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In one sense there can be no conclusion to this book. The chapters represent powerful contributions to an international debate about how to meet both the costs and complex demands of care and the rights of citizens in advanced economies and ageing societies. This debate is very likely to continue into the foreseeable future with no immediately obvious solutions. Several issues, however, are clarified in this volume and some encouraging evidence provided on potential improvements in policy and practice.
One central concern repeated in several chapters and made particularly strongly by Barnes in Chapter Four is that ‘care’ is usually absent from discourses of citizenship, participation and civil renewal. The ‘ethic of care’, as a set of principles and practices, challenges the distinction between public and private virtues and enables connections to be made between care, citizenship and social justice. It encourages policy makers to look beyond conventional boundaries imposed on ‘social care’ and ‘community’ policies and think holistically about the best ways to improve people's lives. This includes not just older people and the conventional candidates included in a narrow interpretation of ‘community care’ but also young people (Stephen and Squires, Chapter Seven; Quilgars, Chapter Ten) and women who, as victims of domestic violence, are often isolated from any type of support (Wilcox, Chapter Eight).
In this context it is important that we do not overlook inequalities of care and the much more acute problems faced in meeting the care needs of those discriminated against on grounds of ethnicity or poverty. As Butt (Chapter Nine) reveals, black and minority ethnic communities’ experiences of care are very variable and only rarely promote choice and control. This is less the result of inadequate legislation than the perpetuation of racial stereotypes and the imposition of a white, ethnocentric perception of care, which often fails to identify the needs of those living in diverse communities. The suggestion that a community development approach may be best for meeting the needs of black and minority ethnic communities, and indeed any groups experiencing discrimination and disadvantage, needs to be taken seriously in the social care world. It is endorsed in Germany by Bönker (Chapter Fifteen), who quotes how the traditional provision of social services through local welfare associations was very effective in meeting the demands of citizens in diverse, multicultural communities.
The first aim of this book is to question current approaches to ‘community care’ in which the meaning of community is ill-defined and the concept of care is taken for granted. Although seen as a much preferred option to residential care, community care has often proved to be isolating and impersonal, offering few of the benefits of inclusion with which communities are strongly associated, hugely dependent on the unpaid services of relatives and friends and limited to meeting needs rather than supporting rights.
The book's second aim is to identify effective strategies and practices, and the thinking that lies behind these, through which individuals may be supported to live normally and safely within communities regardless of income and wealth, age, impairment, gender or ethnicity. This includes not only those who come under the conventional community care umbrella – older people and those with physical and sensory impairments and mental health problems – but also families with young people under anti-social behaviour orders and women experiencing domestic violence.
Part One of this book opens with a chapter reflecting on the key concepts of care, community and citizenship and their importance in the delivery of welfare (Chapter One, Michael Hill). Their translation into policy and practice in the UK is then considered, with questions raised about the lack of relationship between community development and social care (Chapter Two, Susan Balloch). In the third chapter the focus is on Scotland alone, where a tradition of community social work has been sustained and personal care costs are now paid by the state (Chapter Three, Alison Petch).
Part Two contributes to unpacking the concept of care by reflecting on the ‘ethic of care’, which characterises both personal relationships and professional behaviour. The first chapter reflects on this ethic in relation to community cohesion, social inclusion, community involvement and civil renewal (Chapter Four, Marian Barnes). Chapter Five then considers how front-line professionals are coping in a context of increasing ethical uncertainty, shifting professional boundaries and increasing pressures from New Public Management agendas. It examines how professionals hold on to their ethics, avoiding total moral relativisim and/or terminal burn-out (Chapter Five, Marjorie Mayo, Paul Hogget and Chris Miller).
In Chapter One Michael Hill addressed the broad concepts of care, citizenship and community and their interface nationally and globally. In this chapter the focus is on recent policy developments in the UK that have revived concepts of citizenship and community within the context of care. The next chapter from Alison Petch will then look at some of the distinctive developments in Scotland.
In the UK, central government policy has regularly emphasised the importance of community in the provision of social care. Both the Seebohm (1968) and Barclay (1982) Reports saw communities as fundamental to the provision of local social care services, the latter advocating a system of ‘patch-based social work’ to utilise community resources and meet local needs effectively. The demise of community social work in the 1980s coincided, ironically, with the growth of community care policies, the closure of long-stay mental hospitals and the growing popularity of policies for enabling people with complex needs to remain independent in their own homes for as long as possible. Parallel policies for children and families saw a major reduction in the number of children's homes and an emphasis on foster care.
Community social work became a victim of centralisation and cost-cutting in local government just as Sir Roy Griffiths (1989) was preparing his report on community care. As a result, ‘community care’ never became a community-based system of care, but rather a policy for deinstitutionalisation. In spite of this the 1980s saw a rapid growth in residential and nursing homes, particularly after 1984 when legislation enabled individuals receiving social security benefits to receive state funding for residential care if assessed as in need, fuelling an unplanned growth in privately owned homes.
The 1990 NHS and Community Care Act, implemented in 1993, transferred the entire state funding for residential and nursing care for older people to local government social services departments and effectively closed the financial loophole that had encouraged many into residential care. The Act designated the local authorities as ‘enablers’, purchasing residential, day and home care services, mainly from the private and voluntary sectors rather than providing them themselves.
The widespread popularity of evaluation is based on the need to provide evidence of the effectiveness of policies and programmes. This book sees evaluation as an inherently political activity, and, using a wide range of examples, it relates practical issues in evaluation design to their political contexts.
This chapter reflects on an evaluation of partnership working between health and social care services in West Sussex. In evaluating projects to combat ‘winter pressures’, it outlines the mapping of the main relationships between stakeholders, findings from a questionnaire sent to senior, middle management and frontline staff and an analysis of evaluation forms. It shows how national policy drove the projects and how local politics contributed to as well as impeded their success.
Winter pressures are governmentally recognised special problems experienced in winter by both health and social services as a result of a higher incidence of illness, especially among older people, and a consequent increase in emergency admissions. Special funding to meet these pressures was introduced in 1997 for local health and social care communities through Local Winter Planning Groups (LWPGs).
The LWPG provided a prime example of partnership working. Its broad representation included the relevant Health Authority, Social Services Departments, Trusts (acute, mental health, community, learning disability and ambulance services), Primary Care Trusts and Groups, Local Representative Committees, Out of Hours’ Cooperatives, Deputising Services, NHS Direct, Community Health Councils (CHCs)/Patient/Public representatives and members of the voluntary and private sectors involved in health and social care.
National criteria for local winter planning required each health and social care community to submit a single local winter plan to its health and social care region at the end of the July of that year for agreement by the end of September (DH, 2000). In 2000 national criteria focused on flu immunisation, hospital services (critical care and acute services), community and mental health services, ambulance services, intermediate care, social care and primary care. Further issues covered included contingency plans for escalation/control procedures, human resources and communications.
Six broad areas of action being taken to prepare for winter, as set out in the ‘Winter Plan’
• Promoting self-care and preventing ill health;
• investment in capacity and change;
• service improvement and design;
• better preparations and strengthened partnerships; and
• managing the winter.
The Winter Report 2000-01 found many examples of good progress, as well as areas still requiring considerable attention. Its recommendations, however, signalled a greater focus on year round capacity planning as the key to improved services:
Local planning for winter should explicitly include preparations to manage elective as well as emergency demand. LWPGs should operate all year round. (DH, 2001a, para 58)