In this report I will discuss Mental health and community care, I will look at the historical context of community care taking into consideration policies and that stemmed it and competing ideological perspectives that that has impacted on it. I will further look at its benefits and shortfalls since its implementation taking into accounts the impact of the 1990 NHS Community Care Act and current reforms. Finally I will discuss the process of poverty and social exclusion which affects some of these people who have been discharged home as a result.
History of Community Care and Objectives
Dobson (1998) stated that Care in the community represented the major political change in mental healthcare in the history of the National Health Service (NHS)
It was the result both of social changes and political expediency and a movement away from the isolation of the mentally ill in old Victorian asylums towards their integration into the community (Goffman 1961).
The aim was to “normalise” the mentally ill and to remove the stigma of a condition that is said to afflict one in four of the British population at some time in their lives.
The main push towards community care as we know it today came in the 1950s and 1960s, an era which saw a sea change in attitude towards the treatment of the mentally ill and a rise in the patients’ rights movement, tied to civil rights campaigns.
The 1959 Mental Health Act abolished the distinction between psychiatric and other hospitals and encouraged the development of community care.
According to Goffman, (1961) historically, people who were designated as having a mental illness lived in confined institutional environments for years and had limited expectations for returning to the community.
Community care is used to describe the various services available to help individuals manage their physical and mental health problems in the community which is the British policy for deinstitutionalisation. Duane (2003) defined deinstitutionalisation as process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with mental disorder or developmental disability. These services include, for example, nursing or social work support, home help, day centres, counselling and supported accommodation.
The Department of Health expresses the need to promote the development of a personal health plan of individuals, based on who they are, what they want and what their circumstances are.
According to DoH, ‘Health is linked to the way people live their lives and the opportunities available to choose health in the communities where they live’. There have been major improvements in health and life expectancy over the last century and on the most basic measures, people are living longer than ever before (DoH report, 2005).
Rogers A and Pilgrim D (2001) stated that the ideological commitment to community care was associated with vague idea of achieving an ideal society, prior to it being effected as a practical reality. Similarly Titmuss in the 1960s suggested that the notion of community care invented ‘a sense of warmth and human kindness, essentially personal and comforting’ Titmuss (1968). This early positive view emphasised the idea of leaving the disabling environment of the institution behind and ushering in the enabling possibilities of ordinary living.
According to Bulmer (1989), the first use of community care was in the part of mental health, as understanding developed of the negative consequences of institutionalizing mental patients in hospitals, and to discharge the ex-patients and mental handicap hospitals, and to discharge the ex-patients into the community, where they would live in hostel-type accommodation or in their own homes and be cared for by a mixture of professional and personal carers, particularly in day centres and by nursing staff on the one hand and by members of their own families on the other.
Community care in the past has always been a mixed economy, financed by both the state and by user charges and provided by voluntary sector organization, commercial, for-profit organization, the state and the family. Alan Walker (1982, 1989) and Roy Parker (1990) have specifically addressed the problem of defining community care and have pointed out that it has been very easy for one person’s community care to be another’s institutional care. Community care has been a mixture of policies. To the health service any provision outside the NHS equals community care, therefore institution run by local authorities constitute community care.
The mixed economy of community care during the 1960s left wing academics, notably Peter Townsend (1962), made moving request for the deinstitutionalization of elderly and mentally ill people, whereas Titmuss (1968) has already sounded a note of caution when he referred to the way in which the term community care conjured up a sense of warmth and human kindness. All this assumed the main provider of community care to be the state.
In some ways, the idea of community care in mental health ran counter to the dominate trend within the NHS after 1948, which until recently, was centralised and hospital-dominated.
Bulmer (1989) similarly emphasised that in recent years community care has broad meaning including the goal of providing comprehensive outreach, day and residential services and support for ordinary facilities within the locality. In principal at least community care now extends to social inclusion and the promotion of assess to facilities used by other people living in the community and the right and responsibility of participation in local community acitivties.
According to Pilgrim (2001) when the Labour government came to power in 1997, it announced the need for rapid reform of mental health services based on the impression or evidence that care in the community has failed. In 1998, the Health Secretary, Frank Dobson, stated that discharging people from institutions has brought benefits to some. But it has left many vulnerable patients to try and cope on their own. Others have been left to become a danger to themselves and a nuisance to others. A small but significant minority have become a danger to the public as well as themselves.’ Mind, along with many others, disagreed with the statement that community care had failed.
These were based on concerns about control of risky behaviour which led to the spokes enquiry following the killing of a social worker (Isablel Shwartz) in 1984 by patient Sharon Campbell in Bexley Hospital. These were some of the limitations of care discovered and led to recommendation about post-discharge case management DHSS (1998). The report similarly noted the lack of any requirement on the part of services to identify vulnerable patients or provide individualised care plans, and for agencies with responsibilities for mental health to work together.
