Community Care, Ideology and Social Policy

Harry Cowen

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9781138467156
• eBook ISBN:
  9781317903406
• Topic: Politics & International Relations
• Subtopic: Health Care Delivery
• Index: Politics & International Relations

This book offers a comprehensive evaluation of community care strategies within the context of government social policy, and assesses the recent shifts of political power from Conservative to Labour towards the end of the century. Unlike the majority of texts in the field of community care, it makes explicit the historical, philosophical, social and political inter-connections, and therefore provides an in-depth understanding of changing policy issues for students, practicioners and managers in health and social care.

Part I
Social Policies in Health and Social Care

1
Introduction: Community, Policy and Ideology

Prime focus of the book

Community care in social policy is dual-edged, not least because of its ambivalence as a concept. Approaches towards it have changed historically, according to their ideological underpinnings, that is, the predominating social values and institutional frameworks of the time. Currently, the issue of community care is high on the social and political agenda of UK and other governments. Indeed, with the ceding of certain public sector activities such as community care provision to the private and independent sectors it has become effectively a means for running down the welfare state. Government community care legislation has refashioned the contours of health and social care provision since the 1980s. Hence, the resultant changes demand close analysis not simply in the legalistic sense, but in order to assess the impacts upon a range of social groups.

This book argues that community care policy must be understood critically and historically. Community care policy is not only about shifting structures and frameworks, but about the specific client groups such as elderly people, disabled people, people with learning difficulties, and people suffering from mental distress, all regularly marginalised from mainstream social policy. They have been socially ‘othered’ and often trapped by poverty. Policies in this respect have both reflected and affected the othering of social groups, a process encompassing social class, gender, age and ethnic discrimination.

At the same time, the policy shifts have also exerted considerable impacts on the people employed in the health and social care services responsible for the delivery of community care, and expected to respond rapidly in a swiftly changing institutional environment. It is important to comprehend the nature of these organisational shifts, their ideological redirection and reapplications of technology, but also their short-term and long-term consequences. This is an area which cannot be treated in a technicist manner; how a society cares for its communities reflects how it views its citizens.

This introductory chapter attempts to shed light on the definitive issues in community and caring. It shows how historical economic and social changes impinge upon both community and caring; it identifies the key providers of community care and the key issues concerning the recipients of community care.

Definitions of community

As suggested, the term community care is ambivalent. The term ‘community’ alone is the subject of a multiplicity of texts in such discplines as political philosophy, anthropology, geography and sociology (for example, Weber, 1958; Frankenberg, 1969; Bell and Newby, 1971; Plant, 1974; Willmott, 1986; Anderson, 1991; Crow and Allan, 1994). Much of the debate here turns on whether community is a geographically based concept, essentially relating to neighbourhood, or whether it is a purely relational notion concerned with the ways in which humans communicate with each other more generally. But community is a value and not just a factual description (Plant, 1974; Skidmore, 1994). It reflects ideological assumptions as to what is considered good or bad. Its meaning may be historical, cultural, personal or political. Bornat (1993) illustrates the breadth of the concept in collective life (e.g., Willmott and Young, 1957; Cornwell, 1984; Bryan etai, 1985; Cain and Yuval-Davis, 1990).

Raymond Williams, a major social and political theorist, frequently engaged with community in seminal works such as Culture and Society (1958) and The Long Revolution (1965). His Keywords (1983) traces the evolving meanings of community from ‘local’ in the nineteenth century to ‘community politics’ of the twentieth century when community, juxtaposed to the more middle-class notion of ‘service’ to the community, has been used as an organisational tool for direct action. Whatever the definition, suggests Williams, the word is never used in a pejorative sense or viewed unfavourably - a plausible explanation as to why the term ‘community care’ has been adopted by all shades of government as part of their social policy.

But one may also readily understand how the meaning has retained for many a romanticised aspect reinforced by the perspective that community is a feature of the past which has now yielded to the fragmentary thinking and relationships of post-modern developments or the regressive journey from social relationships of community to those of casual association (Tonnies, 1955). Nevertheless, more contemporary ‘oral history’ studies on neighbourhood (Bornat, 1993) have called into question such romantic ideas conveyed by the ‘rural’ and ‘urban working class’ community studies (Willmott and Young, 1957; Jackson, 1968; Dennis et al., 1969; Frankenberg, 1969).

