British home and community care: research-based critiques and the challenge of the new policy

The pace of change in community and long-term care is accelerating throughout the world. In most countries at the leading edge of innovative models during the last decade, the changes have philosophies and ideas in common. In all, the means and ends of policy are becoming more complex and ambitious [1;2;3].

Nowhere is the attempt to put the new policy ends and means in place more coherent and pervasive than in the new British central government's policy for 'community' and long-term care, and its interfaces with the primary, community, and acute health care systems. Although the British messages have much in common with policy in the other countries which have recently done most to develop the new ideas, these messages have a strong British accent, revealing national assumptions, content and meaning, as well as presentation. Therefore, it is necessary to present the main emphases of British policy in the first section of the paper.

The first section establishes that new goals and devices in matching resources to individual needs of users is a central focus of the new policy, and that this focus, like some others, has reflected strands of research©based academic argument. Section 2 summarises some research results describing the consequences of failures to match services and resources to needs, and in Section 3, the paper draws conclusions about what the new arrangements must achieve to be successful on its own most important terms.

The evidence is mainly from a stream of 'production of welfare' studies [4;5]. The focus of production of welfare argument is equity and efficiency in resources, needs-related circumstances, and outcomes of care, and in the relations between them. The rationale of this perspective is that there are ranges over which differences in resources have an important effect on outcomes of evaluative importance. These production of welfare studies describe 'who' gets 'what' (that is, the quantities of various services and other services, measured in physical and monetary units, received by persons and households with various need-related circumstances), 'where', and with what effect on outcomes of value in their own right. The studies also describe how the distribution of services and outcomes are influenced by structures and resources, policies and procedures, expectations and values. Some also analyse the origins of these determining factors and why they vary.