Older People and Access to Care

Correspondence to Denise Tanner, School of Health and Social Sciences, Coventry University, Priory Street, Coventry CV1 5FB, UK. E-mail: d.tanner{at}coventry.ac.uk Summary At the heart of a number of New Labour health and social policyinitiatives are stated concerns with supporting independence,preventing deterioration and extending access to services. Thisarticle examines the potential impact of these initiatives,including Prevention Grants (Department of Health, 2000b), theNational Service Framework for Older People (Department of Health,2001a), the Fair Access to Care Services Guidance (Departmentof Health, 2002a), and the Single Assessment Process (Departmentof Health, 2002b), on older people with ‘low level’needs who have increasingly been excluded from services targetedat those in high risk categories. Key standpoints for this analysisare research findings indicating what older people themselveswant from preventive services. Central messages, consistentwith those from other service user ‘groups’, arethe need for support services that enable older people to continueto exercise choice and control over their lives. New preventivemeasures are evaluated in the light of these findings and foundwanting. It is argued that recent policy initiatives are likelyto do little to widen access to support services for those withlow intensity needs, and, moreover, that the processes involvedin identifying those at future high risk will detract from ratherthan enhance citizenship. A more diffuse approach to preventionis advocated, based on mutuality, community development, andcapacity-building.     

A Comparative Discussion of the Gendered Implications of Cash-for-Care Schemes: Markets, Independence and Social Citizenship in Crisis?

There are moves across many countries away from state-led provision of services for disabled people towards cash-based systems, which have been welcomed by disabled people as increasing choice and control over services and support, and increasing independence and social participation. However, feminist scholars have long warned about the implications of commodifying care for women, and the possible consequences of substituting cash for services for social citizenship have remained underexplored, for both disabled people generally, disabled women and mothers more particularly, and for personal assistants/care workers. This article will attempt to address that gap by carrying out a comparative literature review and policy analysis of the role of policy development and outcomes in cash-for-care schemes, looking comparatively across policy developments in several countries, as well as developed welfare states beyond Europe to examine: (a) the impact of the tensions between various governance levels, particularly local and national government; (b) the gendered impact of such policies on (for example) gendered divisions of paid and unpaid work, citizenship and social participation; (c) the impact such policies have, or are likely to have, on different groups of men and women across the life course and across different social and economic groups; and (d) how such policies can contribute to the well-being and/or detriment of different groups of women (and men) within different social, political, economic and historical contexts.     

Increasing Choice and Control for Older and Disabled People: A Critical Review of New Developments in England

This paper critically examines new policies currently being implemented in England aimed at increasing the choice and control that disabled and older people can exercise over the social care support and services they receive. The development of these policies, and their elaboration in three policy documents published during 2005, are summarized. The paper then discusses two issues underpinning these proposals: the role of quasi‐markets within publicly funded social care services; and the political and policy discourses of consumerism and choice within the welfare state. Despite powerful critiques of welfare consumerism, the paper argues that there are nevertheless very important reasons for taking choice seriously when considering how best to organize and deliver support and other services for disabled and older people. A policy discourse on consumerism, however, combined with the use of market mechanisms for implementing this, may be highly problematic as the means of creating opportunities for increased choice and, on its own, risks introducing new forms of disadvantage and social exclusion.     

Care: A Critical Review of Theory,Policy and Practice

‘Care’ is a source of critical tension in current social theory, and the policy and practice implications of that tension are evidenced in its current prominence on the political agenda of developed welfare states. This article critically appraises current developments in the theory, policy and practice of care, drawing on interdisciplinary developments in political theory, sociology and social policy. Developing feminist and disability‐rights theories, it explores a critical synthesis of conflicting normative and theoretical positions regarding the giving and receiving of care, and of the ethics and justice of care. It examines case studies of current comparative policy developments across a range of different welfare regimes, including the marketization/commodification and de/re‐familiaization of care, exploring ideological and normative trends in the design of contemporary policies. It discusses the impact of theory and policy on the practice of care, looking particularly at the issue of long‐term care for disabled and older adults. Finally, the authors argue for the development of a citizenship‐based approach to care that decouples it from individualistic and paternalistic paradigms that disempower those who give and receive care.     

