Rhetoric or reality? A critical investigation of the market model for community care

In the 1950s the term community care was associated with the movement of people with mental health problems from longstay institutions into the community. More recently, however, the term has applied to services to a much wider range of groups including older people. The thesis is concerned with community care services for this group and in particular, domiciliary care. It seeks to evaluate claims made in the White Paper: 'Caring for People' that its preferred model of community care can provide both increased service effectiveness for consumers and cost control. The thesis argues that community care policy was shaped by 'managerialist' assumptions and that improved performance could be delivered by organisational change, in particular the quasi-market and the use of managerialist techniques. Thus, the two phenomena of 'managerialism' and 'quasi markets' are conjoined, the latter offering to the former the possibility of competition between providers, which in turn is seen to provide greater user choice and value for money. Two key reports from the Audit Commission are analysed as exemplars of managerialism and community care. The connection between the reports and government policy is discussed and the evidence presented in them for community care, as a cost containment policy, is scrutinised. The consumer effectiveness argument for community care is examined by considering, in particular, the relationship between consumer choice and the market model of community care advocated in the Griffiths report: 'Community Care: Agenda for Action' (1988) and the White Paper: Caring for People (1989). It is argued that both the government proposals and much of the critical academic commentary fail to examine various underlying premises, in particular, the salience of 'choice' as a universally desirable objective. The themes outlined above are explored in empirical work undertaken in the case study local authority. The consumer effectiveness issue is analysed with reference to a survey of users of domiciliary care services. The survey is used to examine how far the assumptions made by both government and many academic commentators, with regard to user satisfaction, correspond to those of users. The analysis questions these assumptions showing that 'consumerist' notions of choice of service are much less significant than personal aspects of the service such as 'caring manner' and continuity of relation with carer. Cost control issues are examined by considering an example of 'value for money' auditing in the authority. Analysis of this project suggests the difficulties which such exercises have in generating appropriate norms for service provision in domiciliary care. The thesis concludes by relating the themes explored to current problems in community care policy, in particular the increasing significance of rationing and eligibility criteria