Policy and practice: fundamental contradictions in the conceptualization of community care for elderly people?

Abstract

For more than two decades, community care has been proclaimed the answer to the 'social problem' of the ageing of the population. Since the publication of the Community Care Whit(. Paper (Department of Health 1989), a plethora of discussion and guidance documents have followrd. In this paper, critical examination is made of some of the assumptions that appear to underpin policy and debate about community care. It is argued that recent policy and community care reforms may be affected adversely by inherent conceptual contradictions and conflicting understandings and expectations about community care. It is suggested that the reassuring connotations of the phrase 'community care' may not be reflected in its reality and that the debate needs to be extended to acknowledge and address some of the underlying dynamics, contradictions and interactions that may have a bearing on the success of the reforms.

Client Self-Assessment in Community Aged Care

“…Researchers have argued for some time that this amalgam of client needs and operational imperatives not only compromises the needs-led quality of the assessment but also undermines the whole assessment process by replacing the validated measures at its core with an expert option assessment based on subjectively defined notion of "need" (Caldock, 1994;Ellis, 1993;Hardy, Young, & Wistow, 1999;Richards, 2000); unsurprisingly, it has been found that this kind of approach leads to inconsistent care outcomes (Caldock, 1994;Ellis, 1993;Hardy et al, 1999;Richards, 2000). Self-or co-assessment approaches harbor the promise to address some of these issues.…”

Assessment: identifying the barriers to good practice

“…Moreover, it has been argued that the very use of terms such as 'need' and 'care' places people in a dependent position, reinforcing the perception that they are problematic (Caldock 1994a). Therefore, rather than assessment starting with the hopes and aspirations of users and carers (Middleton 1994), the tendency is for it to focus on deficits and difficulties.…”

“…At a conceptual level, there is a lack of clarity about the definition of key concepts. At the most fundamen-tal level, there is only limited agreement on the parameters and objectives of assessment (Caldock 1993, Higgins et al 1994 with no clear understanding about what notions of 'empowerment' (Department of Health 1993) or 'needs-led' (Baldwin & Woods 1994, Caldock 1994a) actually entail. As a recent official monitoring exercise has highlighted, it is apparent that in many areas:…”

“…These represent basic issues which must be resolved before progress can be made: if one does not know what constitutes a 'need', how can assessment of need possibly occur? The failure to define what 'needs-led' means (Baldwin & Woods 1994, Caldock 1994a) is exacerbated by the fact that practitioners seem to have no vocabulary for defining need without reference to 'service terminology' (Department of Health 1993). This, in turn, compromises the very basis for the NHS and Community Care Act.…”

“…In relation to the involvement of users and carers, the early evidence suggests that, far from involving and empowering such individuals, they remain marginalized (Caldock 1992, Department of Health 1993, Ellis 1993). Moreover, it has been argued that the very use of terms such as 'need' and 'care' places people in a dependent position, reinforcing the perception that they are problematic (Caldock 1994a). Therefore, rather than assessment starting with the hopes and aspirations of users and carers (Middleton 1994), the tendency is for it to focus on deficits and difficulties.…”