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Community care essentially aims to provide individuals in need with social, medical and health support in their own homes, as far as possible, rather than in residential establishments or in long-stay institutions. The enactment of the NHS and Community Care Act in 1990 marked a watershed in the evolution of community care practice in the UK (Means, et al, 2002, p 71). Implemented after years of discussion on the social and financial viability of maintaining people in institutions and homes, the NHS and Community Care Act, initiated by Margaret Thatcher, showcased her desire to radically change the practice and delivery of social and health care in the UK (Means, et al, 2002, p 71).
The years following the passing of the Act have witnessed significant developments in the practice and delivery of social work in the country. This short essay attempts to investigate the basic reasons for the enactment of the NHS and the Community Care Act, its basic ideology and thrust, and its impact on the social work sector of the country. The essay also studies the developments in social care that have occurred in the years following the act, with particular focus on direct payments for people with learning disabilities, social care provisions for carers and the contemporary emphasis on personalisation.
NHS and Community Care Act 1990
Whilst the initiation of the policy of community care in the UK is by and large attributed to Margaret Thatcher’s conservative government, the concept of community care, even at that time, was not exactly new (Borzaga & Defourny, 2001, p 43). The need for community care existed from the beginning of the 1950s. It aimed to provide a better and more cost effective way to help individuals with mental health concerns and physical disabilities by removing them from impersonal, old, and often harsh institutional environments, and taking care of them in their home environments (Borzaga & Defourny, 2001, p 43). Although various governments, since the 1950s, supported the need to introduce community care and tried to bring in appropriate changes, lack of concrete action on the issue resulted in constant increase of the number of people in residential establishments and large institutions during the 1960s, 70s and 80s (Borzaga & Defourny, 2001, p 43).
With numerous negative stories coming out in the media on the difficult conditions in such establishments, Sir Roy Griffiths was invited by Margaret Thatcher to investigate the issue of community care for the residents of such establishments and make appropriate recommendations (Harris, 2002, p 11). The Griffiths, (1988), Report named “Community Care: Agenda for Action”, followed by the publication of a White Paper “Caring for People: Community Care in the Next Decade and Beyond” in 1989 led to the enactment of the NHS and Community Care Act 1990 (Cass, 2007, p 241).
Apart from being a strong attempt to improve the lives of people in long term institutions and residential establishments, the law was also an outcome of the conservative government’s desire to bring market reforms into the public sector and stimulate the private sector to enter the social services, as well as its conviction that competitive markets would be better able to provide more economic services than a bureaucratised public sector (Harris, 2009, p 3). With social services being among the highest revenue spending departments at the local authority level and domiciliary and residential services for older people consuming the bulk of social service funds, community care for older people presented an obvious area for introduction and implementation of market principles (Harris, 2009, p 3).
The act split the role of local and health authorities by altering their internal structures, so that local authority departments were required to ascertain the needs of individuals and thereafter purchase required services from providers (Lewis, et al, 1994, p 28). Health organisations, in order to become providers of such services, became NHS trusts that competed with each other. The act also required local social service and health authorities to jointly agree to community care plans for the local implementation of individual care plans for long term and vulnerable psychiatric patients (Lewis, et al, 1994, p 28).
The act has however come in for varying degrees of criticism from service users, observers and experts, with some observers claiming the altered care conditions to be unresponsive, inefficient and offering little choice or equity (Malin, et al, 2002, p 17). Other experts, who were not so pessimistic, stated that whilst the system was based upon an excellent idea, it was little better in practice than the previous systems of bureaucratic resource allocation and received little commitment from social services; the lead community care agency (Malin, et al, 2002, p 17). The commitment of local authorities was diluted by the service legacies of the past and vested professional interest, even as social services and health services workers were unable to work well together (Malin, et al, 2002, p 17). Little collaboration took place between social and health services and the impact of the reforms was undermined by chronic government underfunding. The voluntary sector became the main beneficiary of this thrust for the development of a mixed economy of care (Malin, et al, 2002, p 17).
Developments after the Enactment of the NHS and Community Care Act
The assumption of government by the labour party in 1997 resulted in the progressive adoption of numerous forward looking policies in various areas of social care. The publication of a white paper in 1998 reinforced the government’s commitment to promotion of community based care and people’s independence (Means, et al, 2002, p 79). The paper focused on assisting people to achieve and maintain independence through prevention and rehabilitation strategies, with specific grants being introduced to facilitate their implementation. The Health Act of 1999 removed obstacles to the joint working of health and social services departments through provisions for pooling of budgets and merging of services (Means, et al, 2002, p 79). The formulation of the NHS plan aimed to improve partnership between health and social care, the development of intermediate care and the construction of capacity for care through “cash for change” grants for development of capacity across social and health care systems (Means, et al, 2002, p 79).
Direct Payments for Individuals with Learning Disabilities
The Community Care (Direct Payments) Act 1996, which came into operation in April 1997, marked a radical change in the provision of community care for people with disabilities, including those with learning difficulties (Tucker, et al, 2008, p 210). It was illegal, prior to the implementation of the act, for local authorities to support people with disabilities by making cash payments in lieu of providing community care services. Policymakers however realised that many local authorities were successfully supporting independent living schemes, centres for independent living and personal assistance schemes (Tucker, et al, 2008, p 210). Such schemes handled community care payments for disabled people and provided them with help to organise assistance or support. The Community Care (Direct Payments) Act built on this situation, allowing direct payments to be made to replace care services, which otherwise would be given by social service departments (Tucker, et al, 2008, p 210).
