This essay will outline and analyse the Care Programme Approach (CPA), a social policy which was introduced in England in 1991. it will critically analyse and evaluate how and why this policy (CPA) was introduced. In doing so, it will attempt to explore the social problems with which the policy was concerned, its ideological origins, its aims and its nature. Finally, this essay will assess the effects of the implementation of the CPA based on issues of access and outcome.
What is social policy?
According to one website I've consulted: The name 'social policy' is used to apply to the policies which governments use for welfare and social protection; to the ways in which welfare is developed in a society, and to the academic study of the subject. In the first sense, social policy is particularly concerned with social services and the welfare state. In the second, broader sense, it stands for a range of issues extending far beyond the actions of government - the means by which welfare is promoted, and the social and economic conditions which shape the development of welfare.
Social problems with which the policy (CPA) was concerned
There are several social problems with which the CPA was concerned and some of them are: The 1984 murder of social worker Isabel Schwarz by a former mental health client as cited by Sharkey (2000) prompted a government inquiry that was led by Sir Roy Griffiths in 1988. His report "Community Care: Agenda for Action" was the forerunner to the National Health Service and Community Care Act of 1990 (NHSCCA) which sets out the foundation for present day Care Programme Approach in England. The care programme approach was also instigated by the Christopher Clunis' unmet needs as noted by the Ritchie Report in 1999. The report criticised the demeaning failures of the health and social services to work together in relation to the needs of people with mental health problems and to protect the public. The emergence of advocates groups such as MIND, the Mental Health Foundation and Informal Carers' pressure group in the 1980s were also major social factors that led to the development of the CPA (Morris (1993). Those groups raise fundamental civil liberty issues surrounding the legal rights of people returned back into the community from psychiatric hospital and the need for appropriate services. Another major concern according to Means and Smith (1998: p48) was "the official report on Ely Hospital, Cardiff, which confirmed staff cruelty to patients at this mental handicap hospital." They argued that "The level of media publicity generated by these incidents became so high that a policy response became inevitable (ibid)".
CPA's ideological origins
There are several factors that affected the development and establishment of the Care Programme Approach (CPA). However, the key factors that influence the implementation of the CPA are: political, economic and social. From the earliest stages of the Poor Laws through to the present day social security system, political factors have influenced welfare provision. Like most other policies, the CPA emerge as a result of the conservatism New Right ideology of minimum state intervention, privatisation, the idea of justice and the emergence of global market forces. The conservative government lead by Margaret Thatcher from 1979 through to the 1990s believed, politically, in reducing the power of the local authority and local government with the notion that "care in the community must increasingly mean care by the community (Lavalette and Pratt 1998: 237)". Mrs Thatcher expressed the view that the sacrifices which the family and voluntary organizations have played in community care from the Victorian era to present day should not be seen as second best or degrading. Her philosophy was built on the importance of mixed economy, choice and given power back to the users of services. Mrs Thatcher was politically concerned with the political structures of the local labour government and the need to give more power to the market forces (private sector) to energize the economy.
The care programme approach policy was also partly motivated by economic factors. The New Political Right regards the free market as the best way forward for organising society. They believed that a competitive market and a mixed economy of welfare is vital in encouraging competition which inspires innovation and efficiency which will inevitable provide better and cheaper services than a nationalised and bureaucratised services. This was a move away from the accepted orthodoxy of the Keynesian economics which sees government intervention in the provision of social care as necessary for the stability of the economy. The mixed economy is therefore seen by the New Right as not only promoting equality and choice but also cost effective. Many believed that the political underlying principle of giving service users choice would cover up the huge spending on the uncoordinated health and social care budget. As a result, both health and social care services were forced to introduce financial and management systems in relation to the purchase of care. For example, social workers became care managers and the purchasers rather than the providers of care.
Regarding social ideology concept, the major social ideology was that, people with mental health problems, were expected to be integrated back into the community with clear and structured care plans. The fatal attacks by dangerous mentally ill people such as Christopher Clunis's who was misdiagnosed and prematurely discharged then ended up killing an innocent person, were major social factors which affected the development of the CPA. The case of Clunis raised significant social issues of the risk and danger posed by people with mental health problems, especially those not receiving proper care. The case also raises major trans-cultural social issues in relation to the significant number of black men placed on supervision register.
The aim of the policy
The Care Programme Approach was introduced in order to provide a clear framework for the care of people with mental health problems outside hospital (Means and Smith1998: p156)", which Thompson et al (2000:573) said this include: "Systemic multidisciplinary assessment, planning, monitoring, and reviewing a care plan, the inclusion of users and carers in the formulation and delivering of care and identification of a lead person or key worker" and that, "all of this is undertaken within a framework that is flexible and responsive to the client's changing needs (ibid)".
