Introduction

Exactly 40 years ago, in 1963, the Ministry of Health of Macmillan's Conservative government produced its Health and Welfare White Paper (Ministry of Health, 1963). Its significance lay in its subtitle: the development of community care. Together with the Hospital Plan of the preceding year, it refocused the objectives and activities both of hospital care within the NHS and services for adults provided by the local authority health and welfare departments, the precursors of the modern social services departments. The Hospital Plan proposed a reduction in the number of beds in hospitals for the mentally ill and mentally handicapped, and ultimately their long-term closure. The White Paper represented the obverse of that commitment. Services for adults who had hitherto been institutionalised were instead to be provided by an expanded local authority service staffed by professional workers. Like the Ten Year Plans proposed for hospitals, local authority health and welfare departments were also required to submit ten-year plans for their subsequent growth and development. The 1963 White Paper thus represented not only the transition from institutional provision to day care and domiciliary services, but also an expansion of increased government welfare activity, which had begun some years earlier in school-age education, into the sectors of health and social care.

Such policies seemed indicative of a revolutionary break with the past, and a significant change in where care was to be delivered. The isolated segregation of the institution would be replaced by a new policy of integration that would enable those adults with special needs arising from their disabilities to maintain a contact and connection with the ordinary life settings and experiences of the majority of the population (King's Fund Centre, 1980). Integration was thus a means of achieving the principle of normalisation (Wolfensberger, 1972).

Subsequent research has significantly challenged that optimistic vision of the early 1960s. Well-attested evidence has highlighted that the rundown and closure of long-stay hospitals far outstripped the development of alternative community services. Over the past 40 years successive governments, in various ways and with varying success, have struggled to make a reality of the ambiguous concept of community care. As a policy objective it has been underpinned by the idea that “it is better, wherever possible, to provide help and support for people living in their own homes, with their own families, in their own neighbourhoods, rather than in institutions” (Bell, 1965, p 419).