The concepts of community care and primary care in the UK: the 1960s to the 1990s

The concepts of community care and primary care in UK health policy have emerged over a number of decades. This paper uses historical methods to investigate the changing definitions of community care and primary care in health policy since the 1960s. It draws on published primary and secondary sources including government documents, journals and the professional press. While policy makers have tended to separate community and primary care, the roles of the professions have tended to cut across the two sectors. The emergence and substantially separate development of the two concepts in policy and professional practice between 1960 and 1990 is described and analysed, illustrating the structural constraints on integration but noting the increasing tendency for the boundaries to be called into question. The second part of the paper examines the impact of the 1990 NHS and Community Care Act, the implementation of reforms during the 1990s and the policies currently being implemented by the Labour government. Community care and primary care have continued to be treated separately in the minds of policy makers. Policy for the former has been largely driven by governments' concern to control social security and NHS spending, whilst primary care policy largely focused on the role of general practitioners (GPs) in implementing market reforms. The new Labour government has put renewed emphasis on public health and reducing fragmentation, stressing partnership and cooperation. But the continued dominance of general practice in primary care policy may continue to be an obstacle to the integration of community care and primary care.     

Partnership working and outcomes: do health and social care partnerships deliver for users and carers?

Working in partnership, both across social care and health and with service users, has been a persistent theme of the health and social care modernisation agenda in the United Kingdom. Despite a relatively underdeveloped evidence base, the development of health and social care partnerships has continued to feature in recent policy and legislative initiatives in the United Kingdom. At the same time there has been a major shift in focus towards the outcomes that support services deliver. A central question remaining is whether the policy initiatives driving the development of health and social care partnerships are delivering improved outcomes, particularly the outcomes valued by people who use services. This article outlines research designed to explore this issue across 15 health and social care partnerships in England and Scotland, building from previous research by the Social Policy Research Unit based at the University of York. It sought to assess the extent to which health and social care partnerships deliver the outcomes that people who use services value, and to determine the features of partnership working associated with the delivery of these outcomes. A robust outcomes framework was defined, which provided the basis for interviews with those receiving support from partnerships. Working with three user‐researcher organisations, interviews were completed with 230 individuals in 2006. On the basis of this, some service users were able to identify features of partnership that particularly contributed to improved outcomes. These included continuity of staff and sufficient staff and a range of resources, including the availability of long‐term and preventative services. Given the definitional and methodological complexity surrounding partnership working, and the challenges of attribution, the study faced some limitations in its ability to make wider inferences about partnership and outcomes. A theory of change should be employed in future studies of this type.     

Future Trends in Health and Health Care: Implications for Social Work Practice in an Aging Society

Major economic, political, demographic, social, and operational system factors are prompting evolutionary changes in health care delivery. Of particular significance, the “graying of America” promises new challenges and opportunities for health care social work. At the same time, the Patient Protection and Affordable Care Act of 2010, evolution of Accountable Care Organizations, and an emphasis on integrated, transdisciplinary, person-centered care represent fundamental shifts in service delivery with implications for social work practice and education. This article identifies the aging shift in American demography, its impact on health policy legislation, factors influencing fundamentally new service delivery paradigms, and opportunities of the profession to address the health disparities and care needs of an aging population. It underscores the importance of social work inclusion in integrated health care delivery and offers recommendations for practice education.     

Unhealthy Acts: interpreting narratives of community mental health care in Waikato, New Zealand

