community care

An imprecise and much abused concept embracing a diverse set of policies for dependent persons-particularly those chronically dependent by virtue of age, mental illness, or mental or physical handicap-which involve, in some way or another, looking after them in the community. In its most general sense, the community is here merely negatively defined as ‘not the institution’; that is, not the large-scale, long-stay institution, such as the asylum or workhouse. Inherent in the concept is, therefore, a contrast between old institutional policies that encouraged the separation of people from the community (ordinary everyday life), and new policies according to which individuals are cared for and integrated into community life as far as possible. This basic opposition is associated with contrasting stereotypes: the vast, impersonal, isolated, impoverishing, harsh, and bureaucratic institution, on the one hand, and on the other the friendly, supportive, enriching, and caring (with its connotations of love) community . It is this contrasting imagery that gives the notion of community care such strong symbolic power, accounts for the ready acceptance of policies put forward in its name, and (regrettably) distracts attention from any precise examination of the care, if any, that is provided.

The actual character of community-care provisions varies enormously and changes over time. Only detailed knowledge of service arrangements and policies allows us to determine their exact nature. In its early usage in the 1930s, community care referred to the boarding out (fostering) of those identified as mentally subnormal. Here and elsewhere the model was of publicly funded and administered alternatives to institutional care. After the Second World War, when community care became a very widely accepted policy objective, it still referred to publicly provided services, including ‘half-way’ houses and small residential units for the chronically dependent, or units in general hospitals for those with acute problems. Not surprisingly, the main obstacle to policy implementation was the capital investment required, in a context of low capital expenditure on state welfare services; studies showed that in Britain the implementation of community-care policies was slow.

In the United States community care spread more rapidly. Although some new state-funded services were established, such as Community Mental Health Centres (which in practice primarily dealt with acute problems), many people with chronic problems were discharged into private facilities such as nursing homes and boarding houses. The introduction of community care consequently went hand in hand with the privatization of care-a trend exacerbated in the 1970s by the cutbacks in federal support for facilities like CMHCs.

A similar pattern emerged in Britain from the mid-1970s, prompted by the state's fiscal crisis , and compounded by public expenditure cuts. Community care increasingly meant private care, whether provided by commercial or charitable groups, or family and friends-a transformation which ensured that public expenditure pressures accelerated rather than curtailed policy implementation. It also ensured that, with the run-down in public services, many individuals faced neglect and marginalization (rather than enjoying care and support) in the community, or else experienced a process of ‘trans-institutionalization’, discharged from one (large-scale) institution only to end up in another-albeit smaller. The marked failures of community care in Europe and the United States, as well as its somewhat limited successes, are now well documented.