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Care in the Community (also called "Community Care" or "Domiciled Care") is the British policy of deinstitutionalization, treating and caring for physically and mentally disabled people in their homes rather than in an institution. Institutional care was the target of widespread criticism during the 1960s and 1970s, but it was not until 1983 that the government of Margaret Thatcher adopted a new policy of care after the Audit Commission published a report called 'Making a Reality of Community Care' which outlined the advantages of domiciled care.
Although this policy has been attributed to the Margaret Thatcher government in the 1980s, community care was not a new idea. As a policy it had been around since the early 1950s. Its general aim was a more cost effective way of helping people with mental health problems and physical disabilities, by removing them from impersonal, often Victorian, institutions, and caring for them in their own homes. Since the 1950s various governments had been attracted to the policy of community care. Despite support for the policy, the number of in-patients in large hospitals and residential establishments continued to increase. At the same time, public opinion was gradually turned against long-stay institutions by allegations from the media. Some might argue that such allegations were politically driven and that the deliberate underfunding, mismanagement and thus undermining of some institutions by the government was used as an excuse by the government to shut them down. It could also be argued that although there might have been incidents of where care should have been improved, the care in many such institutions may have been satisfactory or good.
In the 1960s Barbara Robb alleged that her personal experience of being treated at a hospital in Ely were bad. She put together a series of accounts in a book called Sans Everything and she used this to launch a campaign to improve or else close long stay facilities. Shortly after this the brutality and poor care being meted out in Ely, a long stay hospital for the mentally handicapped in Cardiff, was exposed by a nurse writing to the News of the World. This exposure prompted an official enquiry. Its findings were highly critical of conditions, staff morale and management. Rather than bury this report it was in fact deliberately leaked to the papers by the then Secretary of State for Health Richard Crossman, who hoped to obtain increased resources for the health service.
Following the situation at Ely Hospital a series of scandals hit the headlines. All told similar stories of abuse and inhumane treatment of patients who were out of sight and out of mind of the public, hidden away in institutions. At the same time Michael Ignatieff and Peter Townsend both published books which exposed the poor quality of care within certain institutions.
However, it is important to note that the facilities and care at some institutions were held in high regard by both patients and staff. Graylingwell Hospital, Chichester was an example of the best modern type of mental institution. The Observer reported[when?]: "Patients have every convenience at hand for night requirements, even down to carpet slippers. Blinds and curtains give a home-like comfort to the windows. Books, papers and magazines are liberally provided, while dominoes, cards and games of many kinds serve to cheer and lighten the evenings. Patients are encouraged to take part in outdoor sports, a good cricket and football field being provided. In the winter, dances, theatrical entertainments and concerts in the commodious theatre will continue treatment of the highest curative value.
The notion that films were regarded as an integral part of the therapy and entertainment offered to patients was confirmed by the installation of the hospital's own projection equipment in 1912-1913. Thereafter the hospital increased the frequency of its film shows and would put on three consecutive weekly performances, two of them in conjunction with a concert and band. Graylingwell was unlike most Victorian asylums of that time with the absence of high walls, locked iron gates and implements of restraint. With 130 acres of cultivated farmland the patients also benefited from the occupational therapy which farming provided. This also allowed the hospital to be self-sufficient in farm produce, including a dairy herd, poultry runs, a kitchen garden, fruit-bearing trees and beehives.
In the 1980s there was increasing criticism and concern about the quality of long term care for dependent people. There was also concern about the experiences of people leaving long term institutional care and being left to fend for themselves in the community. Yet the government was committed to the idea of 'care in the community'. In 1986 the Audit Commission published a report called 'Making a Reality of Community Care'. This report outlined the slow progress in resettling people from long stay hospitals. It was this report which prompted the subsequent Green and White papers on community care.
The main aim of community care policy has always been to maintain individuals in their own homes wherever possible, rather than provide care in a long -stay institution or residential establishment. It was almost taken for granted that this policy was the best option from a humanitarian and moral perspective. It was also thought to be cheaper.
The Guillebaud Committee reporting in 1956 summed up the assumption underlying policy. It suggested that:
Policy should aim at making adequate provision wherever possible for the care and treatment of old people in their own homes. The development of domiciliary services will be a genuine economy measure and also a humanitarian measure enabling people to lead the life they much prefer
Three key objectives of Community Care policy:
An important point to note though is: that NHS services are free, whereas social services have to be paid for. So how the care you require is defined, that is health or social care, determines whether or not it will be free.
Sir Roy Griffiths had already been invited by Margaret Thatcher to produce a report on the problems of the NHS. This report was influenced by the ideology of managerialism. That is it was influenced by the idea that problems could be solved by 'management'. Griffiths firmly believed that many of the problems facing the Welfare State were caused by the lack of strong effective leadership and management. Because of this previous work, which was greatly admired by the Prime Minister, Griffiths was asked to examine the whole system of community care. In 1988 he produced a report or a Green Paper called 'Community Care: Agenda for Action', also known as The Griffiths Report.
Griffiths intended this plan to sort out the mess in 'no-man's land'. That is the grey area between health and social services. This area included the long term or continuing care of dependent groups such as older people, disabled and the mentally ill. In 1988 Griffiths said of community care that it was everybody's distant cousin but nobody's baby.
Basically he was saying that community care was not working because no one wanted to accept the responsibility for community care.
Community Care: Agenda for Action made six key recommendations for action:
The majority of long term care was already being provided by Social Services, but Griffiths' idea was to put community nursing staff under the control of local authority rather than Health Boards. This never actually happened. The Griffiths Report on Community Care seemed to back local government whereas, the health board reforms in the same period, actually strengthened central government control.
In 1989 the government published its response to the Griffiths Report in the White Paper Caring for People: Community Care in the next Decade and Beyond. This was a companion paper to Working for Patients and shared the same general principles:
The White Paper followed the main recommendations of the Griffiths Report but with two notable exceptions.
It did however; identify six key objectives which differed slightly from Griffiths Report.
These objectives required new legislation which was enacted in the National Health Service and Community Care Act 1990.
The community care reforms outlined in the 1990 Act have been in operation since April 1993. They have been evaluated but no clear conclusions have been reached. A number of authors have been highly critical of the reforms. Hadley and Clough (1996) claim the reforms 'have created care in chaos' (Hadley and Clough 1996) They claim the reforms have been inefficient, unresponsive, offering no choice or equity. Other authors however, are not quite so pessimistic.
Means and Smith (1998) claim that the reforms:
Under the National Health Service and Community Care Act 1990, people with mental health problems were able to remain in their own homes whilst undergoing treatment. This situation raised some concerns when acts of violence were perpetrated against members of the public by a small minority of people who had previously been in psychiatric hospitals.
The National Health Service and Community Care Act 1990 was passed so that patients could be individually assessed, and assigned a specific care worker; in the unlikely event that they presented a risk they were to be placed on a Supervision Register. But there have been some 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.
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