Community Providers Research Articles

No way out: the delayed discharge of elderly mentally ill acute and assessment patients in north and south Thames regions.

We examined the characteristics of patients occupying elderly-mentally-ill acute and assessment beds in all mental health units within North and South Thames Regions; the proportion of patients defined as no longer requiring acute care (inappropriately located); and the unmet need for alternative service provision these patients required. Of the 1510 patients surveyed, 24.4% (n = 368) were defined as inappropriately located. For inappropriately located patients unable to be discharged home most (52.8%, n = 154) required residential care or nursing-home provision. A large proportion of these patients were very elderly (aged 85+ years), had dementia, and required high levels of supervision. This study indicates that purchasers, mental health service managers and social services departments should devise a more appropriate mix of inpatient and community provision. Particular emphasis needs to be placed on the greater provision of residential care and nursing homes with an appropriate skill-mix to care for this complex care group.

Housing and community care for older people-joint working at the local level

This article looks at prospects for improved housing and community care strategies and provision for older people. The paper outlines five key housing and five key community care issues. It is argued that most of these raise dilemmas relating to joint working and the shifting boundaries between what policy makers define as health, welfare and housing. The article concludes by discussing prospects for the future and claiming that there is some evidence of an emerging shared vision amongst professionals despite the difficult resource climate within which they have to work.

Community health policy and provision in Hong Kong: challenges for 1997 and beyond

As 1997 approaches, and Hong Kong faces reunification with China, the need for a clearly defined health policy that addresses Hong Kong's community health concerns is increasingly apparent. The health consequences of rapid industrialization have highlighted the importance of shifting the present biomedical emphasis in health care towards a primary health care approach. However, unless government responsibility for new policy concerns such as community health is better defined by the current administration, priorities are likely to change after 1997. Analysis of community health policy and provision in the short period remaining before handover is therefore important to chart progress and identify the issues yet to be addressed. By drawing on the experiences of one established community health programme in the non-government sector, attempts to meet the changing health needs of Hong Kong's population are discussed and issues that have implications for the effective delivery of community health programmes in newly industrialized countries are identified.

Community libraries: an alternative to public libraries in Africa

Examines the types of library service provided in Africa with special reference to public library services, and notes that library services left behind by the colonizers are not useful to the mass of the people in Africa today. Suggests the provision of community information outside the library system which will not only provide materials mainly in local languages but also be suited to the levels of the people in the community.

Localities for Epidemiological Monitoring and Health Policy

The impetus behind locality arrangements in Health Districts in the UK is discussed in terms of recent reform of the structure of health services, and in particular the greater stress on primary and community provision, and on health prevention and promotion. Implications for needs assessment and resource allocation are considered. The advantages of using localities for epidemiological monitoring and for assessing inequality are illustrated with a case study of two outer East London boroughs; the reduction of inequity is discussed with reference to the achievement of overall health gain targets.

Resolving London's bed crisis: there might be a way, is there the will?

is the day to day happenings that underlie the MILMIS indicators that are most shocking; these were not captured directly by the survey but came in the form of anecdotes from participants. Some have been highlighted by other commentators (Watson, 1994; Hollander & Slater, 1994). It is common for there to be no admission beds available at all in the South of England. In these circumstances patients, who may be highly distressed or disturbed, may have to be nursed for 24 or even 36 hours In a room in an accident and emergency department while doctors or nurses make numerous phone calls to locate a bed, often at a hospital many miles outside of London. There have been instances where suicidal or dangerous patients have absconded while waiting and others where patients, who would have accepted voluntary admission to their local unit, have had to be compulsorily admitted because they did not wish to go to the distant hospital. While the immediate care of those admitted to distant hospitals may well be adequate, this situation makes a mockery of trust mission statements and commissioning plans that talk of local and accessible services and integration between hospital and community. While not advocating a return to the asylum, it would be difficult to argue that to admit a London resident to a hospital on the south coast is any advance from the days when such patients would have been admitted to the large psychiatric hospitals that ringed London; at least these hospitals had established channels of communication with the local facilities. The MILMIS indicators that relate to ward conditions almost certainly reflect a vicious circle, part of which was described by the Audit Commission (1994). High admission thresholds and few beds concentrate severely ill people on acute units, creating a culture of violence and sexual harassment. Such living conditions are intolerable and not surprisingly many patients will not accept them; those who are not safe to be in the community therefore have to be compulsorily admitted to keep them in hospital (one half of patients were detained under the Mental Health Act; in one service the proportion was two-thirds). In this highly charged atmosphere, containment Is the priority for staff, rather than therapy, rehabilitation and resettlement. This, coupled with inadequate community provision, particularly access to high staffed hostels, delays discharge and further blocks beds (Lelliott & Wing, 1994). Were service planners to design an environment for the treatment of people with schizophrenia on the basis of what is known about the social and environmental factors that contribute to health in such people, the results would certainly not resemble a London psychiatric admission ward. The MILMIS findings about conditions in hospital wards perhaps go some way to explaining why patients prefer community based alternatives to hospital care (Muijen et cd, 1992). Although the MILMIS indicators do not directly inform the debate as to how to resolve the problem for London services, most commentators agree that reducing bed occupancy levels would be an essential element to any plan, but how should this be achieved? The debate has become polarised between those who advocate the apparently simple expedient of creating more beds (e.g. Watson, 1994) and those who hold that the solution lies in creating more effective community services