Nature of the CPA
According to Thompson et al (2000) the CPA was introduced in 1991 and is intended to be the cornerstone of the government's mental health policy. This process applies to all people that are experiencing severe mental health problems who are clients of mental health services, whether on an informal or formal basis. The policy outlined four stages which should be applied to all clients in all cases. The First stage is, to carry out an assessment based on the circumstances of the client, including any support needed by carers. Secondly, to negotiate the care package in agreement with the client, carers and relevant agencies that are designed to meet the identify need within available resources. The third stage is to implement and monitor the agreed package by the appointment of a key worker now known as "care co-ordinator". The care co-ordinator is responsible for the assessment and planning process. He or she could be a mental health nurse, social worker or occupational therapist. The last stage is, to review the outcomes of the care plan and if necessary undertake revision of services provided.
The policy is based on person-centred approach and one that has been important for health and social care to develop integrated policies and procedures around models of assessment, diagnostic evaluation, integrated working relationships around care plans and monitoring people in care and community by means of integrated budgets. Whereas, practice under previous systems were not person-centred instead, they involved offering people limited number of inflexible choices which were more or less organised to meet requirements of service providers rather than the service users and their carers. With mental health placed in psychiatrist hospitals or prisons these residents are controlled and manipulated by those in charge.
The effects of the CPA
The policy helped services maintain contact with service users, stressed the need for service users involvement in decision making; ensures that there is coordination and communication between all the professionals that are involved in the assessment and delivery of the patient's care needs, but failed to provide comprehensive co-ordinated care. This lead to several criticism been made about the policy for example, it has been criticised that working together often leads to role insecurity and role ambiguity, thus creating a major hindrance to working together. The policy has also been criticised for mostly being used for inpatients instead of people in the community. This was referenced by Sharkey (2000) as an important point citing the Christopher Clunis' case due to the failure to offer culturally sensitive services to meet his needs and citing the example of Lavallette and Pratt (1998: 104) in which they commented that " mental health policies and practice based upon white European, middle-class norms of behaviour can result in a system which does not understand that people from other cultural backgrounds may express symptoms of mental health or ill health in different ways". This is useful in enabling the understanding of how Christopher Clunis was failed by all the professionals who saw him. For example, Sharkey (2000: p83) refer to the Ritchie Report that "A GP whom Clunis had visited had struck him off his list because he was abusive and threatening".
The Mental Health Foundation carried out a recent studies which aim was for respondents to talk openly about their mental health issues in relation to employment. They sent out about 3,000 questionnaire and those who replied , 86% were white UK, 3% Black African Caribbean, 2% Black Asian and 4% were other European white including Irish. What the findings has shown is that ethnic minority are uncomfortable to talk about their mental health problems for fear of discrimination and oppression. They also highlighted 85% of those with long term severe mental health problems are unemployed. These can contribute to the stress and anxiety experienced by users, carers, friends and families. For example, living with someone with serious ongoing mental health problems can cause increased strain, worries and distress together with loss of friends and social contracts (example intimate relationships), social isolation (due to stigma attached) and difficulties in coping with particular symptoms. At the same time, the protection of the public from the risk of harm is of paramount importance because patients discharged without adequate supervision or the provision necessary to meet their housing, social and health needs would increase risk to themselves and members of the public as evident in the case of Christopher Clunis. The CPA has also been criticised as a policy that it is largely dominated by medical module of treatment and social issues are neglected by practitioners and this has been highlighted by Thompson (2009) that spirituality is very important component of a person's well-being and despite this concern, people's spiritual needs are often seen to be neglected during treatment or in developing and managing care plans for day-to-day activities. In some cases, as noted by rethink.org, a charity campaigning for mental health awareness, spirituality is even seen as a manifestation of the individuals' psychosis or delusions by some members of society. Even though the policy was introduced so that people with severe mental health problems could be assessed and assigned a care coordinator so they don't present a risk to themselves or the public, there have been some problems with users of services "slipping through the net" and ending up either homeless or causing ham to themselves or others (sometimes even committing fatal attacks). For example, Taylor (2010) wrote on the Metro Newspaper about a man with mental health problem who hadn't been offered treatment on several attempts ended up killing a pregnant woman.
Even though this policy has helped people with severe mental health issues to be integrated well into the community and live supported or independent lives, some people with mental health problems are still seen by the policy makers as a burden and stigmatised as a threat to the community. They are routinely being denied the human rights of freedom of movement, family life, and equal access to paid jobs and adequate financial support which may then lead to homelessness and readmission in institutional care.