Review

Contradictions in community care

Normality is Hard Work: Trade Unions and the Politics of Community Care
Mick Carpenter
Lawrence and Wishart, 1994, £14.99

The reforms of the NHS have overshadowed the other major reform in health and social care: care in the community. The legislation has had a wide impact on a large number of people — users of services and their carers, as well as those providing care professionally. This timely book, commissioned by UNISON, is a welcome analysis of the situation.

Mick Carpenter has looked at community care from a political and historical perspective, with particular emphasis on trade union responses to changes in patterns of health and social welfare. Tracing community care from Elizabethan Poor Law to the Griffiths reforms and the Community Care Act of 1990 he charts the shift from institutional solutions to policies which are said to enable people with disabilities to live as normal a life as possible in their own homes or in homely environments in the local community.

The agenda of the reforms, with the emphasis on users and carers, appears to have captured the moral high ground — the new legislation theoretically gives more power to users, with an assessment of their needs and a choice of how services can be provided. The old welfarism, which was professionally dominated and bureaucratically complex, is contrasted with the radical new reforms.

But the new reforms, with their emphasis on individual rights and market solutions, have failed to deliver effective services to all. Lack of resources, and an emphasis on privatisation raise concerns about standards, and cash-limited responses do not match needs assessment. The book explores these contradictions, with a critique of ‘consumerism’ and market solutions to individual needs, while welcoming the empowerment of users.

The central argument of the book is that good community care will only become reality if it is user-controlled but also worker-friendly. There is a need to build alliances between users, carers and workers, each with their legitimate interests which may sometimes be in conflict. Trade unions in the public sector have had to adapt to the changes, sometimes with difficulty, but are also in a position to work with the new agenda in a positive way. New opportunities are presented to introduce services which can enhance choice and decision making for users, support for carers, and the rights of workers.

The issues are carefully explored and well argued in this important and well referenced book.