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Essay: Exploring the Overview, Changes & Impacts of the 1990 Community Care Act

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The 1990 NHS and Community care act was brought about the biggest change in how the NHS and Community care was run since the 1946 Act that founded the NHS (Glennerster, 2007). It completely restructured the way the NHS and Community care is funded moving control of money to local authorities, who were to purchase the appropriate care necessary creating the purchaser/provider split. This in turn aided in the expansion of primary care services improving treatment that could be provided at a local level helping lessen the amount of referrals sent to secondary care providers that would not require hospital admission. Individual rights are introduced giving the individual more control over what care they receive and in making their own decisions it also gives each individual the right to be assessed by Social Services if there “appears to be a need” (NHS and Community Care Act, 1990) The Act aimed to deinstitutionalise long term care and focus more on providing domiciliary services allowing people to stay in their own homes.

The 1990 Act completely changed the NHS funding structure from being government controlled to NHS trusts and GP fund holders. Local authorities were given control of the money the government allocated to them to be used to purchase services promoting the independent/private healthcare sector (Easterbrook, 2003). The creation of GP fund holders, gave fundholding practices the ability to allocate funds for different services. GPs with more than 9,000 patients, later amended to 7,000 patients could apply to become fund-holders and control their own budget (Glennerster, 2007). This meant that the primary care provider could cover more treatments. For example GP practices could employ their own physiotherapist, podiatrist, Chiropodist. Counsellors could also be employed allowing basic mental health issues to be treated through primary care (Palgrave Macmillan, 2003). Patients had better access to services as the treatments would be locally placed and easier to get to without having to be referred to a hospital, this budget also included funds for any drugs dispensed (Glennerster, 2007). These later became Primary care Trusts (PCT’s) which were grouped by area and responsible for providing primary care through contracts with GP’s, Opticians, Pharmacists and Dentists etc. (Michael & Irving, 2009).

The 1990 Act promoted community home care including domiciliary, day and respite care that can allow people to remain in their own homes (Easterbrook, 2003). This policy meant that more focus was put on keeping people at home and less on service users being moved into long term hospital care or residential and nursing homes. The 1990 Act aimed to deinstitutionalise care by moving from long stay hospitals to independent nursing homes and home care (Michael & Irving, 2009) ,this was to be achieved by providing assessments for service users to be undertaken in order to provide better packages of care for the individual along with better case management (Easterbrook, 2003). The Care programme approach (CPA) was implemented in 1990 this enabled people suffering from severe mental health problems to move from hospital into supported or their own housing (Easterbrook, 2003). The act also outlines the responsibilities each agency holds and makes them accountable for the care they provide (Easterbrook, 2003) as a result along with being in charge of commissioning care, local authorities also had the responsibility to set up an “arm’s-length agency to inspect premises in which care was being provided” (Glennerster, 2007, p. 209). This was to ensure that the care being purchased was within standards and to ensure patients were receiving the correct amount of care and to a high quality.

Before the 1990 act Social Services would provide funding for residential care if your income was below a set level however it was more difficult to get funding for domiciliary care to remain in your own home. The 1990 act allowed more funding to be put aside for domiciliary care. According to Balloch and Hill “Between 1991 and 2001, over half the local authority-run  homes in England closed, with an increase in independent residential homes of 12%” (2007, p22) by 2005 88% of residents in residential homes funded by social services were in independently run homes (Balloch & Hill, 2007). There is evidence that the 1990 Act was successful in increasing domiciliary care between 1992 to 1997 there was a decrease in people receiving two hours or less in care but an increase in people receiving five hours or more (Palgrave Macmillan, 2003). However while the 1990 Act increased home care access for people requiring help with personal and medical care there is a very limited amount of help for household tasks, gardening and shopping that would prevent people from deteriorating into a state where more intensive care is required (Balloch & Hill, 2007). It also did not prevent the rising number of people entering residential care as in many cases it was cheaper and more effective for patients requiring intensive care to be moved into an appropriate home (Balloch & Hill, 2007).

