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clinmed/2001040001v1 (April 25, 2001)
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Conflict and Coercion: Working Together at the Interface of Continuing Health and Social Care?

 

Colin Todhunter

 

 

 

Abstract

 

This paper discusses recent changes that have taken place in the area of continuing health and social care within the UK. The impact of the changes are highlighted through the findings of a qualitative research study that examined recent trends within two Local Authorities in north west England whose geographic boundaries are coterminous with two Health Authorities.

 

The research explored the nature of collaborative processes between statutory health and social services in relation to the work of a designated hospital trust, and the resultant impact that those processes have upon older people and their informal carers. The findings show how the ideals and official rhetoric of continuing care policy in the UK, often underpinned by notions of “user-led” services and “seamless” provision, can be contradicted by the outcomes of professional dominance and rationing. To understand this we must appreciate that “provision” is a negotiated outcome involving managers, paid workers and service users, and that conflict and coercion among the various parties often replace any notion of  “collaboration” and “integration”. Older people (the focus of the study) and carers are the ones who lose out. They are relatively powerless to challenge bureaucratic machinery through which their care is negotiated.

 

The paper concludes that real service user empowerment can only take place through a broad based political and cultural shift in the nature of provision both at agency and societal levels. This would entail the state adopting a more interventionist role in macro economic policy and assuming greater responsibility for its financial redistributive role - and user groups, lawyers, social workers intervening at agency levels to redefine narrowly imposed concepts of “needs” in terms of active “rights”.

 

 

Introduction

 

The official guidance on care assessment and care management stated that the empowerment of users and carers was the rationale underpinning the reorganization of community care (DoH, SSI and SOSWG, 1991). The Audit Commission (1992) reinforced this by “putting users’” and carers’ needs first at the “cascade of change”. To achieve this, services are supposed to operate in a seamless and integrated manner which facilitates ease of access to provision and greater choice for service users.

 

This paper argues that the reality of inter-agency working around continuing care can run counter to the stated philosophy, and may be based more upon conflict and tension as workers use tactics which fall outside of the official rhetoric. Users and carers are often unable to exert influence within a system dominated by professionals and managers who seek to ration provision. The consequence is that service users’ and carers’ rights become debased and secondary to issues relating to the financial cost of provision.

 

This paper begins with an overview of some of the key literature in the area of continuing care which identifies some of the recent policy changes and highlights concerns over the effects. In particular, the impact of the shift between the boundary of health and social care is discussed. The key findings of a research study that focused on older service users (age over 64 years) are then presented. The findings provide added insight into some of the difficulties surrounding this area of health and social policy. The paper concludes by indicating how current difficulties may be overcome.

 

 

 Recent trends in UK health and social care policy

 

From the mid-1970s onwards, the central role of the public sector in planning, managing and delivering services came under strain as a consequence of economic problems and associated struggles to keep public expenditure under control (Lewis et al, 1997); current day philosophies, including individual responsibility, the role of the market and targeting of services then came to the fore in policy debate (Smith et al, 1993).

 

The 1990 NHS and Community Care Act incorporated these ideological goals and had the effect of encouraging a move toward a mixed market of welfare provision. An internal market within the NHS was developed, a purchaser/provider distinction emerged within Health Authorities (HAs) and Social Services Departments (SSDs), and service commissioners were encouraged to plan provision by taking account of services offered by statutory health and social services, the independent sector (private and voluntary), informal carers, and housing providers. The overall stated aim of the reforms has been to develop needs-led services and simplify access to services which are intended to be integrated, responsive and “seamless” (DoH, 1995a).

 

An integral part of this trend has been a shifting of the emphasis away from institutionalized care toward community based care and a primary care-led NHS. The resulting impact has been a reduction in long term care provision by the NHS, and SSDs are finding themselves providing services previously catered for by the NHS.

 

In part, financial constraints on statutory community care provision in the UK have arisen from the increased demands for services, and the shift in balance of care from residential settings to the community. Changes to, and restrictions in, funding for domiciliary care services have also taken place. These pressures have prompted two developments: cost reductions in services, and redefinition of the boundaries between health and social care (Richardson and Pearson, 1995).

