Caring for Older People

An Assessment of Community Care in the 1990s

Linda Bauld, John Chesterman, Bleddyn Davies, Ken Judge

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9781138706262
• eBook ISBN:
  9781351783514
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

This title was first published in 2000:  Caring for Older People provides a unique insight into the world of community care in the 1990's. It presents findings from a national study of social care from the perspectives of older service users, their carers and care managers. Descriptive findings from this longitudinal study - conducted by the PSSRU from 1994 and funded by the Department of Health - are set in the context of the history of community care and developments since the passage of the 1990 NHS and Community Care Act. The study's findings highlight important challenges for policy and practice development in the new millennium.

1

The Development of Community Care

‘Community care may be ... a sweeter smelling rose, a more promising health and social hybrid, but it has to grow in the soil we have...we do not indeed start, as some academic planners sometimes imply, with a clean slate. Reality starts with history’

Richard Titmuss, A Commitment to Welfare, 1968.

The 1990 NHS and Community Care Act ushered in a new era for both health and social services. The changes it introduced were fundamental, altering the role of statutory and independent organisations, changing professional practice and boundaries, and transforming the experience of care for many users and carers. In relation to services for older people in particular, implementation of the reforms took place over several years and it is only now, at the close of the decade, that research and practice are beginning to assess the implications.

As a series of recent texts have highlighted, however, the origins of the 1990 Act are rooted in the development of social welfare and health services in preceding decades (Maclean, 1989; Means and Smith, 1998a, 1998b; Bernard and Phillips, 1998). Community care is not a new idea, and an understanding of its origins is essential to assess developments since the passage of the 1990 Act. While readers should turn to the work of Robin Means and Randall Smith (1998a, 1998b) for a more comprehensive survey of the history of community care, we introduce some of the main developments here, as several are of specific relevance to the care of older people, and to the particular approach adopted in the project Evaluating Community Care for Elderly People (ECCEP).

Origins

Community-based care for older people shares with all social welfare services in Britain a common origin in the Poor Law. The Poor Law reforms of 1834 established a general principle of segregation between the sane and able bodied and the other groups in the workhouses, with older people, children, the sick, the disabled and the insane housed in specialist institutions (Pilgrim, 1993). Subsequent legislation formalised the separation of these groups. Despite the early identification of older people as one of the groups requiring support, and the subsequent introduction of residual social policies such as means tested (1908) and contributory (1920s) pensions and national insurance (1911) it was not until the period following the Second World War that legislation specified the development of community-based services for the elderly. The post-war period is thus a natural starting point from which to examine the development of community care for older people.

The period from 1945-1951 laid the foundations of Britain’s welfare state. Fuelled by a desire for social change following the experience of war, the Labour government introduced a series of pieces of legislation which owed much to the ideas of Beveridge and his reports describing how the ‘five giants’ of want, ignorance, disease, idleness and squalor should be addressed by universalist rather than selectivist solutions (Fraser, 1973). Three pieces of legislation in particular were to affect the lives of older people: the National Health Service Act (1946), the National Insurance Act (1946) and the National Assistance Act (1948). The new framework established free health care at the point of use and marked the decline of the old system of public assistance institutions under the Poor Law (Dalley, 1998). The National Health Service Act introduced a tripartite structure, with general practitioners as independent contractors, hospital services united for the first time and local authority public health departments retaining control of environmental health services and the employment of certain categories of nursing staff who worked in the community, such as health visitors and district nurses. Perhaps most significantly in regard to social care services for older people, Section 21 of the National Assistance Act established that it was the duty of every local authority to provide residential care for those who were in need of care, either due to their age, infirmity or other circumstances (Means, 1997). This provision marked the formal beginning of four decades in which institutional, rather than domiciliary, services were to form the bulk of public expenditure on social care services for older people.

As Means and Smith (1998b), Dalley (1998) and others have pointed out, the immediate post-war legislation established that residential care was the responsibility of local authorities, yet it did not balance this with the power to develop domiciliary services to allow older people to remain at home if they wished. Indeed, it was not until the passage of the 1968 Health Services and Public Health Act under which local authorities were given the responsibility for the overall welfare of older people that any centralised development of domiciliary services would begin, while a coordinated approach to social care provision for older people was not possible until the creation of social services departments following the Seebohm reforms introduced in 1971 (Davies and Challis, 1986; Tester, 1996; Means, 1997). Despite these’ changes and early efforts by particular local authorities to develop innovative approaches to providing home-based services (Ruck, 1958), institutional care remained dominant and attempts at comprehensive development of domiciliary care were slow to succeed. The reasons for this are well documented, but provide the necessary context for the reforms of the 1980s and 90s.

Early developments in community care

The shift away from the predominance of institutional care for older people towards the acceptance and expansion of community-based services took place slowly. In the years immediately following the war, general acceptance of existing institutional provision was first challenged by Nuffield Foundation studies in the late 1940s and early 1950s, particularly the work of the committee led by Seebohm Rowntree (1947). In his survey of old people’s homes, he described conditions in local authority premises (predominantly the old workhouses), some of which housed more than 1,000 people in impersonal and austere surroundings (Maclean, 1989). Although the final recommendations of the committee proposed changes to the buildings and organisation of homes rather than suggesting a reduction in the supply of residential care, they did describe and recommend the expansion of ‘an innovation’, the local authorities home help scheme, which, along with meal services, was proving popular but was in short supply.¹ Later work by Sheldon in Wolverhampton (1948), Townsend in London and other parts of England and Wales (1957, 1962) and Isaacs and colleagues in Glasgow (Isaacs and Thompson, 1960; Isaacs et al., 1972) raised awareness of the poor living conditions of many older people and the scarcity of supportive services, other than residential provision. Table 1.1., taken from Townsend’s The Last Refuge, illustrates the ‘warehousing’ of older people in the former workhouses which became residential care homes, with the majority of residents living in ward-type rooms with a large number of beds and with few personal possessions permitted. These accounts were to support the growth of a gradual consensus that alternatives should be available to institutional care.

