of care and support in line with people's needs. That care and support can be provided from a variety of sources. There is value in a multiplicity of provision, not least from the consumer's point of view, because of the widening choice, flexibility, innovation and competition it should stimulate.... It is vital that social services authorities should see themselves as arrangers and purchasers of care services - not as monopolistic providers (Griffiths Report 1988: para. 3.4).
The notion of the enabling role at the structural foundation of the strategic local authority was mirrored at the social action platform of the service user-professional social worker relationship with the recommendation that the professional acting on behalf of the local authority should adopt a 'care management' role: assessing need with the service user, defining a 'package of care' and purchasing services on behalf of the service user or carer (Griffiths Report 1988).
The White Paper Caring for People which followed in November 1989 accepted most of Griffiths proposals and approved the threefold matrix of user choice, promoting non-institutional services and targeting. However, a crucial element was missing in the Paper: the diversion of finances from the social security budget to the local authorities was not to be ringfenced for community care in the long term as Griffiths had hoped. A specific grant was to be diverted to local authorities in order to implement the outcomes of individual assessment and encourage the genesis of services in the private and voluntary sectors. Interestingly, receipt of the grant was contingent upon the publication of community care plans and would be ringfenced only in the short term.
Community care was to be used as a vehicle for the marketisation of the public sector. Thus, a 'contract culture' was to be applied to the provision of personal social services and social services departments would need to develop processes to specify, commission and monitor services delivered by other agencies. The organisation of service delivery was to be instigated through assessment and care management including devolved budgets and decentralisation (DoH 1989: 23).
The process of these organisational changes were immensely complex: when the NHS and Community Care Act was enacted in June 1990, the government announced that implementation would be phased between April 1991 and April 1993.
The central elements within the local authorities' responsibilities are inter-connected through the matrix of the promotion of outcomes of service user/carer 'choice', encouragement of domiciliary services and the targeting of 'need'. The next section reviews the extent to which the care reforms worked in practice in UK.
Rhetoric or Reality?
There are a number of problems in evaluating the success of community care post-1990 and they include the lack of information before the reforms, the lack of national standards and structural changes in health and local government which have had an effect on it (Meredith 1995; Lewis and Glennerster 1996). The immensity of the task facing social service departments was made clear in the Audit Commission's report The Community Revolution: Personal Social Services and Community Care (Audit Commission 1992). This report exhorted social service departments to gain the commitment of its professionals, develop systems to support strategic and operational aspects of implementation. In the 1993 Audit Commission's report Taking Care: Progress with Care in the Community, 'cautious but steady progress' was reported (Audit Commission 1993: 1) but some authorities were 'rather slower than others, and a few are in danger of lagging well behind' (Audit Commission 1993: 14). In 1996, the Audit Commission in Balancing the Care Equation: Progress with Community Care claimed that financial resources dominated any change in the delivery of good practice and service delivery.
The White Paper Caring for People stated 'The Government will expect local authorities to make use whenever possible of services from voluntary, "not for profit" and providers insofar as this represents a cost effective choice' (Secs of St. for Health et al. 1989: 22). Ways of developing a 'mixed economy of welfare' by slowly but subtly eradicating the 'perverse incentive', would include taking steps to stimulate the instigation of 'not for profit' agencies, identifying areas of their own work which were sufficiently self-contained to be suitable for 'floating off' as self-managed units and stimulating the development of new voluntary sector activity (ibid: 23). A programme Caring for People Who Live at Home was set up in 1992 by the government to encourage developments in day and domiciliary care, particularly by the cheap independent sector, short but human resources was identified as a major hurdle (Walker, 1993).
Residential care is one service where there had long been provision by the independent sector but as Laing and Buisson (1996: 90) point out, it remains less common for domiciliary services and this is considered ripe for expansion. Indeed this is in the context of between 1984 and 1995 there has been a drop of places in the residential sector from 137, 200 places to 80, 800; a massive increase in private provision from 23, 700 places in 1970 to 167, 800 in 1995; a slow growth in the voluntary sector from 40, 100 in 1970 to 52, 800 in 1995 (Laing and Buisson 1996: 25). Between 1984 and 1994 there was an increase in numbers of residents aged 65 and over in England from 180, 576 to 233, 688 but whereas the percentage increase for residents in private homes was 157 % it was only 29% for voluntary homes and there was a decrease in local authority homes of 43% (Government Statistical Service 1995: 14-15).
Although Wistow (1994) et al. claimed that social service departments were beginning to recognise the benefits of the independent sector but that genuine partnerships with the private sector were uneven, with even more stress on the voluntary sector. Henwood's (1995) research has indicated that social service departments were adopting a pragmatic approach to the independent sector because of the need to expand community services. A central feature of the 'mixed economy of welfare' was that individuals should receive a 'package of services' (DoH 1989) if they were assessed as being in 'need'. Allen et al. (1992) found that most older people had only one or two services in their study. In this study, few older people had much choice in what services they received, any say in the time of the delivery, the person who delivered it or how much they received. A study in 1994 found a variable pattern with:
'care management enabling more people with complex needs to remain in the community, but it was too early yet for the needs-led dimension of the process to be a major driving force in the development of new and different community-based services (DoH/SSI/NHSE 1994a: 6).
A specific study, Community Care Packages for Older People (cited in Glennerster and Lewis, 1996), found that there was a clear commitment by both social services and health authorities on care packages but that service users and carers were not satisfied with the system for providing the service where issues of flexibility, consistency and the need for charges need to be addressed. Similarly, Henwood (1995) found pressures on resources was leading to reduced levels of service and a tightening of 'eligibility' criteria. Indeed, the Carers National Association found that the majority carers were dissatisfied with the assessment procedures in the NHS and Community Care Act (1990) (Warner 1994). Although the implementation of the Carers Recognition and Services Act (1996) gave carers for the first time a statutory right to have their needs assessed (Glennerster and Lewis, 1996).
This paper has reviewed the emergence and consolidation of the NHS and Community Care Act (1990) in the UK. The paper has traced the political ideologies which manifested in the 1980s and 1990s which despite privatization and rhetoric of empowerment and self-governance the Act has led to some key implications materialising. Indeed, according to Phillipson (1988) and Walker (1993) there is a myth that private care enables older people to be in more control and more able to choose the kind of services than in publicly provided services. The dangers are that there may be the manifestation of 'elder abuse' unless standards are monitored and inspection takes place (Biggs 1993; Biggs and Powell, 2000). Indeed, a DoH study located that it was of concern that some authorities did not have service specifications to use with private providers (DoH/SSI/NHSE 1994b). There have also been problems when there are few competitors. Large organisations move into areas where profits are to be made and consequently undercut their rivals and then raise prices (Glennerster 1990 et al.) For residents in private and voluntary residential care there is the possibility of closure due to financial failure: 3% of homes for older people were closed in 1995 (Laing and Buisson 1996: 31). Centrally, this raises question of whether quality 'care' is being substituted for economic attainment?
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