 

 

Concerns about recent developments

 

Subsequent attention has been drawn to the uncoordinated and unplanned way many aspects of care for older people have been developed, pointing to major shifts in policy that have never been debated or agreed, and the calling for clearer statements of policy on government on where the boundaries between health, social services and other agencies should lie (Health Service Commissioner, 1994, Audit Commission, 1997). In 1995, central government issued guidelines (DoH, 1995b), requiring HAs to publish locally determined eligibility criteria for continuing health services:

 

specialist medical and nursing assessment;

rehabilitation and recovery;

palliative care;

continued inpatient care under specialist supervision in a hospital or nursing home;

respite healthcare;

specialist healthcare support to people in nursing homes, residential homes, or in the community;

community health services to people at home or in residential care homes;

primary healthcare;

and specialist transport services.

 

 The intention was to clarify the boundaries of long term health care and to restrict them to those cases requiring “active” medical involvement (Wistow, 1997).

 

The guidelines, however, fail to provide a set of national standards and therefore expose difficulties that are faced locally in determining objectively which activities may be classed as health care and which as social care (House of Commons Health Committee, 1995a). The Committee heard evidence that the disparity in different locality’s funding capacity effectively made the provision of long term care a lottery rather than a nationally available service: patients can be unable to access appropriate continuing care provision because LAs have exceeded their budgets, whilst HAs’ local eligibility criteria exclude them from NHS funded care (Health, 1996). The British Medical Association expressed concern to the Committee that by shifting responsibilities for some continuing care services onto SSDs, the guidelines will effectively result in means tested care as opposed to free NHS care.

 

Concerns about who pays for long term care are fuelled by the 1990 NHS and Community Care Act which effectively changed responsibilities for funding arrangements from the Department of Social Security to the relevant LA SSD. After hospital discharge, people may enter a nursing or residential home if deemed unable to live at home. After a financial assessment, they either pay in full (if their savings or assets are £16,000 pounds or more – mid-1998 figure), or will get the LA to pay in full (if the amount is less than £10,000 – mid-1998 figure). The effect of this has been that for some people, care which was previously fully funded through Department of Social Security payments, now includes a personal contribution.

 

There are patients who in the past would have been in an NHS bed, but who are now in a nursing home bed – and paying (House of Commons Health Committee, 1995). There are patients who need long term care who would have previously received relevant services in a psycho-geriatric ward, but now receive services in a private nursing home and have to pay more than before due to them generally owning greater savings/assets. In 1975 of all the people going into long term care, about a quarter received free care; by 1995 this figure was one tenth (House of Commons Health Committee, 1996). The Committee noted that in the absence of clearer guidelines for responsibilities for continuing care provision, health and social services may be tempted to shift the responsibility for care (cost-shunting) onto one another in order to make financial savings.

 

Further difficulties exist. With the relocation of many services to primary and community based facilities there is the likelihood of increased demands on LA SSDs (Henwood, 1995a), and continued demands for earlier hospital discharge are exacerbated by the increasing resource pressures experienced by social services (Henwood, 1995b). This reduces the capacity of social services to respond with the particular mix and type of support that each person may need. A spiraling downward cycle of service provision may follow:

 

“…pressures in acute hospitals for faster throughput of patients are widely perceived as creating pressures for social services and community and primary health services in terms of greater demand for nursing home or residential home placements or intensive home support. On the other hand, changes in social services eligibility criteria are perceived as impacting on the ability of hospitals to discharge patients, with consequential pressures on the management of acute beds or as leading to increased pressure on community and primary health care services.” (DoH, 1996: 1)

 

HAs over the past ten years have withdrawn services they used to provide, leaving social services to cope – with little recognition from government of the additional finances needed. It puts LAs in a dilemma to know which way to divert limited resources (Thompson, 1997). One consequence is that SSDs may no longer afford to support older people before their circumstances become truly dire. In effect, there can be less scope for undertaking preventative work. If anything, applying tighter eligibility criteria will result in only the oldest, most infirm and most severely disabled people acquiring adequate services. The increasing financial strains experienced by LA SSDs have been obvious in recent years, resulting in a number of judicial reviews. Their community services are under increased strain (Rickford, 1998).

 

A fundamental strain exists between resource-driven provision and provision which is user-led. Judicial reviews of the Chronically Sick and Disabled Persons Act 1970 have clarified that a LA may take its resources into account when assessing needs. Section 2 applies to people with sensory impairment, a mental disorder, or others who are substantially and permanently disabled by illness, injury or congenital impairment. Many older people fall within this definition of disabled. It is inevitable that LAs will feel able to allocate less of their budget for Section 2 services, and tighten eligibility criteria to match service provision to the budget (Carroll, 1997), and evidence suggests this to be the case (Anson, 1996).