Child Welfare in England: Problems, Promises and Prospects

This paper discusses developments in child welfare services in England in recent years and, particularly, the role and contribution of research. It is shown that a more significant and coherent body of child welfare research has been developed, which has linked formally to the policy process. Research programmes in England have highlighted specific problems in three areas: first, moving away from a narrow focus on child protection to an approach that provides broader family support for children in need; second, the absence of policies relating to services for adolescents; and, lastly, problems in the delivery of residential care for young people. A major programme of reform has been introduced by the new Labour government, consistent with research messages. It is concluded that research has had an impact on the development of child welfare services in England, although influencing the structure of services, social work practice and outcomes for young people are highly complex issues.     

Gender Identity and Social Services: Barriers to Care

ABSTRACT

Transgender people seek social services for a variety of reasons. This literature review highlights needs assessments and social science research articles (N = 30) from the last 16 years that demonstrate the many ways in which social services are further revictimizing transgender people. Studies indicate that transgender people often encounter ignorance, hostility, and transphobic environments while attempting to access social services, and these environments can dissuade transgender people from gaining needed care. Suggestions are made to address these inequalities and include simple measures that social service agencies can begin with to make their services more transinclusive. Future research should address the bias in social services more directly and also develop a clear plan of action and best practices to help agencies remove discrimination from social service settings.     

Collective citizenship: From citizenship and mental health to citizenship and solidarity

Although the concept of citizenship is a widely used theoretical framework within political philosophy, its use in the field of mental health remains underexplored. Within this context, citizenship emphasises the social inclusion and participation of people who are marginalized and offers a more social and relational view of services and support for people with mental health problems than has been common in mental health systems of care. At the same time, however, the citizenship approach has operated in the context of systems of care in the United States that favour highly individualized conceptions of, and approaches to, care, and these systems of care operate in the social and political context of highly individualized concepts of the citizen. In this article building on the work of other citizenship scholars, we argue that a collective form of citizenship, grounded in the 5Rs framework, holds the individual and collective in creative tension. Furthermore, the paper applies this model to the domain of mental health, where people are treated in individualistic ways and experience marginalisation, making the collective dimension imperative and promoting participation, empowerment and the contribution for social change to people with mental health problems. Our theoretical framework of collective citizenship, while geared toward the needs of persons with mental health problems, also contributes to recent citizenship theory on the inclusion of marginalized, stigmatised, and excluded groups. We illustrate the application of this approach through an ethnographic-participant observation case study of a collective citizenship group with which we are associated.     

‘Disability is not a word we use’: Social workers' professional judgements about support for disabled young people leaving care

Disabled young people leaving care often experience a more complex transition to adulthood than other youths. Still, policy and services can fail to recognize the intersection between a young person's care experiences and disability. Drawing on data from a qualitative interview study with 14 social workers who work with aftercare in the Norwegian child welfare services, we investigate social workers' professional judgements about support for this subgroup of the leaving care population. Our analysis uses the theoretical construct of institutional logics and shows that social workers did not include concepts of disability in their judgements about support for these young people. Instead, the social workers' considerations were guided by three other organizing principles: a ‘medical logic’, an ‘activation logic’ and an ‘aftercare logic’. We discuss these findings in light of critical disability studies and argue for a more nuanced understanding of disability in social work practice with care leavers. Highlighting disability rights and going beyond diagnosis and categorisations of disabled people can challenge a medical model approach to service provision.     

Access to Disaster Services

ABSTRACT

This study uses geographic and network analysis, and regression techniques, to examine access to services for vulnerable populations in disaster, and offer potential interventions to improve access. The population for this study is 67 organizations providing disaster social services in a U.S. metropolitan area, and an additional 25 organizations which are willing to provide these services but do not have a formal disaster relief function. The findings from this study indicate a lack of relief services for vulnerable populations, including African-Americans, people over 75 years old, and female-headed households with young children. During a disaster, a type of social injustice results from (a) the vulnerability of these populations to disaster, (b) the higher vulnerability to disaster of the areas in which these populations reside, (c) the smaller number of organizations serving these areas, (d) the lower capacities and network interaction of these local organizations, and (e) the formidable geographic barriers slowing redistribution of resources in a disaster. If connectedness of smaller, informal organizations to the disaster network were improved, otherwise isolated organizations could be a source of substantial resources for the metropolitan area. Suggestions are offered for interventions, based on services coordination (Provan & Milward, 1995) and community organization models (Soliman, 1996), for correcting the lack of access to services documented by this study.     