Individual rights is one of the main policies implemented by the 1990 Community Care Act it gave individuals the right to assessment if there “appears to be in need” (NHS and Community Care Act, 1990). Local authorities are responsible for assessing peoples’ needs and purchasing appropriate care. The guidance created in 1991 in order for these assessments to be given out include needing to take into account both the wishes of the individuals and their carers, this allows the right level of care to support both. It also focuses on the assessment being the appropriate level for each “individual’s circumstances and needs” (Easterbrook, 2003, p. 151). Individual rights also covers enabling the individual to “live a full life in the community and to be in charge of their own lives” (Palgrave Macmillan, 2003, p. 226). Assessments cover what is classed as community care provided under the National Assistance Act 1948, section 45 of the Health and Public Health Act 1968, section 21 of the NHS Act 1977 and, section 117 of the Mental Health Act 1983 (Easterbrook, 2003).

The 1990 act gave rise to the Multidisciplinary Team (MDT) this brought about changes both in the hospitals and in the community. The MDT would be made up of different services depending on what each patient is being treated for; a cancer patient for example would be involved with oncologists, surgeons, and radiographers, whilst a geriatric patient requiring community care would be involved with physiotherapists, occupational therapists, G.Ps and nurses (Day, 2006). A multidisciplinary approach to community care aimed to provide a more cohesive service with better communication between services whilst the intention of this is to bring both health and social care together the health aspect does take priority resulting in assessments focusing on physical needs and less on people who need support with more cultural and emotional needs (Palgrave Macmillan, 2003) the exception being the community mental health services which may provide their own assessments under the Mental Health Act 1983 (British Medical Journal, 1993; Balloch & Hill, 2007).

There are certain challenges that were found after the implementation of MDTs’ mainly the coordination of meetings and committing the time and resources to them (Day, 2006) this issue arose in the mid 1990’s after the implementation of the act especially with regards to the needs assessments, as local authorities would only give assessments to individuals they felt would qualify due to insufficient budget and a lack of resources provided to the local authorities meaning they were forced to prioritise individuals (Easterbrook, 2003).

In conclusion the 1990 NHS Act brought about several key principles and policies. The chief of these being the overhaul of the structural funding of the NHS and the creation of NHS trusts, GP fund-holders and the purchaser/provider split. The key change in policy being the move from long term institutional care to community care with emphasis on providing more domiciliary care in the patient’s own home. This was implemented through the act by placing the responsibility to assess all users where there “appears to be a need” (NHS and Community Care Act, 1990) to the local authorities. Individual rights was the principle that allowed the individual to request their own assessment and meant both the individual and their carers could convey their wishes helping create a package of care appropriate for each patient, the multidisciplinary team was a key part of ensuring that all needs are taken into account. The creation of GP fund-holders also helped in preventing institutionalisation as it allowed the primary care providers to treat a wider variety of ailments through the purchasing of additional services including community mental health care and local based physiotherapy, podiatry and other services lessening the burden of treating minor ailments in secondary care hospitals. However there were some issues with the way the 1990 act was implemented the biggest problem being that local authorities were not given sufficient budget to provide assessments and packages of care for everyone leading to assessments only being given to those the local authority thought would qualify and not everyone as the act intended (Easterbrook, 2003). Another problem with the assessments being the emphasis on health care and less on preventative care that would allow the user to remain at home such as assistance shopping and gardening (Balloch & Hill, 2007). The act did succeed in increasing care provided at home and whilst over half of social service run care homes closed an increase was seen in the independent sector especially as by 2005 88% of patients in care homes funded by social services were in independent care homes (Balloch & Hill, 2007). Overall the act achieved its main aim of deinstitutionalising care but was unable to provide assessments and correct packages of care for everyone despite moving into the independent sector due to insufficient finding and difficulty assessing people correctly despite multidisciplinary teams.

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