 

Negotiating the shifting boundaries and the rules and procedures around eligibility criteria can be particularly difficult for older people (Allen et al, 1992; Biehal, 1993; SSI, 1995). The net effect of the shift in boundaries between forms of care and the on-going financial constraints implies that older people who lack access to effective means to lever service provision may lose out more than most.

 

 

The research study and methodology

 

A brief outline of the research rational and methods are now presented. Due to limitations of space, not all methodological issues have been expanded upon.

 

The aims of the research were:

 

1)      To explore continuing care provision for older people who had been discharged from a designated hospital trust to return to live in their own homes.

2)      To explore the nature of collaborative processes between health and social services, in the light of recent policy trends, and how those processes impact upon older people and informal carers.

3)      To explore some of the influential factors which affect the nature of decision making processes around care provision.

 

A qualitative methodology was used given the exploratory nature of the research. The intention was to enable respondents to define issues in their terms in a manner which facilitated the open expression of views. Unlike quantitative research which is based on deductive logic, the qualitative paradigm does not begin with a hypothesis from which more or less closed interview questions emerge. Highly structured quantitative studies tend to adopt closed questions which may generate data which are perceived to be relevant by researchers, but may be of minor importance to respondents. The open-ended nature of questions posed during qualitative research allows for more probing analysis and elicits concerns of which the researcher may possess little knowledge of   - at least prior to conducting the study. The qualitative approach is inductive: themes, issues and hypotheses are developed from responses in an on-going manner throughout the study.

 

In-depth interviews were carried out with 30 respondents: managers in two HAs, managers in two SSDs, hospital based social work teams, and managers and nursing staff from a designated hospital trust. Service users and carers were also interviewed – the service users were aged from 65 to 98 years. They had been discharged from the hospital trust within the previous six months and had returned to live in their own homes in the the two LA areas which were covered by the community trust. The LA areas were coterminous with the relevant HAs. Both areas had higher proportions of older residents in comparison with the rest of the UK.

 

In one of the areas the SSD had been involved in developing a continuing social care document with either little or no consultation with their healthcare counterparts. This had resulted in tense relations between the two organizations. In addition, the LA in that particular area was experiencing serious financial difficulties that were undermining attempts to develop an effective care strategy for older people. There was no formal agreement over the HA’s official continuing care policy document.

 

Of the 30 respondents, 7 were carers, 6 were service users, and 17 were paid workers (8 from health and 9 from social services. The profiles of service users/carers were as follows.

 

Male carer (age 35) caring for 67 year old father with stroke.

Female carer (51) caring for 82 year old mother with hip injury and stroke.

The aforementioned 82 year old.

Female carer (67) caring for 71 year old spouse with stroke.

Female carer (63) caring for 98 year old mother with stroke.

Female carer (86) caring for 94 year old sister with stroke.

The aforementioned 94 year old.

Female carer (77) caring for 82 year old spouse with stroke.

Female service user (82) caring for spouse with stroke.

94 year old service user with hip difficulties.

The female (65) informal carer of the aforementioned 94 year old.

Female service user (72) with complex physical impairment.

Male service user (83) with circulatory/respiratory complications.

 

Service users, as a result of their health, had complex physical needs, and were in receipt of intensive packages of care provided by health and/or social services after having been discharged from hospital. Prior to hospitalization they were receiving no or limited support from services. The study was therefore able to explore some key aspects of how large packages of long term care for older people were accessed and negotiated.

 

It was not necessary or desirable to produce a statistically scientific based sample. Qualitative research does not usually require large numbers to make up a sample. The study required a sample that was highly diverse and reflected a diverse range of opinions and experiences. The intention was to gain a range of views from people in disparate circumstances. Sampling could be described as purposive – governed by the selection of  those respondents who will maximize theoretical development, and locate strategic data which may refute emerging hypotheses.