The inquiry into the care of Christopher Clunis was also another reason why the community care needed a reform.
Rogers and Pilgrim (2001) explained that inquiry examined the manner in which services failed to respond adequately to Christopher Clunis, a young black man With a diagnosis of paranoid schizophrenia who stabbed a stranger (Jonathan Zito) at Finsbury Park underground station. This highlighted a number of problems why the Labour government called for the reform of the community care policy because of the inadequate support for in the community with severe mental health problems.
In 1999 The Government published the National Service Framework [NSF] for mental health modern standards and service models for England. The NSF spelled out national standards for mental health services, what they aimed to achieve, how they should be developed and delivered, and how performance would be measured in every part of the country.(DoH
Community care is the support by informal and formal carers of the elderly, the disabled and the mentally disordered groups in the community who are usually in their own homes rather than in institutions.
According to Bulmer(1989)the ideas with which community care came about is due to the mixture of sociological propositions about the nature of modern community life, including personal ties between relative, friends, and neighbours.
The Griffiths Report: ‘Community Care: Agenda for Action’
Margaret Thatcher invited Sir Roy Griffiths 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’. According to the report, 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.
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:
Minister of State for Community Care to ensure implementation of the policy – it required ministerial authority.
Local Authorities should have key role in community care. i.e. Social Work / Services departments rather than Health have responsibility for long term and continuing care. Health Boards to have responsibility for primary and acute care.
Specific grant from central government to fund development of community care.
Specified what Social Service Departments should do: assess care needs of locality, set up mechanisms to assess care needs of individuals, on basis of needs – design ‘flexible packages of care’ to meet these needs
Promote the use of the Independent sector: this was to be achieved by social work departments collaborating with and making maximum use of the voluntary and private sector of welfare.
Social Services should be responsible for registration and inspection of all residential homes whether run by private organisations or the local authority.
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. rewor
According to the Mind, In 1989 the government published its response to the Griffiths Report in the White Paper Caring for People. It set out a framework for changes to community care, which included a new funding structure for social care. This would mark the beginning of the purchaser/provider split whereby social services departments were encouraged to purchase services provided by the independent sector. The report promoted the development of domiciliary, day care and respite services to enable people to live as independently as possible in their own homes. Other objectives included quality initiatives around assessment of need and case management. Carers’ needs were addressed by prioritising practical support initiatives for them. The next decade saw a dramatic increase in the number of voluntary and private sector service providers.
The impact of the community care reforms
The community care reforms outlined in the 1990 Act have been in operation since April 1993 Glennester, (1996).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:
introduced a system that is no better than the previous more bureaucratic systems of resource allocation
were an excellent idea, but received little understanding or commitment from social services as the lead agency in community care
the enthusiasm of local authorities was undermined by vested professional interests, or the service legacy of the last forty years
health services and social services workers have not worked well together and there have been few ‘multidisciplinary’ assessments carried out
in reality little collaboration took place except at senior management level
the reforms have been undermined by chronic underfunding by central government
the voluntary sector was the main beneficiary of this attempt to develop a “mixed economy of care”
The Care Programme Approach (CPA )
According to Rogers and Pilgrim (2001) there was a light with the introduction of the Care Programme Approach in 2001. It introduced an attempt to improve and standardise the delivery of community care services. The CPA set out a practice framework for health authorities in England, giving guidance on how they should fulfil their duties as laid out in the National Health Service (NHS) and Community Care Act 1990. The programme contained four key elements namely,
Arrangement for assessing the health and social needs of recipients of specialist mental health services,
The regular use of care plan that identified which provider was responsible for different aspects of a person’s care
Key worker who would monitor and co-ordinate care for the individual
Regular review and if appropriate changes to the care plan.
Through the introduction of the CPA, patients identified at risk have been required to be kept on supervision register (DH, 1995). The idea was that all patients in contact with services would be subject to CPA but that some require greater scrutiny and service input. Pilgrim et al stated that the Labour government inherited this method in 1997 and continued to endorse it as the mainstay of good quality community-based management for people with mental health disorder, despite the concept of community care being problematic by health ministers and controversial cases such as that of Christopher Clunis.
Social exclusion occurs when, marginalised by society, people are not able play a full and equal part in their community. Many people who experience mental distress experience stigma and discrimination, and live in poverty. They may find it hard to find adequate housing or access employment. The net result is that people can become seriously isolated and excluded from social and working life.
Following the publication of the Social Exclusion Unit’s (SEU) report into mental health and social exclusion, the National Institute for Mental Health in England (NIMHE) have been charged with implementing the 27 action points listed in the SEU report. NIMHE are working on a number of policy areas including employment, education, social networks, housing and homelessness, direct payments, income and benefits.’ (DoH 1998)
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