Direct payments provide flexibility in the way services are provided to eligible people. The giving of money, in lieu of social care services, helps people to achieve greater control and choice over their lives and enables them to decide on the time and mode of delivery of services (Tucker, et al, 2008, p 210). Direct payments can not only be used for services to satisfy the needs of children or their families but also enables carers to purchase the services they need to sustain them in their roles. Research conducted in 1997 in the utilisation of direct payments by people with learning difficulties revealed that whilst utilisation of direct payments by people with learning disabilities was increasing, such utilisation was low among women and individuals from minority or black ethnic groups (Tucker, et al, 2008, p 210). Research also revealed the presence of wide differences in the interpretation of the capacity of persons for consenting to direct payments by local authorities. Whilst some local authorities felt that direct payments could be sanctioned to all persons with learning difficulties who were able, with assistance, to successfully control and use direct payments, other authorities did not heed the fact that such people could indeed be assisted to communicate decisions and consequently assumed their inability to consent to direct payments. Such interpretations, it was felt, could debar many people in need from obtaining the facility for direct payments (Tucker, et al, 2008, p 211).
Assistance for Carers
Recent years have seen a number of social care initiatives for easing the condition of carers. Carers are people who provide assistance and support, without payment, to family members or friends, who are unable to manage without such assistance, on account of illness, frailty or disability (Government Equalities Office, 2010, p 1). Carers can include adults who care for other adults, parents who care for disabled or ill children, or young people who care for other family members. The government’s social care policies for carers include supporting people with caring responsibilities for (a) identifying themselves at early stages, (b) recognising the worth of their contribution, and (c) involving them from the beginning in designing and planning individual care (Government Equalities Office, 2010, p 1).
Such policies aim to enable carers to (a) satisfy their educational needs and employment potential, and (b) provide personalised support, both for carers and the people they support, to enjoy family and community life and remain physically and mentally well. Whilst the NHS and community care Act 1990 looked at carers as valued resources because of their ability to provide support, it did not refer to their rights; relying instead on rhetoric to deliver the message of their value to society (Government Equalities Office, 2010, p 2). Succeeding years have however witnessed greater focus on the needs of carers and to progressive introduction of suitable laws and appropriate policies. The passing of the Carers (Recognition and Services) Act 1995 drew attention to the needs of carers. This was followed by the passing of the Carers and Disabled Children Act 2000 and the Carers (Equal Opportunities) Act 2004 (Government Equalities Office, 2010, p 2). These acts entitle carers for (a) assessment of their needs, (b) services in their own right and support in accessing education training, employment and leisure opportunities. The proposed equality bill introduces four new opportunities for carers. It (a) requires public authorities to give due consideration to socio-economic disadvantages, whilst exercising strategic planning functions, (b) takes account of associative discrimination with regard to disabled people, (c) provides for prevention of indirect discrimination, and (d) calls upon public bodies to ensure that their policies are designed to eliminate harassment and discrimination and further equality of opportunity (Government Equalities Office, 2010, p 2).
The concept of personalisation in social care, whilst discussed for some years, was formally inducted into social care practice in the UK with the publication of Putting People First in 2007.
The concordat outlined the concept of a personalised adult social care system, where individuals will have extensive control and choice over the services received by them. The government committed that social services would progressively be tailored to meet the preferences of citizens, with person centred planning along with self directed support becoming mainstream activities, assisted by personal budgets for maximising control and choice (Aldred, 2008, p 31). Whilst personal budgets and direct payments form an important aspect of personalisation, the idea concerns fitting services to the needs of people, focusing on outcomes, and recognising the worth of the opinions of service users assessing their own needs, planning their service, and producing their outcomes (Aldred, 2008, p 31).
Conclusions and the Way Forward
This essay investigates the reasons behind the enactment of the NHS and the Community Care Act and studies the developments in social care that have occurred in the years following the act, especially in areas of direct payments for people with learning disabilities, social care for carers and personalisation. It is obvious from the results of the study that social care in the UK has experienced significant change and metamorphosis since the enactment of the 1990 act.
Whilst significant progress has been made a consensus s growing that the British social care system is facing a crisis because of drivers like increasing demographic pressures, alterations in family and social structures, rising public expectations, increasing desire for greater choice and control, and eligibility for services (Glasby, et al, 2010, p 11). The need to move people out of local accommodation because of rising rents exemplifies the challenges faced by the social care system.
With the financial system becoming more challenging, the social care system will have to find ways of improving efficiencies without diluting the quality of care (Glasby, et al, 2010, p 11). The next round of social reforms, whilst attempting to achieve better delivery efficiencies will have to renew its commitment to satisfying social expectations and basic human rights, reducing costs, preventing future needs, helping people to regain independence, freeing individuals to contribute, and supporting carers to care and contribute to society (Glasby, et al, 2010, p 11).
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