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SUPPORTING FAMILY AND COMMUNITY CARE

Malcolm Payne
Professor of Applied Community Studies, The Manchester Metropolitan University,
799 Wilmslow Road, Didsbury, MANCHESTER M20 2RR.
Telephone: UK+(0)161-247 2097, FAX: UK+(0)1204 853499, E-Mail: M.Payne@MMU.AC.UK

Introduction
Recently, I visited a colleague in another University in Bristol in the south-west of
England. She works in a campus on the edge of the city, surrounded by grassland in
imposing buildings more than a hundred years old. The University moved into these old
buildings a few years ago. I used to live in Bristol myself 20 year ago, and visited these
building regularly as part of my work. At that time, they were a psychiatric hospital for
mentally ill people. Some patients with acute illnesses were admitted for a few weeks,
then discharged home again. But many of the patients had lived there for many years,
some for most of their adult life, but now they have been moved out to live outside
hospital, and the buildings have been turned into a University. This is in response to a
government policy of ‘community care’, which has been strengthened and developed in
the 1990s.

This is not simply a British phenomenon, but a worldwide trend (Brown, 1985; Ramon
and Giannichedda, 1988). It affects not only mentally ill people, but many groups of
people in need of long-term care. Neither is it solely a government or political policy.
Professional developments have also contributed to the movement towards this policy. It
also responds to the personal preferences of many individuals and to the wishes of
communities in many different countries.

The basic assumption which lies behind such policies is that people who need long-term
care prefer to remain in their own homes and receive help from family and friends in the
community around them. It is also thought that this brings benefit to the family and
community in promoting mutual support and strengthening society generally. It often
seems more cost-effective too, but this is now seen as a false argument. This paper
focuses on the movements towards care policies of this kind and the form of social work
practice needed to implement them. The fundamental social work issue is whether people
can be cared for in the community, whether the community wishes to care for them and is
capable of doing so. If there are public services, can they be interweaved with informal
and community care?

The following discussion , which draws from my book Social Work and Community
Care, (Payne, 1995) is divided into three parts. First, I examine British community care
policy and its development as an example of the worldwide trend towards this kind of
community policy. Then, I look at some of the problems that have arisen with the policy
and its implementation. In the third section, I want to explore the professional
implications of introducing such policies: what are the implications for our practice as
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social workers? In doing so, I want to examine widespread practice policies such as case
management, multiprofessional work and networking. These three numbered sections are
then followed by a brief conclusion, making suggestions for applying these issues to
different contexts.

1 British community care policy


The reason why we remark on community care is that as societies have become more
complex, their response to dealing with social problems has been to create institutions for
people who seem to need help. Community care policies represent a shift away from
institutional care as the main policy for dealing with social need. However, because the
reasons for preferring institutional care were not always concerned in the first place with
providing good care, the reactions to this shift have been complex and need careful
analysis to understand them.

There are four issues to be considered. The first is whether we should consider
institutional care to be ‘good’ care, and why we think community care might be better.
Arising from this, the second point, there is the question of the idealisation of
‘community’ and ‘family’ and why this takes place. The third point is the question of cost.
Fourth, there is the question of the relationship between formal and sometimes official or
government action and informal and non-official and non-government action.

The view is widespread around the world that institutional care is undesirable as a way of
providing for social needs, but this has obviously not always been so, because there are
many institutions in social provision around the world. We therefore need to ask why
institutions have been used and why they have fallen out of favour.

In small communities, particularly rural communities, few social problems exist and they
are managed by members of the community as they arise through collective action. As
communities become larger and more complex, not all problems can be handled in this
way because people are more distant in their social relations, they may travel away from
their families, so that support is lost, large-scale industry, motor transport and the like
tend to create problems of ill-health and disability as a result of accidents and since more
people are together, social problems are accumulated, too. So there seems to be a larger
problem as the result of urbanisation and industrialisation. It is out of these general social
processes that the need for a wider range of helping professions, including social work,
has been appreciated.

