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Since the establishment of the Welfare State in the 1940s, the National Health Service and Community Care Act is among some of the most important laws in health and social services in Britain (Adams, 2002). Its’ policies, based around ‘autonomy’, ’empowerment’ and ‘choice’ was supported by many writers who saw it as the cure to alleviate the “deep and destructive” problems encountered by social care (Levick, 1992). This paper will seek to explain the impact that subsequent social policy has had on social work practice and that of the experiences of older people since the inception of the 1990 NHSCCA. The paper will attempt to analyse the range of services available to older people before and after the 1990 Act and examine some of the main policies of the Act.
The term ‘community care’ was first coined in the 1960’s and was originally used to describe the relocating of people from psychiatric surroundings into less institutionalised ones (Thomas and Pierson 2002). Prior to this, however, community care policy was derived from 18th Century Poor Law, which was the only legislation to meet the needs of older people, until the introduction of the National Health Act 1946 and National Assistance Act 1948 (Wilson, Ruch, Lymbery and Cooper, 2008). However, despite the new Acts, which ‘helped to create a different world for social care’ (Wilson et al. 2008: 623), Townsend (1962, cited in Wilson et al 2008) reported that there was little social care provision for older people in the immediate post-war period other than residential care, which Townsend claimed clearly varied in quality. Furthermore, Beech and Ray (2009) argue that past policies have not considered the diverse needs of growing old and the number of physical, emotional and psychological changes that are faced by older people.
Subsequent post – war governments became increasingly sympathetic in the shifting of care services from residential settings to community based, which became a priority of the (1979-97) Conservative government (Adams, 2002). By the mid 1980’s, many political commentators and professionals were calling for policies which involved the replacement of inappropriate residential care, which was still as Townsend had commented in the 1960’s as variable in quality, and the introduction of high quality community care (Adams, 2002). Adams adds that it was hoped that community care would tackle the segregation, isolation and the stigmatisation felt by older people who may have been institutionalised for long periods of time. However, Adams (2002) points out, once the Conservative government had brought about the privatisation of public services, which included a programme of social security financing that in effect, encouraged older people to enter residential care and simultaneously leave community care services under-developed due to a lack of public investment.
The Audit Commission (1986) heavily criticized community care and the government appointed Sir Roy Griffiths to report on the future of community based services. This led to the Government White Paper ‘Caring for People’ (Department of Health, 1989a) which ultimately transformed local authority social services departments from providers to purchasers of services to create a market economy. This had an effect on front – line social workers as they were involved more in the care management of older people, like assessing needs and devising care packages (Adams, 2002). Holloway (2008: 315) supports this and claims that a common complaint among practitioners is ‘we’re not social workers anymore, we’re just care managers’. This led to a ‘contract culture’ with the marketisation of the public sector where social service departments would need to commission and monitor services carried out by outside agencies (Department of Health, 1989: 23). Furthermore, social workers were more often removed from direct work with service users and there was a sharper focus and greater accountability, coupled with constraints on resources and ‘gatekeeping’ for those who are in the greatest need (Levin and Webb, 1997).
The NHSCCA (1990) increased the recognition of the need for community care and health care to become partners in services and to include voluntary agencies and housing departments, which heralded developing policy philosophy after 1990 (Braye and Carr, 2008). Furthermore, there was a belief that service users should have more control of the services available to them and being able to purchase the services they want, as opposed to not taking part in decisions regarding services provided for them (Braye and Carr, 2008).
Another significant policy development for older people, explained by Wilson et al. (2008), was the National Service Framework for Older People which placed an emphasis on independence and autonomy. To increase the levels of independence, intermediate care; which was initially outlined in the NHS Plan (DoH, 2000) was brought about in a bid to reduce the number of days older people spent in hospital and as Lymbery (2005) points out, was often an unwanted and expensive form of treatment.
Policy dilemmas are evident in the national eligibility criteria, Fair Access to Care Services (DH, 2002), which is a framework to ensure equality of access to people in need of social work intervention (Beech and Ray, 2009). Due to financial constraints, the needs of older people are only being met if they fall into the ‘critical’ or ‘substantial’ (CSCI, 2008). Furthermore, as Lymbery (2005) points out, older people experience negative effects with regards to access to services and options due to current policy, despite emphasising promoting independence, through the eligibility criteria, doubt surrounding the privatisation of services and the rules of assessment.
This paper has charted some significant policies and services available to older people before and after the NHSCCA (1990) and has found that despite privatisation and the rhetoric of independence and promotion of choice, some key implications have materialised for older people. However, despite the Act, the paper suggests there are tensions between limited resources and unlimited needs with the role of social work changing from provider to enabler. This has had some practitioners comment that they are now care managers rather than social workers due to there being less direct work with service users and more work creating care packages.
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