 

Service users and carers were contacted through hospital based social work teams, and managers and workers were contacted directly. As a matter of protocol, key senior managers were contacted prior to the study beginning and permission to pursue the study was granted. Permission to conduct an interview was sought personally from all participants who subsequently gave their informed verbal consent. The aims and implications of the research were discussed with participants before interviews took place, and people were assured that they would not be named or referred to in the completed work. They were also sent a letter providing relevant information about the study prior to making personal contact. Complete anonymity and confidentiality was assured. Participants were made aware that they did not have to answer any question if they did not want to, and they had the right to terminate an interview at any time. As interviews would be taped, they were assured that the tapes would be destroyed after one month. All respondents were made aware that they could have access to the research findings if they so wished.

 

The interviews focused on certain themes. With paid workers they included the nature of links between agencies, issues relating to accessing services, and the impact of eligibility criteria in their locality. Interviews were conducted at their place of work. Service users and carers were interviewed in their own homes, and were asked to discuss the nature of their health and their experiences of services. Interviews with workers lasted on average for 70 minutes, and with service users/carers for an average of 40 minutes.

 

The interviews were taped and transcribed. After reading interview accounts certain prominent issues emerged and eventually were developed into sensitized concepts through a process of comparing and contrasting findings both within and across interviews. Tentative hypotheses then emerged and were developed through continuous testing by referring to the interview material. An outline of the analysis is now provided.

 

A first list of prominent issues was constructed from spontaneous utterances of respondents. They became focal points for analysis (operationalising concepts). They may have, for example, included descriptions about procedures relating to needs assessment. As these issues emerged a number of experiential topics became apparent. This led to a second list being constructed. For instance, in relation to needs assessment, this may have included respondents’ downplaying of subjective/felt need. The second list was in effect a list of sensitized concepts. Through constant re-reading of interview transcripts during the study it became possible to construct a third list of possible reasons why respondents, for instance, downplayed felt need. Sometimes the question “why” was asked during interviews and so the list combines explanations offered by respondents directly, and deductions made from reading the transcripts. By having dialogue with both the respondents and subsequently with the transcripts it was possible to sort and construct some summary  findings. The analysis corresponds to the framework of sensitising concepts; developing hypotheses/typologies; and expanding/narrowing focus in order to marry interview responses with wider issues relating to health and social services (Hammersley and Atkinson, 1983).

 

 

The research findings

 

The findings highlighted some of the consequences of the blurring of the boundaries between health and social care. They also indicated that official continuing health care guidelines contributed little toward cementing better working relations, and more coherent and responsive provision. Issues of rationing and cost-shunting between health and social services influenced a need for strong levels of organizational and professional control over the care system. As a result, service users and carers were relatively powerless. Powerlessness could be countered by users and carers gaining access to individual workers who were sympathetic to their needs, and particularly knowledgeable of the workings of the system of provision. Those workers were also prepared to go beyond the official rules and procedures in order to secure more adequate services. In the absence of those workers, informal carers in particular had to be particularly vocal and persistent in their dealings with agencies if adequate provision was to be made available.

 

Quite strong degrees of resource defensiveness were detected between agencies and this effectively contributed toward poor working relations among higher level managers who influenced how budgets were spent. Tensions at the “top” impacted negatively upon inter-agency relations further down the organizational hierarchies. An atmosphere of suspicion based upon fear of cost-shunting tended to pervade relations between the health and social service boundary, particularly among managers – this was less discernable among more operational staff who tended to adopt a more pragmatic approach.

 

The continuing social care document (mentioned previously), being circulated among staff and agencies at the time of the research, was viewed by managers as constituting a rearguard action by social services against continuing health care policies which had been developed locally. The unilateral way in which the social care document had been developed by social services further contributed toward inter-agency tensions. Staff in social services viewed the document as a response to continuing health care documents which, in their view, had given health services the “upper hand”.

 

Staff in health and social services complained that health care eligibility criteria, as officially published in the continuing health care documents, were vague and could be interpreted in any number of ways. Both sets of staff noted that continuing health care criteria had been inconsistently applied – decisions appeared to have been arbitrary. In their view, people who should have received continuing health care sometimes did not even though they appeared to fit the eligibility criteria. On other occasions the reverse seemed to prevail. They attributed this to factors which related to cost-shunting and political expediency, and to the notion that staff lacked appropriate knowledge of the continuing health care policies and documents. Various staff asserted that the open-ended interpretation of  continuing health care eligibility criteria was useful in allowing a role for “professional judgement” in response to needs which could be highly individualistic. Staff in social services, however, felt that it could serve another purpose. In one respect, it had less to do with catering for individualistic needs, and more to do with providing health service with an open-ended device for legitimating decisions in disputes with social services. In the words of one hospital social worker:

 

“Health just keep changing the goalposts. They just want us to take the key responsibility for funding cases”

 

One manager argued that social services were unlikely to win many disputes over continuing health care because health services could implement the eligibility criteria to suit themselves. By implication, the intervention of  “professional judgement” in respect of who fits the criteria can serve as a cost saving device.