At the beginning of this process, putting people in institutions seemed a useful approach.
First, it appears cost-effective, because a greater number of people may be cared for by a
relatively smaller number of staff than if carers had to visit them in their own homes and
communities. Specialist staff can be available more easily. Also, for people with
disabilities a special building can be provided and adaptations do not need to be made to
many different homes, which are then unnecessary for the next people who live there.
Second, people in institutions are out of the way. They do not offend or upset others by
their behaviour or disabilities, which many people find distressing when they see them.
They can be protected from being exploited by others, for example people with learning
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disabilities need not be sexually exploited or have their money taken away from them, and
disabled elderly people cannot be exploited by offenders. If their behaviour is dangerous,
other people can be protected from them. This does not mean only violence or disturbed
behaviour, although this can be a problem. Elderly people or people with learning
disabilities who cannot manage being a pedestrian in modern fast traffic, for example,
may be a hazard to other road users.

However, in the history of many countries there is another reason why people are
segregated into institutions. That is, institutions are used as a threat to exert social control
over working class populations. If your behaviour is strange, you may be put in a mental
hospital, if you are elderly and do not look after yourself, you may be put in a home, if
you do not care for your children properly, they may be taken away from you and put in a
home, if you misbehave, you will be sent to prison, In the 19th century, many European
countries had workhouses for poor people. If you were unable to provide for yourself
through employment, you could not receive financial allowances, but had to enter these
institutions, which were specifically designed to be unpleasant, as an incentive to avoid
using them.

The use of institutions as a threat to achieve social control, and their association with
people who are segregated from society for public safety or their own, means that
institutions came to be associated with the mad, the bad or the inadequate. They were not
known as people, but as special groups. So the public does not know these people and
their problems, perceives them as a problem and is not concerned if they are poorly
treated in the institution. Because people dislike leaving their own family and community
to live in such places, they become separated from normal life and the standard of care is
very poor. Because they are separated from normal life, the people in them learn to rely on
the institution, and do not practise the skills needed for ordinary life. They lose the ability
to deal with modern life. We call this becoming institutionalised. Thus, in institutions for
long-stay care, people lose their motivation for personal development and improvement,
and they become a burden on society rather than a contributor to it.

While all this is true, it does not mean that institutions are completely irrelevant or
useless. Certain needs can only be met by the specialist services or protection offered by
an institution. It is also possible to organise institutions so that they provide training and
treatment which helps people move forward (Kennard, 1983). You can also reduce the ill-
effects of institutionalisation by institutional policies such as normalisation (Brown and
Smith, 1992) which plan life in institutions in informal, supportive and caring ways to
mimic ordinary social relationships outside the institution.

The second issue is that, related to all this, we have tended to idealise the ideas of ‘family’
and ‘community’. We associate warmth and happiness with close interlocking
relationships with kin and with people who share our interests or our lives. This is
sometimes the reality. However, we also know that most murders and much conflict and
anger takes place within families, and that neighbourhood disputes can be very serious
and hard to resolve. The importance of family and community relationships to most of us
means that people who have no family or community or are separated in some way from it
are even more excluded than if family and community were not so important. So whereas
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in principle family and community is always the preferred way of resolving social
problems, as these social structures break down under the pressure of modern societies,
people become more isolated and we have to do more to help isolated people into contact
with others (Bulmer, 1987).

We return to the third issue, the problem of cost. Family and community care appears very
cost-effective, compared with professional care, so most societies go along with the
assumption that it is to be preferred. However, research shows that close family and
especially community networks grew up in times of hardship and distress, when you stuck
together or you did not survive. So they may not actually have been preferred, it was just
that there was no alternative. As societies become richer and more able to provide a
satisfying lifestyle for their people, there is less reliance on family and community
networks. Moreover, this is true for Britain, people like to be self-reliant, or rely on
people who are very close to them for personal care and support. I suspect this may be
true everywhere, as well as in Britain. People come to expect that the richer society
around them will support them, rather than their having to rely on the personal exchange
which was ore relevant in adversity.