Childhood burns in Ghana: epidemiological characteristics and home-based treatment

The objectives of this research were to study the epidemiological characteristics and home-based treatment of childhood burns in the Ashanti Region of Ghana. Children aged 0–5 years with a burn history were identified through a community-based, multisite survey. A standard questionnaire was administered to mothers of 630 of these children to elicit information on their sociodemographic characteristics and the circumstances of the burn event. Ninety-two per cent of the burns occurred in the home, particularly in the kitchen (51 per cent) and the house yard (36 per cent), with most of them happening in the late morning and around the evening meal. The main causes of the burns were scalds (45 per cent), contact with a hot object (34 per cent) and flame (20 per cent). ‘Cool’ water was applied to the burned area in 30 per cent of cases. Otherwise, treatment with a traditional preparation was the most popular first-aid choice. Since a considerable proportion of burns happened between meals when children ‘play with fire’ in the house yard, the provision of alternative play activities and community play areas may reduce the incidence of burns to these children. Secondly, we recommend that education on first-aid management of burns be intensified, with special emphasis on alternatives to the use of traditional preparations.

The ‘ward-in-a-house’: Residential care for the severely disabled

This paper is concerned with the care of the most difficult and severely disabled new patients presenting to mental health services in the U.K. Questions of definition will be examined and the clinical and social characteristics of the population discussed. Since the defining characteristics (and prevalence) of this group are strongly affected by the overall service context, the range of community provisions within one health district (Cambridge) will be described. Examples of a new kind of institutional solution-the 'ward-in-a-house'-will then be presented, together with the underlying principles of management and care. The benefits and limitations of the model will be discussed.

Consumer Credit Law, Distributive Justice and the Welfare State

Consumer credit law has historically registered, and been part of, conflict between the interests of creditors and debtors, and this conflict has often represented wider class antagonisms. Many ofthe most far-reaching protections for debtors developed in the USA and Canada, partly as a substitute for the absence of community provision,2 but also as part ofa political and geographic conflict between a debtor and creditor class.3 The importance of credit to accessing basic consumption needs, and as a mechanism for achieving mobility and status has also meant that issues of race and gender discrimination have been an important aspect of credit law in the USA, connecting it to the discourse and struggle over civil rights. It might be expected that conflicts over such 'macro' dimensions of power in credit relations would be linked to 'micro' analysis of power in consumer credit law. However, the dominance of the market failure model in contemporary