This paper provides a regional commentary on the progress of deinstitutionalization in an era of restructuring in New Zealand. The commentary focuses on the Waikato region, where the transition to community-based psychiatric care has been underway since the announcement of the closure of Tokanui Hospital in 1993. We use media reports to construct a narrative illuminating the distinctive threads of alternative discourse on the re-placing of people with mental health problems and sites of treatment 'into the community'. Our interpretation of this local narrative is cast against a series of backdrops: firstly, we provide an abbreviated history of deinstitutionalization in New Zealand; secondly, we examine mental health care as a sector within a rapidly evolving health system; and, thirdly, we reflect on the implementation of community mental health care in a re-regulated civil society. We argue that the effective implementation of community care has been hampered by the lack of concerted policy in the mental health care sector, by a fiscal squeeze on the health care system and by the impingement of non-health care legislation (the Commerce Act, the Privacy Act and the Resource Management Act) on the local expression and management of community care. In the Waikato narrative, we also identify administrative practices that have recast people with mental health problems as criminals and re-established prisons as the site of treatment. We conclude that the media in New Zealand have a role that extends beyond simply reporting on events. Indeed, the media act as a reflexive conduit; journalists interpret issues and through their 'stories' help to shape the course of events.     

Early steps in implementing the new community care: the role of social work practice

This paper presents findings from a research project in which needs-led assessments and care management were examined during the early years of implementation of the 1990 NHS and Community Care Act. The findings are analysed in relation to a model of social work processes, i.e. phases of assessment, intervention and evaluation. A purposive sample of 24 cases was used, spanning elderly, physical disability, learning disability and community mental health teams in two divisions of a 'county' social services department. Practitioners, providers, users and carers were interviewed. The research illustrates the enduring importance of social work values, knowledge and skills in situations of rapid organizational change and policy development.     

The Use of Public Policy Analysis to Enhance the Nursing Home Reform Act of 1987

Given the prevalence of abuse and neglect in nursing home care delivery vis-à-vis elderly and frail residents, and despite the advent and implementation of the Nursing Home Reform Act of 1987 (a policy that sought to diminish such conduct in such institutional settings), deficiency citations in nursing home care and services remain both problematic and common. By employing public policy analysis, and by analyzing various social science theories applicable to the improvement of care delivery and quality, this article seeks to develop methods to enhance compliance with the Nursing Home Reform Act and reduce care deficiencies in nursing homes.     

Partners in care?: views and experiences of carers from a cohort study of the early implementation of the Mental Health (Care & Treatment) (Scotland) Act 2003

Carers are seen as legitimate stakeholders in wider policy processes and increasingly as ‘co‐producers’ and key providers of care. Mental health carers, however, especially those caring for relatives subject to compulsory care and treatment, often feel overlooked and marginalised, caring in complex circumstances with little or no professional support. The Mental Health (Care & Treatment) (Scotland) Act 2003 (MHCT Act) implemented in 2005 aspired to change this for the better. This article focuses specifically on findings from seven focus groups and 10 individual interviews with 33 carers from three Health Board areas and the State Hospital in Scotland. Interviews were conducted at two stages during 2007 and 2008 as part of a wider study. Participating carers were supporting relatives who were under different compulsory measures and so had experience of new procedures under the MHCT Act. The data were gathered as part of a cohort study exploring service users’, carers’ and professionals’ early experiences of the Act’s implementation. A topic guide was used to explore the impact of compulsion on carers; the ‘Named Person’ role; Mental Health Tribunals; the principles underpinning the MHCT Act; and suggestions for improving the law. The study found that new provisions, in particular the Named Person role and Mental Health Tribunals, had resulted in positive change. However, many carers still felt isolated and unsupported. They remained critical of the lack of consultation and involvement at both individual and collective levels. Few were aware of their right to a carer’s assessment and many were sceptical that this would make any difference. Acknowledging the study’s limitations, we discuss the implications for practice in light of broader policy agendas of personalisation, recovery, recognition for carers and promotion of more community‐based mental health services.     