 

Social service managers thus felt that health services had an unfair advantage when it came to making decisions about who is responsible for aspects of continuing care provision, and that social workers were less inclined to attempt to access continuing health care money which had been set aside by the HAs for designated areas of care, because they felt that they could not succeed. On a more level playing field, they argued, more workers would be inclined to try to access continuing health care as they would feel that they would be successful. A manager in social services expressed his concern:

 

“We have been dumped on. You have people currently in hospital who’ve got a tracheoctamy stuck in them. They are being fed, watered, pressure areas are being treated every half hour – totally immobile – total nursing care – and health services are saying that it is not continuing health care because they are not actively treating the person. So you get into all these bloody pedantic arguments. To me, without that treatment they would die. So they are actively treating them. We have to fight the toss on every care and its an unequal battle”,

 

As far as more operational staff were concerned, the rules governing access to continuing health care services could prevent them from accessing adequate provision for their patients/clients. In effect, the operationalisation of eligibility criteria could entail service users being denied services to which workers – sometimes health service staff as well as social service personnel – perceived they should have received. One method of combating this and accessing appropriate services was to “work around” existing organizational rules in order to extend existing boundaries, thereby acting against the official preset nature of relations both between and within organizations. This either continued to operate outside of the formalized system of care provision or was performing a positive function by gradually modifying the boundaries of the current system. In effect, staff could relax certain rules, coerce other staff to act in a certain manner, or could tell untruths about a certain service user’s situation in order to acquire particular services.

 

Relaxing certain rules by one set of staff could be reciprocated at a later date by other staff in order to facilitate the transition of service users through the process of acquiring care. Such informal exchange relations were a key component of the process and relied on the development of good interprofessional relationships.

 

Disagreements and tensions over who was responsible for what, and who should pay, were often at the forefront of relations at all levels of workers. One social worker admitted to telling “downright lies” to staff in health services in order to gain access to certain services, whilst carers told of on-going situations whereby they had to constantly battle and argue in their attempts to influence decision making processes. One social worker noted:

 

“Its about being economical with the truth. I’ve coerced others to do the same. At the end of the day I will do what is best for people – that it what I’m here for. It’s a fight all along the line. It just gets ludicrous. And it really does get stressful.”

 

A health service manager stated:

 

“Responsibility for continuing care is a nightmare. There is a spirit of un-cooperation between health and social services. I didn’t come to work here to do this. I’ve had it dumped on me and there is no one for me to dump it on.”

 

Particular staff highlighted tangles over which agency was responsible for the costs of care and that such conflict in itself could result in overall financial waste as patients were left in the “middle”, sometimes on hospital wards – waiting to be discharged. In effect, cheaper provision could have been made available but the system of accessing care had ground to a halt. A social worker agreed:

 

“I had a woman with Motor Neurone disease. She rapidly deteriorated but again all the arguments arose about who should pay for what, where and how. It is farcical because she just remained on the ward in the meantime and was still costing money. A lot of money is wasted as people continue their squabbling.”

 

As a result, staff indicated that their “rule bending” tactics could not only serve their clients’ best interest, but overall the subsequent outcome could be more cost effective – for whichever agency. The actions of such workers could produce benefits for individuals, but could also contribute toward the wider well-being of a sometimes problem-ridden system of care provision, at least in the shorter term.

 

If certain staff were having difficulty in negotiating the system of continuing care, then it was patently clear that service users and informal carers were at a greater disadvantage. Far from exaggerating their difficulties, there was a tendency for them to downplay their own service related needs. Although they perceived that (better) services could have improved their situations, they did not make requests for provision because they felt that service would not be forthcoming (or were unaware of their existence). They also perceived that services should go to “more deserving” cases than themselves. Service users and carers noted that services were experiencing financial constraints and, as a result, “accepted” that provision had to be rationed. In this situation, respondents, particularly carers, either struggled on alone without services, or purchased their own out of their private finances.