Also, although family and community care looks cost-effective, compared with
professional care, it imposes an immense burden on the family and community. As a
social worker, I was constantly amazed at the stress and struggle that families would take
on to care for one of their family members, and the support that would often come from
neighbours and friends. However, there are long-term consequences for the health and
future lives of carers. They often have to give up work: this lowers their income, reduces
their chance of building up a pension or savings for the future, so that their old age is
more stressful as well. Looking after a disabled or elderly family member at home often
disrupts children’s development and lifestyles. So there are costs, but they are hidden,
long-tern, non-money costs.

Although there are aspects of providing social care in institutions which are cost-effective,
and I mentioned these above, cost problems escalate. When you first build the institution,
it is relevant to the care that you planned, and it needs little maintenance. Also, if there is
inflation in the economy, the loan that governments usually take out in order to build an
institution loses value quickly. However, over the years, the institution retains the same
form, but treatments and care systems change, and the building has to be adapted and
updated, so it becomes more inappropriate. By the end of a hundred years, many of
Britain’s old institutions, like the hospital I mentioned at the beginning, became very
expensive to maintain.

Also, as they become more expensive, institutions suck in more money, and there is little
money available for additional or alternative services in the community. Since these are
not available, more people have to use the institution, because these are the only forms of
care available. While institutional care is cost-effective for people who have severe
problems, if people with minor problems have to use them because there are no lower-
level services available, you begin to spend more on such people than they really need.
Also, because people in institutions become ‘institutionalised’, as I have suggested, they
become dependent on the institution and cannot leave, even if they would be able to care
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for themselves with training and support. So they stay, and as more people come into the
institution, they create overcrowding and the system in the institution has to become more
routine, so the new people who come in become dependent and so it goes on. Eventually,
therefore, institutions become too expensive.

Finally, the fourth issue, there is the question of formal and government services as
opposed to informal care and non-government services. Since the middle of the century
most European social services have been provided or financed by governments, and an
increasing element of public expenditure has gone on various kinds of health or welfare
expenditure. The increasing cost of this has made management of economies more
difficult. Although it is an exaggeration to say that the burden is impossible, one political
stance which has been influential in the 1980s argues that this is so. However, this
financial argument has become mixed up with an argument that governments providing
care through formally organised services, managed by official bureaucracies creates
dependency on the state, and discourages appropriate independence and self-
responsibility. Also, it is argued that state bureaucracies are often too inflexible to provide
sympathetic and sensitive personal care to people. This is better done through family and
community care, or at least through a wide number of alternative providers, who can do
things more informally.

There is an alternative argument here that the state is the expression of all our joint
collective support for each other, and it is appropriate for caring services to be offered
though formally organised state provision. For one thing, the state can ensure equivalent
standards and policies so that everyone is treated equally. However, many people argue
that there is a balance here. The reality seems to be that a single state service tends to
become less flexible, so that a mixture of state and alternative provision seems best, with
the government assuring the standards and level of provision through regulation.

Community care policy in Britain has seen the implementation of many of these policies
and presents a case study of many of these debates. As medical and other treatment
improved in the 20th century, the 19th century institutions became less appropriate, and
throughout the century, there was a professional movement away from keeping people in
institutions. Moreover, in the 1950s, opinion moved towards encouraging people to seek
treatment and help when they needed it, and the legal requirements to enter an institution
was obstructing people’s preparedness to get help in the early stages. So, the law was
changed to make it possible for people with mental illness to receive treatment in
hospitals without being forced to enter a mental hospital, and deal differently with people
who needed to be compelled to receive treatment because they needed protection or
because of other people’s safety. Now, their case was reviewed independently by doctors
and social workers and they could appeal against the decision to compel them to have
treatment.