Corporate failure as a means to corporate responsibility

Milton Friedman has argued that corporations have no responsibility to society beyond that of obeying the law and maximizing profits for shareholders. Individuals may have social responsibilities according to Friedman, but not corporations. When executives make contributions to address social problems in the name of the corporation, they are doing so with other people's (shareholders') money. The responsibility of corporate executives is a fiduciary one, to serve as an agent for the corporation's shareholders, and to uphold shareholders' trust, which requires executives to maximize the return to their shareholders, who can then, if they choose, contribute their own money to worthy causes. Of course, shareholders face the decision problems inherent in the classic “prisoners' dilemma,” where the choices that are collectively sensible are individually unreasonable. Given their dilemma, shareholders should not expect to be able to control executives sufficiently to make them perfect agents, dutifully seeking to maximize shareholder profits in every decision. But, at least as an ideal, Friedman would argue that executivesshould serve as perfect agents andshould not reduce corporate profits by contributing to social causes. Friedman's critics have focused on the assumptions implicit in Friedman's conceptual framework, one of the more important of which is that executives have no other fiduciary responsibility other that the one they have with their shareholders. The purpose of this paper is to stay within Friedman's conceptual framework and, at the same time, the question Friedman's view on the social responsibility of business, even as an ideal. We do this by focusing directly on how managers will behave, given their status as agents and the extant costs shareholders must incur to closely monitor their executives, and then drawing on important conceptual insights regarding the inefficient provision of community or public goods, best articulated by Friedman himself. Friedman has argued that contributions to many social problems generate positive neighborhood, or spillover, effects. Because of these positive spillovers, a prisoners' dilemma exists with collective rationality calling for everyone to contribute to the solution of a social problem, but with it being irrational from the perspective of each individual to make such a contribution. Once this prisoners' dilemma is recognized, the possibility exists that all shareholders would be worse off if the shareholders of each corporation had the ability to exert perfect control over their corporate agents, thereby preventing them from violating Friedman's prescription for social responsibility by making corporate contributions in excess of profit maximizing levels.

The costs of accommodation and care. Community provision for former long-stay psychiatric hospital patients.

The development of community services to replace two long-stay psychiatric hospitals in the North East Thames Health Authority region of the UK has been the subject of a research programme since 1985. The economic evaluation is conducted by the Personal Social Services Research Unit; research results relating to the first five cohorts of hospital leavers are reported in this paper. When followed up 1 year after discharge, almost half of the sample were living in highly supported residential care units, most of which were managed by district health authorities. More than 40 services provided outside the accommodation facility were used by clients and, although contact with certain professionals remained constant, some changes in service use over time were marked. The average total cost of community care for this group was 493 pounds per week (1992-93 prices), accommodation facility costs comprising approximately 85% of the total. In the new service configuration, district health authorities fund half of the costs of supporting the hospital leavers, 50% less than when they funded long-stay hospital placements. The rest of the funding burden is borne by a range of agencies, resulting in pressure on budgets and staff case loads.

Communication and Collaboration in Community Care for Mentally Disordered Offenders

Mary Barker of Bristol University and Barbara Swyer of the Wessex Project, Winchester identify the short-comings in information-sharing and collaborative planning for community provision for mentally disordered offenders, as illustrated vividly by the inquiry into a fatal attack in London. They spell out the issues for improving practice and describe a current multi-agency initiatve in Hampshire.

A national audit of new long-stay psychiatric patients. II: Impact on services.

This second report of a national audit of new long-stay (NLS) psychiatric patients describes the services caring for the patients and the reasons why patients were still in hospital. Data analyses addressed the prevalence of NLS patients, the residential resources available to services, the distributions of patients within services, clinicians' views as to the appropriateness of current placement and the reasons for any inappropriate placements. The average point prevalence was 6.1 per 100,000 population; it was significantly lower in England and Wales (5.6, s.d. = 3.2) than in Scotland and Northern Ireland (10.7, s.d. = 6.4, ANOVA F ratio = 10.9, P < 0.01). The estimated rate of accumulation was 1.3 per 100,000 population per year. Many English services had very few non-acute psychiatric beds and 31% of English NLS patients, despite their protracted lengths of stay, were housed on acute wards. Assessors thought that 61% of patients would be better placed in a non-hospital setting; 47% were thought to require a community-based residential setting, and of these over one-half were still in hospital because no suitable community placement was available. Many NLS patients remain in hospital because their residential needs are not met by existing community provision.

Asian and black elders and community care: A survey of care providers

Abstract For the increasing number of Asian and black people who are in the older age groups, a factor in multiple disadvantage is marginalisation in community care planning and provision. Asian and black elders are regarded as numerically insignificant, and the stereotype that Asian and black communities have a special capacity to ‘look after their own’ facilitates an expectation that they will make up for deficits in health and social services provision. This article reports on a survey of care providers’ perspectives on the implications of community care policy for Asian and black elders in Bradford. The main lines of argument are that whilst in theory the policy opens up possibilities for ethnic minorities, these can only be realised if it is recognised how problematic the stereotypical expectation is, and that pressures on Asian and black carers and the limitations of the ethnic minority voluntary sector must also be recognised.