 

Their felt needs were therefore stifled before they became expressed, and never reached the arena of the more formal decision making process governing access to service provision. Perceptions about restricted access to services had been formed from their previous personal contact with service providers and other service users, or had been fuelled by wider cultural depictions of public sector services being “strapped for cash”, conveyed through the mass media. This process served to act as an informal rationing device and arguably reduced the strain on an already burdened system. One manager agreed:

 

“If there weren’t so many staff to go through and so many battles to have, then it might just be a bit smoother for people. Its about how we are perceived, and I think service users are a bit more afraid to come forward for additional help.”

 

Despite the rhetoric of providing service users with a voice in determining the nature of provision, the findings indicated that the boundaries of debate concerning provision could be quite closed due to a number of factors:

 

1) The older people discussed here were disadvantaged by the debilitating effects of their poor health and isolation; they were thus limited in the capacity for getting involved in decision making processes relating to care.

 

2) They were also disadvantaged in getting views across because their competence to communicate needs and aspirations was weakened by their lack of knowledge about formal rules and procedures governing access to provision.

 

3) Their desires were distorted and compromised by bureaucratic structures. For example, case conferences and assessments conformed to the preset procedures determined by health and social services, which deemed certain users to be more of a “priority” than others. In effect, needs could be compromised by decisions already made and operationalised through eligibility criteria.

 

Due to health factors, older people were at times unable to get involved in attempting to influence decision making processes, and they often lacked access to informal carers who may have acted as advocates. Therefore they lacked the capacity to lever appropriate service provision. Having access to informal carers was still no guarantee that provision would be forthcoming. In the absence of  suitable provision carers could experience great stress. One carer stated:

 

“When you are doing it to your own, it is frightening because its painful for them. Checking the ulcers and fixing the peg tube is all medical, but its all placed on me. The nurse said that a few years ago all this would have been her responsibility. I said that at the end of the day if anything goes wrong, whose responsible for it? Not me, because I was forced to do it. I wanted the nurse to do it. I was crying but she said I had to do it. Its frightening to have a tube attached to your mother and you’ve got to feed her. The social worker agreed it was wrong and said there are plenty of people in my situation.”

 

Even when service users had access to effective advocacy it could still be an uphill struggle to acquire provision. One carer stated:

 

“I was down at the hospital banging on doors and wouldn’t go away until they gave dad the services he needed. He wasn’t going home in that state – he wasn’t ready. I feel sorry for these old fellas who have got no relatives to speak up for them. You see them in hospital just left staring at the wall. It’s a case of being able to shout the loudest, and it shouldn’t be like that.”

 

It was noticeable that poorer respondents were at a greater disadvantage when provision was not made available. To them the notion of “independent living” was a distant ideal. They could not buy services with private finances, and wider structural factors such as poor housing compounded their general situation and overall poor health.

 

Conclusions

 

The findings draw attention to the nature of accessing provision within a system littered with bureaucratic barriers and budgetary constraints. This hardly provides a background for a fair and an equitable system based upon processes of inherent impartiality and integrated services. Those who are able to shout the loudest, who have a good working knowledge of the system, who are able to exert their “professional judgement” and are prepared to manipulate processes through veiled coercion and innovative (deviant) procedures demonstrate how provision is underpinned by a rationale which lies beyond the official rhetoric of rational choice and debate. Care provision can be based more upon propaganda and a distortion of needs and domination between parties, thereby replacing any notion of a  universal interest and reasoned debate shaped by the rational exchange of views..

 

There seems to be a tacit expectation by policy makers that the process of accounting for service user views would be based on a certain amount of equal opportunity for users to get involved in decision making processes and debates around their care – putting users’ and carers’ needs first (Audit Commission, 1992). Supposedly, debate would be relatively open. The nature of on-going care provision, however, is dominated by decisions taken by professionals and organizations which result in limited levels of help for service users, which are legitimated through “impartial” eligibility criteria. The research outlined here raises questions about issues of equality of opportunity for certain staff and service users/carers to influence outcomes around accessing suitable provision.

 

The current procedures underpinning the management and control of services place limits on the capacity of  the system to move toward a user/needs-led approach. In fact “need” is not synonymous with requirement (Meredith, 1993), and assessment is in part a way of separating needs from want in order to ration resources (Clark et al, 1996). This has particular implications for older people given that the assessment of their often complex needs can be a continuous process that is impossible to disentangle from the negotiation and availability of services (Barnes, 1997). A shortage of resources and a need to ration undermine values of choice, control and dignity.

