Feature

Keys to the future?

The new community care arrangements got underway in April. For some users, doors will open — but others may find themselves out in the cold, says Gail Wilson

The last stages of the NHS and Community Care Act 1990 became fully operational in April this year. The act offers great opportunities to professionals and service users but also poses enormous problems.

Where things go well, health and social care professionals will find themselves much clearer about what they are trying to do, and with more freedom to decide how to do it. They will have more chances to work together constructively and more opportunities for joint training and service planning. New ideas and new ways of working will be offered by services in the voluntary and private sectors. Service consumers, whether they are called patients, clients, users or customers, will be happier with the support that enables them to continue living in the community. They will also exercise more power and hold service providers accountable more often than they have in the past. However, when services are good and professional morale is high, consumer complaints can be seen as a way to better services rather than as a threat to staff security. All this adds up to a future with more job satisfaction and more respect from users and society alike.

This rosy scenario will only be achieved in places where the stresses and strains of any organisational change are overcome and the special problems built into the new community care policy dealt with in more or less satisfactory ways. There is certainly no simple solution. The three biggest problem areas are: getting beyond consensus in inter-professional and inter-agency working; finding a way of doing user-friendly rationing and minimising perverse competition.

As the white paper Community Care in the Next Decade and Beyond said, better services mean that health and social services have to co-operate with each other and with the voluntary and private sectors - where they exist. Under the new act, social service departments have to take steps to bring the private sector into existence if it does not exist locally. But neither the white paper nor the act explained how such co-operation is going to be any easier to bring about than it has been in the past. (Commentators have been lamenting the lack of inter-agency co-operation and inter-professional working since the early 1970s.)

Previous attempts have shown that it is relatively easy for health and social care professionals to agree on things such as the importance of good quality services, respect for users and even common assessment procedures. The problem is that consensus covers up very real conflicts over territory, professional values and career paths.

Some of these conflicts are easier to address than others. For example, inter-professional groups can usually agree to look at the language they use and to discuss why words like ‘community care’, ‘counselling’ or ‘assessment’ can mean different things to people with different professional training.

However issues that affect professional status are much more difficult to deal with. Whose patient or process is it? Whose career prospects will be reduced if they are not seen to be part of a strictly professional hierarchy.

There is often an assumption that the modern, mission-statemented, consumer-oriented care agencies are in the business of competing to ‘sell’ their products to their ‘customers’.

There are two problems with this private-sector type approach. The first is that the customers (purchasers) are very rarely users, if users means patients or clients. The second is that health and social care are rationed services with strictly limited budgets. The care professional cannot go out and exceed his or her ‘sales targets’ and expect senior management to be overjoyed.

It follows that both assessors and providers will find themselves rationing the services that users need to live dignified lives in the community. At the same time they are being exhorted to produce a user-friendly and user-responsive service, and even to empower users.

It is not surprising that users, for example carers who have been led to expect real support under the new system, are disillusioned. Instead of the support they need, they are told that they are not eligible, that there are not enough staff, that the service does not exist, or that the waiting time is in months not weeks.

Whatever the rhetoric about needs-led services, the major aim of the NHS and Community Care Act was to stop central government income support being used to pay for private residential care. The government is not now going to turn round and allow community care services to be offered on demand. Health and social services have always been rationed under the NHS. They cannot be sold like soap powder and at the same time shared out on the basis of need.

Service rationing and the budget limits that go with it also leads to another big problem for care providers. As in America, where Health Maintenance Organisations hold free introductory parties on the third floor of buildings with no lifts, there is going to be competition for the fittest users. Faced with a block contract, what service provider will not think about shedding the really expensive users in favour of the ones who make little demand on staff time. Knowing that money is tight, what assessor will not be tempted to refer the difficult user to another agency?

Already, in parts of south London, homes for elderly confused people cannot get a regular GP. Instead the ‘burden’ of patients is rotated every three months among neighbouring practices. In future some of the most expensive or most difficult users will fall into the gaps between services. Staff will be faced with real conflicts between their professional values and the need of their agency to compete. But the competition will be not to provide services for some.

It is hard to say which professionals will do best out of community care. Much will depend on local decisions. If senior managers understand the conflicts built into the new policy they will be able to go some way towards minimising problems for front line staff. But if they are still seduced by the macho management image of the private executive, they will not. Front line staff will then have to cope with mixed messages from above and discontent among the consumers.

Among users it is clear that young disabled people are most suited to make the best of the changes. They tend to be relatively well educated, energetic and able to call on public sympathy and they have the advantage of being relatively few in number so that even if they get many services the total cost will not be great. People with learning difficulties or mental health problems may have to rely on local lobbies and voluntary groups to influence how much of the cake comes their way. In some areas their services will improve.

In contrast older people will almost certainly lose out. Their numbers are due to rise dramatically - a 50 percent increase nationally in the over-80s. The possibility of a 50 percent rise in the expenditure devoted to health and social care (especially on residential care) was a major reason for the new policy. So cuts are inevitable. Carers of older people, as opposed to young adults, are going to have to fight very hard to maintain their share of community care resources.