Bulmer (1987) suggests that in spite of the multiplicity of meanings, two elements remain crucial to the definition of community from within a social care context: first, the focus upon local social relations within a geographical area; and second, the sense of belonging which is also entailed in the concept. However, the one is not necessarily entailed within the other. To be part of a geographical neighbourhood does not mean being part of a community or strong social network, namely, because of the factors of inclusion and exclusion. With the ‘universal’ economic and social changes of the late nineteenth and twentieth centuries, the physical boundaries of community have been increasingly displaced by the symbolic boundaries marking insiders from outsiders (Cohen, 1985). Such insider-outsider distinctions, argue Crow and Allan (1994), are increasingly significant, especially in relation to ethnicity in modern British society.

This issue of community and the growth of symbolic boundaries is important in community care. Black and Asian people are among clients in need of‘community care’ (Chapter 9). So too are the other ‘official’ clients of community care such as disabled people (Chapter 6) and people suffering from chronic mental illness (Chapter 7), ‘exiled’ into the large psychiatric institutions from their social network and forced ‘to negotiate membership of a new network and (become) institutionalised’ (Skidmore, 1994, p. 38).

It is worth reminding ourselves that in recent history the ideological ‘othering’ of the physically different, the weak, the disabled bodied and mentally impaired led to the ultimate fate of genocide under Nazi social policy - part of the latter’s project in delineating the unnatural from the natural (Cowen, 1994). Many of these groups still encounter social hostility and remain dependent upon being accepted into the formal network of community care.

‘Need’ and concepts in care

If we accept that there is a need to care, then it makes little sense discussing social policy outside the context of needs. But what do we mean by ‘needs’? Can we define and measure them? Generally, there are two major approaches: one argues that basic, ‘objective’ needs exist; the other argues that needs can only be socially relative, that is, they depend on the culture or the specific society. For our purposes, the most significant and pertinent contemporary attempt to erect a universalistic framework belongs to Doyal and Gough (1984, 1991) who identify the basic, universal needs as good physical health and personal autonomy, differentiated from a discrete series of intermediate needs. They contend that all people have the right to a basic need-satisfaction. Such basic needs constitute the very preconditions for being able to participate in social life.

But what is an adequate standard of basic need-satisfaction? This will vary between cultures, so that social needs, which relate to issues like sickness and poverty, may arise from shared social conditions among certain social groups, and may only be dealt with at a social rather than an individual level. Clearly, social needs’ definition is a socially contested one because of variation between societies (Bradshaw, 1977). Bradshaw notes that the concept of social need is inherent in the idea of social service, ‘which historically has been organised to meet recognised needs’ (ibid. p. 33). He erects a taxonomy of needs delineating normative need (defined by ‘experts’); felt need (equating to want); expressed need (felt need transformed into action, i. e. the effective demand for a service); and comparative need (according to the characteristics of those receiving a service).

Hence, social needs and social policy inhabit a political territory. A critical literature bears testimony to the ways in which needs are subject to manipulation: privatisation policies, for instance, have shaped our ideas of autonomy (Lodziak, 1995). At an empirical level, the Leeds Metropolitan Pilot Study (Wetherly, 1996) provides a useful case in the political implications of need-satisfaction. First, there has to be a central role for the state or the public sector. Also, as implied by the Commission on Social Justice (Borrie, 1994), the meeting of social needs requires national strategies for social justice. Again, the legislative requirement for assessment of needs at the local level (NHS and Community Care Act 1990) demands resolute interagency collaboration - a persistent failing to date in community care. Furthermore, without the participation of local users, it is virtually impossible to acquire information on unmet needs (Wetherly, 1996).

As we shall see in Chapters 3 and 5, social policy leaves unmet for socially excluded groups the basic need of good physical health (Benzeval, 1997) and the autonomy necessary for participation in social life. The possession of autonomy presupposes education. Widening access to education is important for facilitating satisfaction and autonomous living. But for almost two decades governmental education policy was posited upon a model of individual choice which marginalises those still in need of the basic educational provision. (Because of this, the new Labour Government placed education at the top of its own social policy agenda.) With respect to provision for the intermediate need of appropriate health care, more than 400 empirical studies have documented the widening health divide in Britain between rich and poor from 1985 to 1993: yet the government policy response was minimal (Benzeval, 1997).