 

In general, the whole concept of  “eligibility criteria” presupposes a scale of need, and LAs may state as a matter of general policy that they will only provide services for different levels of risk as defined by the criteria (Clements, 1996). The latter can be used to regulate provision in line with resources. This introduces an element of comparative need as service users are essentially in competition with one another for limited resources – having their needs weighed against those of others (Tanner, 1998). Effectively, given LAs limited statutory responsibilities for providing specific services and their legally legitimate capacity for reappraising eligibility for assistance (Preston-Shoot, 1996). A person’s needs may remain the same, but eligibility criteria may change. The “right” to access services and the “right” to receive them is determined through “need” as manipulated by service organizations.

 

Strains exist within the system of continuing care as the research showed, and, as highlighted elsewhere, emanate from various cultural, professional and organizational boundary differences (Webb, 1991; Dalley, 1991). However, they are now overlaid by the more recent cost-shunting issues resulting from further shifts in the boundaries away from health care toward social care. The findings from the research study indicate that service provision is shaped by decisions taken by HAs and SSDs which, throughout the country, experience different pressures on their resources. The result is that services users experience disparities in care provision according to where they live (Browne, 1996).

 

As it currently stands, the system is based upon narrowly defined notions of prescribed need.  The outcome runs counter to the ideal of “need” which, according to community care guidance, should be defined within a context which supports normal living, independence, quality of life, equal opportunity, equal access to service provision, and the right to self determination, dignity, fulfillment and choice (DoH, 1990; 1991). Clearly, continuing care adheres to limited notions of those ideals.

 

A more open-ended dialogue governing policy and provision would allow the system of provision to move beyond the shifting bureaucratic and professional constructions of need which are constrained by resource availability and sectionalized agency remits. One particular solution as far as “care” is concerned is to embrace a broad based political and cultural shift. This would entail a move toward adopting a “rights-based” approach to needs (Doyal and Gough, 1991) – one that does not adopt a narrow portrayal of need by overly individualizing it in terms of a “problem” to be alleviated on an individual level. This approach would move beyond safety-net and reformist approaches to welfare provision which is currently underpinned by the depiction of older people as a “burden” or “problem” (Vincent, 1997). Currently, services are constrained by the wider cultural, political and economic parameters set by the wider society.

 

The needs of older people are wide ranging and require a broad approach if they are to be addressed. This includes tackling poverty, housing, transport, and other issues affecting older people’s quality of life which ultimately impact upon their health and social care needs. Their needs do not only encompass physical or social care, but are also political and economic in essence. Their current levels of social exclusion in part produce their “need” for “continuing health and social care” – prevention being a better option than the current dominance of  “care and cure”.

 

Older people need to be given opportunities to mobilize their rights to active citizenship as opposed to them being more passive recipients of services. One way of achieving this would be for service users and carers to be fully involved in challenging the professional and bureaucratic assumptions held about provision, and the wider structural issues of ageism, class and gender discrimination that determine older people’s capacity for attaining optimal health and citizenship.

 

In some ways “consumerism” has opened the door to this challenge. Emphasis has been placed upon researching individual expressions of service users’ needs and upon consultation exercises with user groups. Through this process, socially marginalized groups most notably the disability movement have been given a vehicle for expressing non-service specific issues about wider concerns relating to denied citizenship rights and community development (Pilgrim and Todhunter, 1997). At present, services may want to treat people as individual customers with service-specific needs, thus neglecting their collective needs or rights of citizenship. For instance, a social model of need (or “old age”) has far more wide ranging political and economic implications than a service specific medical one (Bradshaw, 1994). Change may be developed further by social workers, lawyers, user groups and carers intervening at the agency level to capture the space left by vague legislative drafting and the unclear concept of need, and to challenge the relevance of current service provision (Preston-Shoot, 1996).

 

The role of central government in this process cannot be overlooked. There appears to be a lack of will by “new” Labour to effectively challenge the hegemony of the “free” market or private-business led economics and to increase the financial redistributive role of the state. The welfare state and “old age” continue to be constructed within this paradigm. A failure to realign the role of the state will lead to the continuation of  the subsequent underfunding of  continuing care provision, and the persistence of  inadequate definitions of need operationalised through expediency.

 

 

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