Changing clinical practice: evidence-based primary care in Australia

Evidence-based health care (EBHC) is a concept which in the past decade has gained momentum internationally. Its emphasis on linking practice and policy more closely to evidence from research and literature has challenged many assumptions and established practices in health care, whilst helping the move away from an over-reliance on medical authority and accumulated wisdom. Since the concepts of EBHC were first introduced their relevance for primary care has been examined and there has been active debate over the extent to which primary care should be restructured to accommodate these new concepts. Many argue, for example, that they devalue important but less measurable aspects of primary care. Furthermore, little is known about whether EBHC has changed practice in primary care, despite a range of implementation strategies having been put in place. This paper focuses on the response of primary care practitioners and policy makers to the challenges of EBHC in Australia. Government investment in EBHC infrastructure is detailed, and the implementation of EBHC is described from the perspective of primary care providers, individuals with chronic illnesses and other consumers of primary care services. Current issues facing Australian primary care in implementing EBHC include the relative paucity of direction from a policy framework, the dearth of multi-disciplinary primary care teams and the lack of experience in Australia of primary care health service reform.     

Joint working in community mental health teams: implementation of an integrated care pathway

Abstract Integration of community mental health services is a key policy objective that aims to increase quality and efficiency of care. Integrated care pathways (ICPs) are a mechanism designed to formalise multi-agency working at an operational level and are currently being applied to mental health services. Evidence regarding the impact of this tool to support joint working is mixed, and there is limited evidence regarding the suitability of ICPs for complex, community-based services. The present study was set in one primary care trust (PCT) in Scotland that is currently implementing an ICP for community mental health teams (CMHTs) across the region. The aim of the study was to investigate professionals' experiences and views on the implementation of an ICP within adult CMHTs in order to generate learning points for other organisations which are considering developing and implementing such systems. The study used qualitative methods which comprised of individual interviews with three CMHT leaders and two service development managers, as well as group interviews with members of four adult CMHTs. Data was analysed using the constant comparison method. Participants reported positive views regarding joint working and the role of an ICP in theory. However, in practice, teams were not implementing the ICP. Lack of integration at higher organisational levels was found to create conflicts within the teams which became explicit in response to the ICP. Implementation was also hindered by lack of resources for ongoing support, team development and change management. In conclusion, the study suggests that operational systems such as ICPs do not address and cannot overcome wider organisational barriers to integration of mental health services. Integrated care pathways need to be developed with strategic input as well as practitioner involvement and ownership. Team development, education about integration and change management are essential if ICPs are to foster and support joint working in integrated teams.     

Has Massachusetts health care reform worked for the working poor? Results from an analysis of opportunity

PurposeHealth care reform was introduced in Massachusetts (MA) in 2006 and serves as a model for what was subsequently introduced nationally as the Patient Protection and Affordable Care Act. The Boston Area Community Health survey collected data before (2002–2005) and after (2006–2010) introduction of the MA health insurance mandate, providing a unique opportunity to assess its effects in a large, epidemiologic cohort.MethodsWe report on the apparent effects of the mandate on the same participants over time, focusing specifically on the vulnerable working poor (WP). We evaluated differences in subpopulations of interest at pre- and post-reform periods to explore whether MA health care reform resulted in an overall gain in insurance coverage.ResultsMA health care reform was associated with net gains in health insurance coverage overall and among the subgroups studied. Our findings suggest that despite being targeted by health care reform legislation, the WP in MA continue to report lower rates of insurance coverage compared with both the nonworking poor and the not poor.ConclusionsMA health care reform legislation, including the expansion of Medicaid, resulted in substantial overall gains in coverage. Disparities in insurance coverage persist among some subgroups following health care reform implementation in MA. These results have important implications for health services researchers and policy makers, particularly in light of the ongoing implementation of the Patient Protection and Affordable Care Act.     

Independent hospice care in the community: two case studies

Following its remarkable success over the past 25 years the hospice movement is now at a watershed in its development. The growing legitimacy of palliative care as a health care specialty has coincided with the development of the internal market within public sector services, and the promotion of community care. The impact of these changes is now being felt by the hospice movement and may well result in radically new forms of service provision. The focus of this paper is on the future direction of the hospices. We argue, that in the present policy context the main priority must be palliative care in the community, using two case studies of innovative services to illustrate how this might be achieved. We also explore a variety of factors which may constrain the development of community care for dying people. These include the diminishing experience of families and primary health care workers in managing death and dying and the often strongly held belief that hospice care must be in-patient care. New community services may also face difficulties both in finding a market niche which complements rather than supersedes existing provision, and in securing service contracts where provision cuts across the health and social care divide. These issues are explored through an examination of the models of care developed by the two hospice groups, their integration within existing networks of provision, and their relationship with purchasing authorities.     