Another significant intermediate need wedded to basic health is for adequate protective housing. For instance, poor or costly heating will produce hypothermia among elderly people. As later chapters discuss, homelessness has risen, while the supply of social housing provision has been severely curtailed. Other policy areas relating to the meeting of intermediate health needs, as identified by Doyal and Gough, include adequate nutritional food and clean water, a non-hazardous work environment and a non-hazardous physical environment. Under the realm of ‘autonomy’, bearing closely upon mental health, the authors catalogue the intermediate need for security in childhood; significant primary relationships; physical security; economic security; education; safe birth and child bearing.

The notion of care also invites unpicking. Some would argue that it has no intrinsic connection with community and indeed leads us away from the idea of community altogether. To quote: ‘[The] affective bases of community care are kinship, religion and race, not community … Kinship remains the strongest basis of attachment and the most reliable basis of care that we have. This is especially true among women’ (Abrams, cited in Bulmer, 1987) and is immediately apparent as soon as one realises that much of the care provided is of an informal nature; further, a fine dividing line runs between formal and informal care. Bulmer suggests four diverse sources of community care: statutory care, commercially provided care, voluntary care of the formal (and public) category and informal care which tends to be private.

What is the meaning of care? Bulmer (1987) points out that although the term seems self-explanatory, one is frequently unclear as to the types of help, support and protection in question when the term is used. There is a difference between the often demanding ‘tending’, entailing physical contact, and other non-physical material and psychological aspects of caring such as general support for elderly or frail persons or mentally distressed people, and more general expressions of concern. Thus care comprises physical tending, material and psychological support, and the more generalised concern with respect to others’ welfare (Bulmer, 1987).

Clearly, until the public sector intervenes, the real care falls in the tending categories and within the informal and most personal context. And this is precisely where the issue of gender becomes central. Historically wives, women and daughters have usually borne the weight of care, providing an invisible form of labour and consistently deflecting the burden away from the state - a condition of exploitation which is compounded by community care policies (Dailey, 1996). On the other hand, when policy makers act on the assumption that women will automatically follow their culturally designated caring roles, they do so in a climate where males are often not acceptable as carers.

These overarching social assumptions of the feminine naturalness for doing the caring (as well as caring about the people close to them) and the unnaturalness of the male to do the caring (while nevertheless accepted as caring about another person) are inextricably linked to the fact that in defining care, its foundation has traditionally been viewed as the nuclear family: ‘With woman as carer, man becomes the provider; the foundation of the nuclear family is laid … It becomes the ideal model to which all should approximate. Its basis is an ideological “familialism” ’ (Dailey, 1988, p. 15).

It will be argued in this book that community care policies are founded on this ideology of familialism. If one accepts the thesis that all policies are premised upon such an ideology, it calls into question the validity of the distinction often made in the literature between formal and informal care. Bulmer (1987) suggests a continuum between formal and informal care running across four diverse forms of care: statutory; commercially provided; voluntary; and informal care. A major aspect in the study and implementation of community care policies is the extent to which formal and informal care may be interwoven. Yet the idea of a continuum may also hide a rigidity and lack of flexibility. To quote Dailey (1988, pp. 115–16): ‘concepts such as the continuum of care, which sees dependent people moving from one form of care into another as their dependency-related conditions improve or deteriorate, often fail to recognise the regimentation that that may involve.’

Since state policies, as we shall see, have been framed so as not to interfere with traditional family (private) patterns of caring, those in need of care, including aged people, and no longer capable of caring for themselves have become dependent upon family members (and upon women within the family in particular). When the family can no longer care for the person, the state has taken over almost total responsibility, rendering the client in turn totally dependent on the state institution, for example a mental hospital or a residential home (Bulmer, 1987). The caring relationship, in that it involves persons in forms of dependency to a lesser or greater degree, also implies the exertion of power and the empowerment of some people or groups over others.

Conversely, the dependants of care may all too easily become disempowered. It may be argued that many forms of dependency are socially constructed. At the same time, one cannot separate this personal and socially constructed dependency from economic circumstances and economic dependency. How far for instance have community policies empowered people with physical disabilities (see Chapter 6)?

Disempowerment and ...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Dedication
• Contents
• Series Editor’s Preface
• Preface
• Acknowledgements
• Part I Social Policies in Health and Social Care
• Part II User Groups and Community Care
• Bibliography
• Index