憨老家庭生存状况的个案研究

憨老家庭是指老迈家属照顾智障者的家庭。本研究对憨老家庭物质条件、精神状态、家庭内部支持和家庭外部支持四个方面的生存状况做初步的了解。研究方法：选择三个憨老家庭进行半结构的个案访谈。结果：（1）憨老家庭有居住和经济收入等基本物质保障;（2）老年监护人和残障子女之间有很好的支持;（3）憨老家庭的社会保障和福利主要来源于国家对老年人的政策;（4）社会支持系统对憨老家庭的支持还有欠缺。     

社会工作方法在残疾人福利服务中的应用

我国残疾人社会福利政策涉及残疾人事业的各个领域,而残疾人的特殊困难决定了落实残疾人福利政策并非易事。基于残疾人福利服务工作具有与健全人服务不同的特殊性和复杂性,应将残疾人社会工作作为残疾人福利服务的重要手段,不断实践社会工作方法以适应残疾人服务的发展。本文从论证残疾人社会工作对康复服务的重要意义切入,提出应持续不断发展残疾人社会工作对残疾人的服务和扶助,发展制度化和常规化的残疾人社会工作,逐步解决残疾人及其家庭面临的特殊困难,最终使残疾人更广泛地享受各项残疾人服务的实惠。     

Citizenship, Volunteering and Active Ageing

Many voluntary organizations depend greatly on the unpaid services of older volunteers, a significant number of whom are women. At the same time, shifts in welfare policy have been towards emphasizing individual economic autonomy and self-provisioning, often to the detriment of older, more vulnerable members of society. Using data from an organization working for and with older people in the North-East of England and through in-depth qualitative interviews, our study found that volunteering is an expression of citizenship for older people. In our analysis, we identify two strands in the meanings of citizenship for older people: volunteering as leisure and work, and volunteering as care and civic consciousness. These correspond with liberal conceptualizations of citizenship and republican models of citizenship. Data from our in-depth interviews demonstrate a strong commitment to society and fellow citizens among older people that counterbalances individualistic and instrumental reasons for volunteering promoted by the state and market. Our findings suggest that government views of volunteering as a route to paid work, as a panacea for society and therefore needing to be more 'work-like', are discordant with the perspectives of older volunteers. Rather than the neo-liberal views of the 'citizen-worker' or 'citizen-consumer', citizenship that is based on the 'common good' and feminist perspectives of 'caring citizenship' are arguably more beneficial to society. Finally, we describe the pressures and constraints facing older people that could discourage formal volunteering in the future.     

New Labour, Old Functionalism: The Underlying Contradictions of Welfare Reform in the US and the UK

Through references to Hansard, official papers, Fabian pamphlets and pertinent texts from the fields of politics, sociology and social policy, this piece illustrates the similarities of thought behind the deliberations of New Labour and those of the early American functionalists and their modern-day counterparts. Examination of the rhetoric used by both parties shows that there are three main focal points of comparison. On one level there is a shared belief in the cohesive impetus of realistic 'aspiration' in a stratified society. On another, there is a mutual desire to balance individual 'rights' with communal 'responsibilities'. Finally, there is a common concern over the apperceived problem of the 'underclass' and how to deal with it. On the basis that these interrelated topics influenced social policy through the intensity of debate around them, the piece moves on to set the resultant American and British models of 'workfare' alongside the proposed 'New Deals' of New Labour. This has a threefold purpose. First, by detailing these examples the influence of the likes of Charles Murray and Lawrence Mead in future Labour policy may be observed. Second, the American association is particularly important in that the theoretical basis and practical experience of US social policy in the 1980s can act as an actual, realized example of the problems facing the proposed welfare policies of New Labour. Third, this comparison allows the piece to move on and discuss the failings of such authoritarian welfare programmes in the light of modern capitalism and modern society. In this way a conclusion on the effectiveness of New Labour and its unrealized 'New Deal' for Britain is broached.     

Treatment Barriers to Social and Health Care Services from the Standpoint of Female Substance Users in Finland

Abstract

This qualitative study discusses barriers affecting female substance user’s treatment access to welfare services. The study consisted of seven group discussions and three individual meetings with 13 women in Helsinki, Finland. Institutional ethnography was used as the theoretical framework for the study. The research questions are: (a) What treatment barriers do women face?, (b) What reasons are there for them not receiving services?, and (c) How do the ruling relations coordinate women’s experiences? Women faced multiple barriers affecting their access to services. They could be interpreted as being: determined by the service system, such as a difficulty in meeting the various criteria in order to be granted access to services; determined by the lack of trust; or determined by personal choices. The study suggests that the service system should be organized according to the needs of the service users. Future research is needed to address the questions such as how social and health care services could better co-operate, and how the different sectors of the service system could break down the institutional barriers.     

