INTRODUCTION
"A feminist approach should mean more than putting women in the picture. It means criticising and renewing conceptual apparatus and understanding social policy as part of wider social process." [1]
In this essay I shall attempt to analyse some feminist responses to the governmental initiative to shift the emphasis of care for several social groups who are identified as needy from care in institutions to care within the community.
In order to do that, I shall also outline briefly the development of that concept in historical terms and the way in which attempts have been made, in governmental and field levels, to implement the practical implications of the community care concept.
I shall include several instances where community care in practice is discussed to examine some of the theoretical issues involved.
HISTORICAL BACKGROUND
Most commentators on community care view the fiery speech given by Enoch Powell in 1961 as a turning point in governmental policy towards the those which the government recognised at the time as mentally handicapped people. [2]
The big Victorian asylums which had been built with the explicit intention of providing a safe place for people who were perceived not to be able, or want to, deal with the humdrum of daily life, were showing up their implicit content as places in which people were incarcerated and deprived of their civil rights. Psychiatrists like Thomas Szaz and R.D. Laing and sociologists like Ervin Goffman were instrumental in creating ripples amongst official and professional circles by raising questions about the ethical nature as well as the
clinical effectiveness of the treatments people were subjected to in big institutions. [3]
It wasn't until ten years later when the Government have began to show some level of commitment to changing the approach to providing care to the elderly, people with physical disabilities, learning difficulties and mental health problems, through a long sequence of laws, white papers and other governmental publications. For example, the 1971 white paper "Better Services
for the Mentally handicapped" began suggesting dates for a move from hospital to community care. This was followed by a policy of joint funding between the health authority and local authority, starting in 1976, to begin the shift of financial and managerial responsibility to the local authority. The complex restructuring of both services over the last two decades and the complicated
relationship between the two in terms of shared aims and practices have been perceived by critics as inhibitive to the noble intentions of the initial shift. [4]
A landmark in the community care continuum was the Griffiths report published in 1988 which became central to implementing community care policies. The Griffiths report outlines the way in which local government should become responsible for providing care by being a buyer of packages of care from the statutory, private, voluntary and the informal sectors. A year later,
Kenneth Clarke the Health Minister announced the embracing of the suggestions made by Griffiths and the ensuing White Paper, Caring for People, detailed the mechanics through which those were to be implemented in the future. The point of implementation has been delayed until next year. And in the meanwhile, Michael Heseltine admitted in an interview in the Independent that the government intentions with community care, specifically with regard to
psychiatric care, are under threat due to the lack of adequate
provision in the community. [5]
THE CONCEPTUALISATION OF CARE
Underlying this essay is the assumption that women do most of the caring in this society, professionally and informally, as mothers, wives, daughters and sisters as well as care workers in various professions. This assumption is supported by many studies such as Leat,[6] Ungerson, [7] and others. These studies show that men also care, in lower numbers and often in specific circumstances, such as a spouse looking after wife. Considering the higher proportion of women in the population, it is still safe to say that caring is still considered to be a female role.
Hilary Graham differentiate between the public and the private aspects of care in her analysis of the low status of care in society which in turn infers low status on anyone who engages in it, especially women.
"On the one hand, the experience of caring and being cared for is intimately bound up with the way we define ourselves and our social relations. On the other, caring is an integral part of the process by which society reproduces itself, and maintains the physical and mental health of the work force." [8]
She goes on to show how caring, both as a feeling of love and as labour, has become the central component in the process of women defining themselves and their relations to other women, to men and to society at large. Men, on the other hand, are defined in terms of their competitive position in society and as inevitable receivers and beneficiaries of care-by-women. Women are expected
to behave in a caring way from an early age and are not encouraged to shift their emotional inspiration and from the maternal figure, while boys are stigmatised if they do not model their behaviour on that of the father.
She goes on to demonstrate that the material value of caring, as a commodity, is very low, whether it is preformed as an unpaid duty within the privacy of the home, or as low paid occupation outside the home.
It is assumed that since women do the caring, they are intrinsically better at it and furthermore, that they find personal fulfilment in it, on par with the personal fulfilment which men derive from attaining high status positions in society.
This works both ways, so that a woman who chooses to take on 'masculine' vocations, ie ones where the care element is not dominant or significant, is seen as a exception, and as a deviant if she chooses not to take on the role of the carer within her own home on top of that. Caring is thus a way of keeping women away from employment and greater involvement in society's power
structures.
Graham's point is that community care as a policy appears within a particular context where such care is already largely done by women, formally and informally, and the assertion that care is better done within the community and within the home merely reinforces and legitimses a situation which already exploit women as people and as workers. She would argue that the intention
behind community care is not to enable users to become independent members of society, as that would require more resources that the government is prepared to commit as well as radical changes in society's views of its vulnerable members, but rather to shift their dependency from the state unto the community, the family and in the long run to women.