All this encouraged a reduction in the number of people needing treatment in mental
hospitals, which reduced in size. Eventually, this became official policy, and was also
applied to other people needing long-term care, such as elderly people, children and
young offenders. The financial problem arose, however, that the cost of institutions was
so great that money could not be spared for community services. At first, additional
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money was focused on community services, rather than being given to institutions. This
led to two problems. First, institutions reduced their standards and there were a number of
scandals about poor-quality care. People did not want to work in them. Second, as the
economy slowed down in the 1970s, there was no growth in the economy, so
improvements in community services could not be made. There were special devices for
transferring money from institutional to community services, but these did not have much
effect.

The effect of all these problems was that people who needed help were not getting
services at all, and the reduction in importance of institutions lost momentum. Through
various unexpected consequences of changes in government policy, a large number of
private, that is for -profit, non-government institutions grew up, especially for elderly
people, and supporting people in these institutions began to cost the government a lot of
money. So, there was a review of policy and this led to a new piece of legislation, the
National Health Service and Community Care Act, 1990. This has been brought into force
during the 1990s, although the development of policy is still continuing.

The new community care policy is concerned with continuing deinstitutionalisation for
people needing long-term care. This means organising services in the community for
people who might need to go into hospitals or homes, so that they do not need to be
institutionalised. It also means helping people already in institutions to return to the
community, and reducing the size and complexity of institutions so that living in them is
more like ordinary life.

The service is provided by a ‘mixed economy of care’. Thus, although the government
pays for much of the service, people can contribute from their own income or savings, if
they have any, and their families also contribute. Services are not provided mainly by
government agencies, but by voluntary associations and by private companies. In many
areas, the local social services also have arrangements for paying neighbours or people in
the community to increase the support their would provide. Part of the reason for the
‘mixed economy’ is to encourage as much variety as possible, and to ensure that provision
is a close to the preferences and special needs of the community and family as possible.
However, it also aims to reduce the government’s costs. Since the legislation was
introduced by the former Conservative government, it also reflects their political
ideology. That is, they believe in the reduction of government involvement in providing
services to the public, and they prefer competition in a market, which drives down costs
and provides choice among alternatives through encouraging competition. Because most
of the expenditure comes form government sources, however, the market is rather
artificial, and is usually called a ‘quasi-market’.

How are services provided to people within the market? This is done through a social
work practice innovation called in Britain care management but this is known
internationally by the American term case management; for simplicity I shall use the term
case management. The idea of case management is that each person who has serious care
needs is allotted a case manager, usually a social worker, although other professionals,
especially nurses, also do this job. The case manager works with the client, or service
user, to make an assessment of the situation. They then create a care plan, which will
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consist of a package of services drawn fro the services available in the area. The case
manager is also encouraged to be creative. For example, they might negotiate with
neighbours or local businesses to provide services such as help in the home or meals for
someone who cannot manage their home or do cooking. The case manager then organises
the services and monitors whether the package fits together and is suitable for meeting the
client’s needs. It is adjusted as needs change. The local government social services
department is responsible for providing or organising for others to provide a suitable
range of services in their area. The services used in each individual package are drawn
from a local plan which sets out what services are available.

The crucial aspects of this service are:


· the participation of the client or service user in assessing and planning the situation,
· the explicit provision for including informal care by neighbours and friends in a
package, and
· the idea of organising a coordinated package of care which is relevant for the
individual, rather than providing a routine service. This reduces the tendency to give
people more than they need, and so reduces waste of money.

2 Problems with recent community care developments in Britain


Having presented the history of the development of community care policy and some
indication of the present arrangements, I now turn to say something about the problems
that have arisen in implementing the recent community care policy changes.