A Review of the Applications of the REHAB Assessment System

In the last 10 years, as part of the push towards greater community provision of services for the psychiatrically disabled in the UK, assessment has assumed a prominent position. A variety of different assessment instruments have been employed, including assessment of patient attitudes and opinions, of the environment, social networks and basic living skills (Carson, 1991; TAPS, 1992). Amongst the differing assessment types, behaviour rating scales have a distinct contribution. They are particularly applicable to group settings such as hostels or hospital wards and have the advantage of being objective, behavioural, able to measure change in functioning over time or due to some intervention; and most importantly, they yield numerical scores which can be assessed against “hard data” in the form of norms or scores from other populations, especially those from other countries.

Women—partners in interprofessional care

This article outlines some of the implications for interprofessional care of including disabled women and women carers as equal partners in the provision of community and primary care seruices. Reference is made to the importance of recognising the discrimination against women in many of the current approaches to such partnerships.

A cost function analysis of residential services for adults with a learning disability

Successive UK governments have pursued a policy of community care for people with learning disabilities which, in the past ten years, has led to a marked change in the nature of residential provision. Research evidence on the costs and quality of alternative forms of community provision is inconclusive and contradictory. It is therefore timely to consider whether or not community residential facilities have delivered the expected quality of service at appropriate cost. The paper presents the results of a cost function analysis of a random stratified sample of staffed community facilities in England excluding London. Both costs and quality of care were found to vary greatly amongst community residential facilities. The most important factors explaining differences in cost were case-mix factors relating to client age, dependency and length of stay. Facility characteristics such as the type of building, the internal layout and the structural quality were not significant. Quality of service measures such as the extent to which care-regimes were client orientated and made use of local community services were positively and significantly associated with costs. Type of provider had no impact on costs independent of differences in case-mix and quality of care with the exception of the private for profit sector which appeared less expensive than other agencies. The shortcomings of the methods and implications of these findings for policy makers are discussed.

Learning disabilities. Community homes: institutions in waiting?

This article explores the assumption that community care is better than care in an institution for people with learning disabilities. Parallels are also drawn with community provision of residential and nursing home accommodation for people who are elderly, those who have a physical handicap, and people with a mental illness. While community care is recognised as a valuable option, the authors argue that it must be correctly implemented, and identify the need to move further forward.

An analysis of a new longstay population: the need for mental hospitals

AbstractObjective: The Objective of this study was to analyse the characteristics and disabilities of patients becoming new longstay in a Mental Health District, to describe their needs and define the implications for service development. Method: All patients entering into the new longstay category between January 1st 1981 and December 31st 1991 were analysed. New longstay patients were defined as those remaining continuously in hospital for one year or longer. An accumulated inpatient group, still resident in the hospital, was examined using the Community Placement Questionnaire (CPQ), a standardised questionnaire useful for estimating needs for care and accommodation. Results: The analysis revealed a globally disabled patient group, largely intractable to treatment, the majority of whom required care and supervision in the longterm. An estimate of new longstay bed requirements, based on a stay of 1-5 years, was 11.3 per 100,000 for those under 65. The assessment team categorised current inpatients into four groups with regard to placement recommendations. An analysis of the CPQ results supported these recommendations which were: Specialist Unit for chronically disturbed Geriatrics, Geriatric Unit, High Support Staffed Hostel and Medium Support Staffed Hostel. Conclusions: Despite current service practice and community provision new longstay patients continue to accumulate. Given further specialist alternative community structures, it is suggested that these patient's requirements can be met without the need for continued longstay mental hospital beds.

Case Management

"This paper discusses the advantages and disadvantages of case management systems for the co-ordination of care of people with long-term mental illness living in the community. Many of the principles are equally applicable to other client groups with long-term needs, e.g. elderly people or people with learning difficulties. Some of the historical background to the emergence of case management concepts is discussed, culminating in the recent White Paper on Community Care. The underlying concept of case management is examined, together with a number of fundamental questions concerning who should act as case managers, what kinds of training they will require, problems of inter- and intra-agency co-operation, and the empirical evidence regarding its effectiveness. It is concluded that case management could be an important element in a comprehensive range of mental health services, but it is not a substitute for basic community provisions."