Baldwin and Twigg, as well as other writers such as Pascall explore further the nature of caring as a mechanism through which women maintain men and support their survival and the survival of the very social structures which they are oppressed by. They show how the words 'family' and 'community' are used to conceal the fact that it is women who are central to those social institutions and that by the use of those words, women's labour remains hidden and unrewarded.
They examine the argument put forward by supporters of the community care initiative which says that community care provides people with greater opportunity to exercise more control over their lives and reduce the power of professionals in that context. Accepting that this is so, they ask at what price to
women as carers would this reforms be implemented. It appears that statutory support for carers is more available for male carers. When voluntary networks are relied upon, it is usually women who operate those.
They examine the argument put forward by Finch which suggests that community care cannot but continue to exploit women and therefore care should remain within institutions and conclude that although her perceptions are accurate, collective ways of caring can be alternative to the heavy burden placed on individual carers, usually women. Such collective efforts could be care within communities where the care is both less gender oriented and better appreciated and rewarded, such as in the Jewish community.
Pascall demonstrates the relationship between care and dependency in women's lives when she considers the alternative of community care as a social policy and lamentably accepts that women's exploitation is intrinsic to it, since the family as a unit is seen as the basis for the majority of community care.
"If the dependency of women cannot be wished away, neither can the dependency of most who are cared for. The dependency of elderly and handicapped people is more traditional theme of social policy then the dependency of women... The care of most dependents has been the province of women, has belonged to the domestic arena, and has been unpaid. It has thus made women dependent. At the same time, it is probably correct to argue, as Jane Humphries done, that the family has generally been a more humane setting
for the care of dependents than state institutions." [9]
She goes on to show the hypocrisy with which social policy makers relate to the family. On the one hand, the values of the family as a stable nuclear cell are extolled and both men and women are encouraged or even coerced, through education, to maintain that institution, and at the same time, while making a virtue of women's role in keeping families together, those same policy makers are still failing to create supportive statutory structures for women. They are expected to maintain the family out of duty and love, rather then the agents of the social order which they really are.
"Community Care, then, has flexible meaning. It may be used to contrast with institutions; or to imply informal networks of provision. While the rhetoric changes, the underlying meaning is more consistent. As Finch and Groves put it: 'in practice community care equals care by the family, and in practice care by the family equals care by women'". [10]
Parker enlarges on one of the most important aspects of community care as a social policy: money.
"Since the mid-1970's official policy statements have increasingly argued that not only is the state unable to bear the costs of expensive institutional care, it also cannot afford to provide a comprehensive network of health and welfare services to support the many elderly or disabled people who live outside formal
institutions.” [11]
And what better way of saving money then institutionalising the unpaid care preformed already by women! Parker goes on to demonstrate how, despite the rhetoric, governmental policies fail to provide those networks of support for carers, ie for women, who are now expected even more to shoulder the labour of care.
THE REALITY OF COMMUNITY CARE
The government's real intention in introducing community care has been criticised often. Barbara Hudson from NALGO highlighted that
" The white paper did not acknowledge the need for additional funding to provide services. Neither did it consider how the need would change with the aging population or how the service delivery would be monitored... the rights of clients and of hidden carers were also ignored". [12]
According To Ms. Hudson then, the intention of the government in introducing community care was not for humane motives but rather in service of its market economy ideology, aiming both to boost up the private sector's involvement and by that creating a tiered care system, as well as exploiting the hidden network of carers, mainly women.
One of the main features of community care, as outlines in the Griffiths report is the joining of forces between local authorities and the health authority in purchasing services from the private sector. The government believed that this would not only produce better service in terms of client's choice but would also cut in costs. A recent example from Bexley proved just the contrary. A local company was set to provide residential and day care facilities for more then a hundred people with learning difficulties and after the first year in operation was half a million pounds over spending its two million pounds budget. [13]
The cost of providing a good service proved too high and not only in terms of finance, but merely as a consequence of the elaborate administration involved.
"It is almost inevitable, says Nick Johnson, Bexley's Director of Social Services and Housing, that there will be problems when a local authority joins forces with a health authority which does not have the same flexibility to raise income to meet service needs."
In this case, the health authority has coughed up half of the sum and the other half would have to be raised either privately or through cuts in the new service. Would the health authority do so in the future, or would the service have to reduce its quality and provide inadequate service?
Similar concerns are expressed in other areas where initial attempts have been made to implement community care.
"While a lot of the white paper is welcome, we (Kent's Social Services) are concerned that our overall, continuing strategies should be enhanced - not jeopardised - and that all depends on whether we get enough finance. If not, we cannot pilot the new schemes." [14]
Once the government realises the community care may be more costly if implemented according to the noble principle of improving client's choice, would it provide the necessary funds? Or are we likely to witness grand plans declining fast and worsening conditions for clients, who will by now be tucked away from public scrutiny in the private sector?