Second-tier reviews of complaints in health and social care

There has been a flurry of recent government initiatives concerning how citizens should be able to take up grievances against the state. In the fields of health and social care, people have been expected to use internal complaints procedures to resolve grievances. Research in this area suggests that there have been problems with the existing complaints procedures and there has been particular criticism of the 'second-tier' review stage in both health and social care. This has led to the introduction of more independent means of review. Different models of review have been developed in England, Wales and Scotland. Based on a review of recent policy documents and legislative instruments, this article looks at recent changes and proposals and considers the relative merits of the different models in the three administrations.     

Choosing and paying for care

This paper presents data from before and after implementation of the 1990 NHS and Community Care Act in 1993. It shows the low proportions of the population who are covered by private health insurance and draws attention to the fact that, although some older people have considered private health insurance, few are covered. Comparing data for people aged <65 with those aged >65, the paper explores the preferred sources of help in a range of situations. The findings show that in most instances, statutory services are preferred. Data for older people aged >80 are presented comparing findings from 1990/91 and 1995, which show that use of services for which charges have been introduced appear to have fallen. Low take-up of dental and optician services are identified. The implications of the findings for social policy are considered and it is suggested: that insurance cover for long-term care should be organized at a national level; that greater attention should be given to service preferences of users and potential users; and, that the effectiveness of various health and social care services should be evaluated.     

Exploring the influence of service user involvement on health and social care services for cancer

Background Service user involvement in health and social care is a key policy driver in the UK. In cancer care it is central to developing services which are effective, responsive and accessible to patients. Cancer network partnership groups are set up to enable joint working between service users and health care professionals and to drive service improvements. Aims and objectives The aim of this study was to explore the influence of the cancer network partnership groups’ service user involvement activities on cancer care. Design This was a qualitative study involving documentary analysis and in‐depth case studies of a sample of partnership groups. Setting and participants Five partnership groups were purposively selected as case studies from Macmillan regions across the UK; documents were collated from a further five groups. Forty people, including core group members and key stakeholders in cancer services, were interviewed. Results and conclusions The evidence from this study suggests that cancer network partnership groups are at their most influential at ‘grass roots’ level – contributing to patient information resources, enhancing access to services, and improving care environments. While such improvements are undoubtedly important to patients, the groups’ aim is to influence strategic changes, for example in cancer care commissioning or macro‐level policy decision‐making. The evolution of open, participatory relationships between service users and professionals, and recognition of the value of experiential knowledge are seen as key factors in influencing cancer care. The provision of dedicated resources to strengthen service user involvement activities is also vital.     

Healthy partnerships,healthy citizens? An international review of partnerships in health and social care and patient/user outcomes

As a result of changes in the governance of health and social care organizations across developed welfare states they are under increasing pressure to work in partnership with each other (at an organizational and inter-professional level) and with the private and voluntary sector. Drawing on a comparative literature review of the theoretical and empirical evidence from health and social care partnerships across developed welfare states, this paper aims to examine the policy drivers behind such changes and the effects the changes have had on the governance of health and social care, the results for service commissioners and practitioners, and particularly the results for patients and service users. It examines some of the evidence that suggests that patient/user involvement and outcomes may at best be unaffected, and at worst be negatively compromised by shifts towards increasing partnership working in health and social care. It will conclude by discussing what lessons can be drawn about service re-organization and user involvement in welfare organizations generally, and how best to protect the interests of vulnerable and disenfranchised groups of service users.     