Nursing Homes in England and their Capacity to Provide Rehabilitation and Intermediate Care Services

The numbers of older people living in residential and nursing home care in the UK have risen exponentially since the early 1980s when the closure of long–stay geriatric wards and changes in social security funding of care home places led to a rapid expansion of the care home industry. While the implementation of the 1990 National Health Service (NHS) and Community Care Act shifted the responsibility for the commissioning and funding of these services to local authority social services departments, the provision of most health services (such as general practitioner care, physiotherapy and specialist nursing services) to nursing home residents remains the responsibility of community–based NHS practitioners. Recently, the attention of policy–makers in the UK has been focused on the need to improve the throughput of the acute sector. Older people who have received treatment but are not yet able to return to their own homes are to be transferred into intermediate care facilities, often by using nursing home beds, with the aim of supporting short–term rehabilitation outside of the acute sector. This paper presents evidence from a study of health service provision to older people living in nursing homes in England. It examines whether nursing homes have the capacity to fulfil the rehabilitation and intermediate care function envisaged by policy–makers. It concludes that shortfalls in the provision of NHS services to nursing homes and difficulties faced by nursing homes in paying for health services themselves may hinder the rehabilitation potential of intermediate care placements in nursing homes.     

Defining responsibility for care: approaches to the care of older people in six European countries

This article examines the social care of older people in six contrasting European countries. Family, institutional and community care are compared, focusing on vulnerability, empowerment and the gatekeeping of resources. The article considers the position of older people in each care system by presenting individual case studies. The six countries include the family-oriented systems of Ireland, Italy and Greece, and the individual-oriented systems of Denmark, Norway and England. To improve the care of older people in any of these welfare cultures, resources need to be developed that work with existing sources of care but extend the rights of older people, at least to assessment and an equitable matching of needs to the care services available. Overall, the different levels of provision of organised social care services are a major aspect of inequality within and between the countries. Whilst there is little prospect for any major policy transfer across national boundaries, there is potential for selective cross-national learning with regard to particular service developments.     

Promoting Personalization in Social Care Services for Older People

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.     

Increasing User Choice or Privatizing Risk? The Antinomies of Personalization

Within a very short space of time, the concept of personalizationhas come to occupy a central place within dominant social workand adult care discourses within the UK. Through an analysisof one influential model of personalization, this paper willexplore the factors behind the concept’s current popularity.I shall argue that this popularity is due primarily to its congruencewith key themes of New Labour thought, including individualization,responsibilization and the transfer of risk from the state tothe individual. I shall conclude that, given its acceptanceof the marketization of social work and social care, its neglectof issues of poverty and inequality, its flawed conception ofthe people who use social work services, its potentially stigmatizingview of welfare dependency and its potential for promoting,rather than challenging, the deprofessionalization of socialwork, the philosophy of personalization is not one that socialworkers should accept uncritically.     

Regional Welfare System Developments in Russia:Community Social Services

Micro-level studies of welfare service developments are largely absent from the literature on Russian social policy issues, which tends to concentrate on macro-level social security arrangements. This paper highlights the emergence of community-based social services in the post-1991 era, examining their development in two provincial Russian cities, based on an empirical study carried out in 1998. The paper adds to a growing literature which seeks to understand "welfare systems" from the perspective of welfare services as opposed to a social security or policy-based approach. It takes a user-group perspective on the services by looking at their use by, and relevance for, disabled children regarded as having learning difficulties, and their families. The empirical data indicate the shape of "new" services in the field sites, the means by which such institutions were maintained and their integration into the welfare sphere as a whole. Their development and maintenance at the local level is explained in part by socio-economic, political and administrative factors in these regions. By highlighting the various factors that help to maintain welfare provision and drive change at the local level, the case studies indicate the possible shape of future welfare developments in Russia as a whole.     

AUSTRALIAN WELFARE REFORM: FROM CITIZENSHIP TO SOCIAL ENGINEERING

This paper examines the changes in the terms of citizen‐state relations that are coded in Australia's current program of welfare reform. It argues that welfare reform entails a shift from welfare as a limited social right of citizenship to welfare as a form of support conditional upon completing specified obligations, and from the provision of support as a cash payment to support coupling cash with personal services. Together, these shifts have the scope transform the relation between citizen and state fundamentally. This is no less than a shift from social policy citizenship in which claimants are presumed to act on their own behalf to paternalistic support and care directed to reforming character and values as well as to meeting need. The paper argues that this shift violates the fundamental equality essential to social policy citizenship.