First, there is an inherent conflict between trying to respond to clients’ and service users’
choice and participation, and providing a creative package of services, while the
government seeks to contain expenditure. While a proportion of cases have achieved an
improved quality of service and flexible provision, these are very much the exception, and
such cases often have special needs, and therefore more creative responses. The average
elderly person will continue to get a very routine service, and probably has experienced
reductions in amount of service or quality and increases in cost. Equally, case
management has not been creatively implemented in many cases because the range of
services available negate its value. The strongest criticism has been about the increased
level of charging for services, lack of services available and the need for workers to ration
services rather than creatively developing them.

Second, and more important, there is evidence of considerable difficulty over the
assumption that informal and non-official care can be included in the mixed economy of
care (Bulmer, 1987). Most informal and family care relies on women, although husbands
do provide extensive care for their wives, where they become elderly or disabled.
Generally, carers are women. Demographic change has led to several criticisms of the
assumption that women will be able to provide care in their families and community. For
one thing, over this century there has been a reduction in the size of families, and whereas
in the early part of the century anyone would have had numerous female relatives, now
there are fewer. Also, many more women go out to work, so they are less available for
extensive caring tasks, or taking up full-time caring will damage the family’s income.
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Therefore the political and social assumption that family and community care is the
preferred way of responding to social needs may have become outdated.

Third, it is not clear that the mixed economy of care in a quasi-market will be effective
way of organising services. While it is flexible and offers choice, it fragments what were
coordinated and planned services and makes organising a coherent set of services in an
area more difficult. There are problems at both the planning level and at the level of
organising services for particular service users. In planning, people form different
professions and services must be brought together and negotiate an agreement about the
most appropriate range of services. They also come from different sectors. The market
places them to some extent in competition with one another, so their interests may be in
conflict. Also, different professional positions and values may be represented by different
services and these can be had to align. At the level of providing services, each different
profession and provider must carry out assessments for their own purposes, so a
coordinated plan based on the case manager’s assessment made with the participation of
the service user may be displaced b a variety of conflicting plans. Of course, although
these criticisms are made of the present system, many of them were also present in the
previous, service-based organisation, so it is important not to exaggerate the difficulties of
the present system.

3 Professional implications of community care policies

These three problem areas in community care policy have led to developments in
professional practice, which seem to be necessary to implement a community care policy
effectively. These include developments of case management, in multiprofessional work
and in networking. Each of these connects with the other.

Case management

There are three forms of case management. The one presumed by the British government
system is ‘social care entrepreneurship’. In this, case managers, who are usually social
workers, act as entrepreneurs in the system. It is their job to create the package of care,
exploring the system and being creative in fitting the different elements of care together.
This approach has its origins in American case management, and developed to deal with
the relatively fragmented mixed economy of the American care system. It is used
particularly where there are very disadvantaged or disabled people in the community who
need access to quite extensive services.

A different approach, ‘service brokerage’, developed from Canadian models. In this, the
case manager acts as a consultant to the client or service user, who themselves carries out
the investigation, makes their own assessment and organises the package of services. This
approach is particularly useful for people already in the community who may need
services but are intellectually capable; for example physically disabled people. It has the
advantage of placing responsibility with the service user themselves and gives them
greater control over the process. At the point where the package of services is being
delivered, the service user is much more aware of how the services fit together and to
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respond immediately to problems. The worker’s role is to find things out for the service
user, help them organise their thinking and in particular to act as the service user’s
professional advocate where administrative arrangements need to be made or where the
service use’s needs have to be represented to a service, or official reports written.

A third approach to case management is a multiprofessional approach, in which a team of


workers from different professions and agencies work together: this might include social
workers, psychologists, housing managers, nurses, doctors, physiotherapists and others.
This approach is typical where a patient in a hospital or resident in a care home is being
discharged into the community. Typically, a meeting involving the client and all the
relevant workers would consider the needs to be met and the approach to be taken.
Assessments of needs from different professional points of view would be brought
together. A plan would be created, and a keyworker is often appointed who cats as case
manager, but also has the responsibility of keeping in touch with the other professions and
their roles.