Professional and service-user perceptions of self-help in primary care mental health services

Self-help is becoming an increasingly accessible option for addressing mental health problems. Despite this, self-help is subject to a variety of interpretations, little is known about how professionals and service-users conceptualise self-help, or how service-users engage in self-help activities. This study aimed to explore the views of self-help by service-users and health professionals in one area of Scotland, including the perceptions of what constitutes self-help and how it might be used to address mental health problems in primary care. The research involved semistructured interviews with 31 primary care mental health professionals, and in-depth interviews with 34 service-users. We found that professionals and service-users describe self-help in different ways, which has great implications for referral to and implementation of self-help in primary care settings. It also emerged that self-help was not necessarily perceived to be able to address the causes of mental distress, which could leave some professionals defaulting to offering no interventions despite the fairly positive attitude service-users show to self-help strategies. Finally, professionals need to be convinced that interventions are useful, effective and accessible as there are significant barriers in professionals using self-help; if they are not convinced, such approaches will support their therapeutic approach. The research supports the need to develop methods of delivery that offer self-help as part of a broad package of care that also considers social causes of distress.     

Case study of how successful coordination was achieved between a mental health and social care service in Sweden

This paper summarises the findings from an empirical longitudinal study of a health and social care consortium for people with mental health problems in one area in Stockholm. The aim was to describe the formation and structure of coordination within the consortium, and to assess the intermediate impact on care processes and client outcomes. A multiple-method case study design, theoretically informed by the Pettigrew and Whipp model of strategic change (1993) was applied. Data was gathered from interviews with informants from different organisations at different times in the development of the consortium, and from administrative documents, plans and service statistics showing some of the intermediate changes and client outcomes. The findings revealed activities and factors both helping and hindering the formation of coordination arrangements. One of the most significant hindering factors was the central county purchasing organisation focusing more on volume and costs, with payments for specific units and services, and with less emphasis on quality of the services. Few studies have described implementation of changes to improve coordination with reference to context over a long period of time, as well as assessing different results. This study contributes to knowledge about improved methods for this type of research, as well as knowledge about developing coordination between public health and welfare services. One lesson for the current policy is that, where full structural integration is not possible, then client-level coordination roles in each sector are useful to connect sector services for shared clients.     

Primary health and social care services in the UK: progress towards partnership?

There has been a shift in the theoretical debates around the ways in which organisations deliver the state's objectives of providing health and social care services for its citizens, focusing on issues of welfare governance and the encouragement of partnership working between organisations. This article develops these theories by focusing on developments in primary health and social care policy in the UK, which have undergone a radical change recently. Responsibility for commissioning health care services now falls to primary care groups and trusts (PCG/Ts), run by general practitioners, other primary care practitioners, managers and lay members, and there is some pressure on primary care groups and primary care trusts to engage in partnership working with social services, for example, to cut hospital waiting lists or provide intermediate care services. One policy option is for these organisations to form Care Trusts, integrating the commissioning of health and social care for older people and ending the historical organisational divisions between health and social care in the UK. This paper examines evidence from the first stage of a 3-year longitudinal quantitative and qualitative study of the development of partnership working between PCG/Ts and social services departments in England. It examines whether the evidence suggests that the integration of health and social care is feasible or desirable in older people's services.     

Despite obstacles, considerable potential exists for more robust federal policy on community development and health

The implementation of the Affordable Care Act of 2010 and the Obama administration's urban policy create an opportunity to link community development with health in new and powerful ways. The administration's policy emphasizes improved access to and quality of care through coordinated local and regional approaches, expansion of access to healthy food, and the support of environmental health-including clean air, water, and soil-and healthy homes. New federal programs, such as the Affordable Care Act's Community Transformation Grants, seek to prevent death and disability through policy, environmental, programmatic, and infrastructure changes. But fragmented congressional jurisdiction and budget "scoring" rules pose challenges to needed reform. We argue that government agencies need to adopt so-called systems of innovation, or organizational practices and support mechanisms that seek continuously to test new models, refine promising ones, bring to scale those that work best, and restructure or terminate what does not. We also argue that a strong and well-focused policy advocacy coalition is needed to help drive reform focused on the social determinants of health.