Care, Communities and Citizens

It is, perhaps, timely ‐ before the next millennium is on us ‐ to review progress on the implementation of the NHS and Community Care Act of 1990. To aim high is natural; to expect too much could be unfortunate. For here we are, 50 years or so after the foundation of the welfare state, still seeking answers to questions about user empowerment, needs‐led services, inter‐agency collaboration and the rights of citizens to health care free at the point of delivery. “Why”, I heard one blind, physically‐disabled man ask the senior social services manager, “after all these years are you suddenly asking us what we want?” Why, indeed.

The impetus for what would appear to be a cultural sea‐change in provider‐recipient relationships requires an explanation: a sudden conversion of a Conservative government on the political road to Damascus? A surge of humanitarianism lit by a moral beacon among the tawdry half‐light of Tory materialism? Patients First; Citizens’ Charters; choice; consumerism; complaints procedures ‐ all the trappings of the brave new world of “welfare pluralism”.

Yet, were there not less revelatory motives steering Griffiths and the government of the time towards the apparent emancipation of vulnerable people? Did the Audit Commission not have a word or two to say about the “perverse incentives” which allowed the social security system to pour millions of pounds into subsidising the costs of residential care? I recall the chant of “cost‐effectiveness” resounding through the plethora of community care projects subjected to evaluations commissioned by the relevant government departments.

Was there not also a direct linkage between the impact of management gurus such as Tom Peters and health economists à la Enthoven on Thatcher’s hardening attitude towards public expenditure and the development of quasi‐markets in health service provision; between the adoption of commercial imagery and a denial of the collective as a move towards social equity? The Local Government Training Board had published its volume Getting Closer to the Public before Griffiths reported in 1989. “Community care” was a slogan waiting to be discovered by politicians dedicated to the cult of the individual; to the precept of personal responsibility for maintaining physical and economic wellbeing; and to the erosion of the welfare state’s foundations.

Perhaps this “analytical deficit” is not to be lamented in a book, described by its author as centrally concerned “with the way in which the policy is experienced by those who use community care services and by members of their families who support them”. The book, in fact, is not Mayer and Timms revisited ‐ with verbatim observations illuminating the gap between professional judgements and citizens’ interpretation of “need”. The text is primarily focused on the emergence and development of user and carer groups in Britain, as advocates for distinct individuals who, because of some impairment, are disabled by society. It is an audit of consumerism in practice.

At this level, Marian Barnes has provided undergraduate students with an informative descriptive account of participative and, occasionally, adversarial initiatives taken by and on behalf of family carers and direct consumers of social services. The style of writing is fluent and coherent, with copious references (including 35 relating to her own publications) which reflect the continuously‐important task of monitoring the effects of community care practice on its intended beneficiaries.

Yet, it would appear an opportunity has been lost. The title strongly implies a sharp involvement with three key conceptual political icons:

(1) care;

(2) communities; and

(3) citizens.

The last two feature quite prominently in the discussion of rights, responsibilities and the physical location of care. Yet the analysis should not avoid stating, perhaps, the obvious: that meaning is dictated by those groups in society who have the power to impose their interpretations on others. If, as Barnes rightly states, “community” actually means family and kin, why do we seem to have acquiesced with Thatcher’s ex cathedra announcement that “there is no such thing as society”?

Partly, this stems from the adoption of a “care” paradigm, in attempts to help people who have very limited access to fulfilling jobs; to public buildings and transport and to decent, appropriate housing; and who often lack autonomy, adequate income and society’s respect. “Care” tends to limit perceptions of need to what social services and large‐scale voluntary organisations have available. “Needs‐led services” are still designed by dominant professional alliances.

Having conducted the reader through an impressive and sympathetically observed array of user and carer group activities, Barnes ‐ in the final page ‐ dismisses the quest by some disability activists to replace the notion of “care”with “rights”. This is an honest statement but one that reveals a commitment to so‐called user‐empowerment only on those terms prescribed by service providers.

Some of the most impressive collaboration between providers and users towards truly participative systems for service planning is being led by housing associations. Tenant participation is no longer token; it is beginning to chip away at entrenched positions of power. Most of the housing staff involved have no social work qualifications. There is a message there, I believe.