Inevitably, this different approaches have influenced each other, so dealing with some of
the problems raised with the conventional ‘social care entrepreneurship’ model.
Multiprofessional meetings might be included in the process if there are a lot of
professionals involved. To maintain the service user’s independence and involvement,
they may very often take up part of the plan to implement themselves, with help from the
case manager, or would act as their own case manager, with help from a keyworker.

Multiprofessional work

Attempts at developing multiprofessional work have been particularly important in


health-related work for many years. The traditional model was often of a doctor taking
responsibility for a patient, working with a team of people who might include social
workers, to whom the doctor would prescribe responsibilities within the doctor’s plan,
rather as the doctor prescribed medicines. As such systems developed, other workers took
part in discussion with doctors and influenced their decision-making.

As work has become more focused on the community, the doctor’s role has become one
among many, rather than always taking on a managing or controlling role. The main
problems involved in discharging a mentally ill man who has a history of violence from
hospital require effective nursing, liaison with the community and various psychological
assessments and treatments, as well as traditionally medical ones. Thus, expertise is
contributed to a multiprofessional team from different points of view, and responsibility
taken by different workers for different aspects of the work. This requires careful
coordination among the different workers, and usually the development of a team ethos,
objectives and methods of working.

The multiprofessional approach with particular service users can help to overcome the
limitations on service which come from its being provided from a number of different
agencies by different personnel.
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Networking
An important development has been a concern for networking. The professions and
agencies involved can be seen as a network, in which a number of points in the social
service system are linked by the relationships between various personnel. The families
and communities can also be seen as networks of people, connected by relationships. An
important objective of practice is to increase the number of links among a network, and to
increase the strength of those links.

The number of links can be increased by putting more people in touch with one another.
Generally, the more links there are, the more redundancy there is in the system. That is, is
one connection fails and someone does not receive a piece of information, they are more
likely to find it from someone else if there are many links in the system.

The strength of links can be increased by improving relationships and understanding


between people in the network, by increasing the frequency of their contacts and by
careful planning of contacts. All this means that work contacts can be more relevant when
they take place instead of wasting time. Some people are better at making and maintaining
links than others, and this is a useful professional skill which can be developed. In many
multiprofessional teams training about new aspects of work or developments in practice is
taken together to strengthen links and shared aims and methods.

Some conclusions
In giving this account of the development and some of the problems with community care
policy in Britain, I have tried to give an impression, first, of the debates which go on
about the development of services within, and the complex mixture of political,
administrative and professional developments which go together top create a developing
field of practice. Second, I have tried to outline the basic elements of case management as
a practice technique and mode of organisation within services, since this is a widely
discussed model of practice in any parts of the world at present. Third, I have tried to
suggest the importance of multiprofessional work and networking. Although the first has
had a long history in health and social care, doing t well is becoming an increasingly
important aspect of improving the quality of services. Networking, that is, increasing the
number and quality of links among families and communities, is a relatively new concept,
but is bringing dividends in conceiving of the role of social work specifically as a way of
developing family and community support. The traditional forms of social work were
much more concerned with personal problem-solving by the client, involving the worker
in a professional therapeutic relationship, or with the delivery of social services to people
in need. Networking is proving to be a useful sociological concept contributing to
practice, which connects services and personal helping to the need to promote family and
community support.
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References

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Routledge)

Brown, P. (1985) The Transfer of Care: Psychoatric Deinistitutionalisation and its


Aftermath, (London, Routledge).

Bulmer, M. (1987) The Social Basis of Community Care, (London, Allen and Unwin).

Payne, M (1995) Social Work and Community Care, (London, Macmillan).

Ramon, S. and Giannichedda, M. G. (eds)(1988) Psychiatry in Transition: The British


and Italian Experiences, (London, Pluto).