Deinstitutionalisation began, however, not with old people’s homes but with the psychiatric hospitals of the 1950s. Indeed, the first official mention of the term ‘community care’ is attributed to the 1957 Report of the Royal Commission on Mental Illness and Mental Deficiency, which preceded the 1959 Mental Health Act. The 1957 report stated that ‘it is now generally considered in the best interests of patients who are fit to live in the community that they should not be in large and remote institutions such as the present mental and mental deficiency hospitals’ (cited in Pilgrim, 1993, p.171). A closure programme of psychiatric hospitals began, buoyed by concern from central government (expressed in the 1959 Guillebaud report) about the rising costs of hospital care. Targets for closure were formalised by the 1962 Hospital Plan for England and Wales. The Plan set out a programme for the closure of a significant number of hospital beds over a twenty year period. The number of inpatient beds for each category of patient (including geriatric patients) was stipulated and the remainder were selected for closure, with the intention being that the released resources would be made available for community health services (Dalley, 1998). The Plan was followed by a series of documents (such as the 1963 DHSS White Paper Health and Welfare: The Development of Community Care) which reaffirmed the government’s commitment to deinstitutionalisation and the promotion of community alternatives. Indeed, Means and Smith (1998b) have argued that there was general agreement in policy documents from the 1950s onwards that older people in need of care should be allowed to remain in their own homes, but that this ideological shift was not matched by a corresponding shift in resources. Equally importantly, these early changes in legislation and practice did not amount to a comprehensive approach to the developing domiciliary provision, but were rather adaptations to existing structures and organisations, most notably the NHS. The creation of a policy model for community care was to come much later.

Table 1.1 Distribution of beds, by size of dormitory (39 former public assistance institutions)

Thus by the late 1960s social policy in relation to older people remained focused on residential care. The community-based provision that did exist was patchy and of varied quality. The 1963 White Paper highlighted wide variations in home help provision across the country, insufficient supply of other services such as meals, and a shortage of staff (DHSS, 1963). Part of the problem stemmed from decisions made regarding the separation of responsibilities for different aspects of health services following the war. Responsibility for community-based, non-medical services was not clear and, as mentioned previously, local authorities were obliged by legislation only to provide residential care for older people.² Two important changes took place at the end of the 1960s which were to change how community services were provided. The first was the passage of the 1968 Health Service and Public Health Act, which stipulated that local authorities had the responsibility to look after the welfare of older people in their communities, including the obligation to provide a home help service. The second was the 1968 report of the Seebohm Committee, which was to shape the Local Social Services Act of 1970.

The post-Seebohm era

The Seebohm Committee was formed in 1965 with the remit of reviewing the responsibilities and organisation of local authority social services in both England and Wales. The recommendations which emerged from the committee in 1968 centred around one main issue: the need to form new local authority departments which would unite the previously fragmented social work functions (such as children’s and mental health services) and provide a single point of entry for all clients. The legislative changes which followed Seebohm — the 1970 Social Services Act, 1972 Local Government Act and the 1974 reorganisation of the National Health Service — were to transform the organisation and administration of social work and complete the separation of health and social care services. Box 1.1 describes the committee’s recommendations regarding the establishment of social services departments.

The reforms which Seebohm recommended were prompted by a variety of changes in public attitudes, central government thinking and the concerns of social workers themselves. A review of social work education and training had taken place in the late 1950s, chaired by Eileen Younghusband (Younghusband, 1959). In 1962 the core recommendations of the this report were implemented. They centred around the need for more formalised social work training to increase the number of qualified social workers with a generic training base. A national institute of social work training was formed, and a new two year professional certificate was introduced in higher education colleges in addition to existing university programmes. These changes reflected a growing desire among social workers for the development of a common core of knowledge and enhanced professional status.

Changes in other parts of the UK, most notably Scotland, were also influencing reform within social services. Following the report of the Kilbrandon Committee in 1964, the Social Work (Scotland) Act of 1968 had combined separate functions such as children’s panels and social work services into the same departments within local authorities (Adams, 1996). These changes amounted to the introduction of the first comprehensive approach to providing social services in the UK. Adams also points out that wider societal factors were at work at this time in all parts of the country which supported moves towards expanded and less fragmented social services. He suggests that there was enhanced public expectation regarding what social services could deliver, driven by the demands of rising juvenile crime rates and awareness of the growing number of older people; changing public attitudes towards people with problems; growing popularity of community- based services and an increase in local authority spending on personal social services, with real expenditure doubling between 1960 and 1968.

Box 1.1 Seebohtn Committee’s recommendations for a unified social services department

A so...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• List of Tables, Boxes and Figures
• Preface
• 1 The Development of Community Care
• 2 Origins, Design and Context
• 3 Need-Related Circumstances of Users
• 4 Need-Related Circumstances of Carers
• 5 Care Management
• 6 Consistency
• 7 Informal Carer Inputs
• 8 Formal and Independent Sector Inputs
• 9 Outcomes for Users
• 10 Outcomes for Carers
• 11 Conclusion
• References
• Index