This is beginning to happen already, as registered homes owners are facing reduced income as care funding is transferred to local authorities from social security and are responding with lowering of standards. Local authorities are struggling to maintain appropriate level of inspection and abuse is likely only to be reported by relatives, if there are any. And those relatives will be under greater pressure to assume responsibility for the care of their dependents as public alternatives are being as abolished one by one. [15]
Further proof of the government's lack of sincerity is the treatment that advocacy groups receive in their applications for grants. There can be no clearer expression of client's choice then an advocacy group but recent experience show that such groups are being given lip-service size grants which almost
guarantee that those groups will not be able to function properly unless they remain heavily reliant on informal and voluntary support, ie women. [16]
Wilson sees this exploitation on women as deliberate.
"One way of looking at social policy would be to describe it as a set of structures created by men to shape the lives of women." [17]
She goes on to say that whether policy makers reproduce traditional views and roles for women consciously or not, the end result operates both in the way those policies are shaped and carried out.
She demonstrates how the notion of integration has been a central one within social policy thinking this century. Social policy has been aiming to preserve, through integration, the role and stability of the family, and women's role within it.
Community care as a social policy is in danger of becoming a vehicle to shifting responsibility away from the public domain into the private, family domain. Community care as a policy celebrates the role of the family in looking after the needy. Wilson puts this in historical perspective and shows how the achievements of the feminist movement of the 60's through its attempt to do away with the family as the only symbol of women power and autonomy in society are threatened by a policy which transfers responsibilities to the family without providing adequate state provision and support on the one hand nor actual recognition of the significant role which women will have to play
within community care.
The strongest argument for community care, outside being a money saving exercise, is that it will provide consumers with a better service and greater choice. Pidgeon highlights several occasions where clients are in danger of actually losing out by moving into community care. [18]
Areas such as free chiropody, free outings, library service where the librarians are aware of the special needs of the users are just a few of the examples he highlights. Who will provide those services in the community? And if they are
provided, who will pay for them? The informal carers?
He alarms us of the danger that clients may be impoverished, both financially and socially, by the move out of institutions while the service as a whole will indeed save money and therefore show the exercise to be working well.
Another issue in community care is the transfer of power from the medical hierarchy to a care management structure which is more multi-disciplinary one, as well as the transfer of power from a government department to a local authority. Sue Lieberman reports from Scotland where community care is already in full implementation:
" There is more then a suspicion that, despite good intentions at the grassroots (ie informal carers), the community care agenda in the grassroots (ie informal carers), the community care agenda in the grassroots (ie informal carers), the community care agenda in the grassroots (ie informal carers), the community care agenda in Scotland is being deliberately undermined by a combination of medical resistance to transfer of resources into the community and government unwillingness to support local authorities effectively in their lead role. [19]
It is becoming clear that the community care initiative will be difficult to implement with its full agenda of clients choice for another reason, which is the reluctance of the medical profession to let go of their authority. [20]
" Most developing care management systems in Britain appear to operate within the medical-psychiatric paradigm... which invalidates parts of the mentally ill person's experience and insists that the person accepts the externally imposed definition of this experience..."
Ward reinforces the point that community care is rhetoric created to create heavier reliance of existing informal and familial networks of support (women) by showing the little support government intends to give voluntary organisations and advocacy groups. [21]
Finch outlines the way in which community care has changed its emphasis since the 60's from being care in the community to care by the community. She claims that since this shift has occurred the meaning of community care has become obscured and misleading.
" The range of services which can variously be put under this heading is so diverse as to make the term useless as a description; and the use of 'community care' as a concept has shifted so fundamentally from care in the community to care by the community to the interweaving of statutory, voluntary and informal services, as to make it only useful as a means of obscuring the real issues rather then illuminating them." [22]
In this instance, Finch does not advocate an abandonment of the community care model as she has done elsewhere. She takes a more pro-active approach and suggests the areas that feminists need to be aware of in implementation and developing of community care practices.
" This is a matter of overcoming a situation in which equal opportunities policies in one area are undermined by policies in other areas which effectively make women's lives more confined... Specific to the field of community care... changing the terms in which the debate about these issues is conducted. The most limited forms of concrete changes would entail the promotion of different forms of community care which encourages men to take on unpaid caring tasks in equal numbers to women, for example, by greatly increasing the financial support available to carers."
CONCLUSION
Feminist criticism of community care is based on the existing exploitation of women who are seen in society as natural carers. The government initiative is seen as more then its apparent drive towards increasing the choices of the users but rather as away of reinforcing a situation where one group of needy people would become more dependent on another group of socially exploited people, marginalising both and creating a situation wherein future improvement would be totally dependent upon individual initiative and enterprise, concepts well integrated into current thinking.
The feminists critique would claim then that in order to improve care for users, more fundamental changes are needed then those suggested through the recent legislation and the ensuing implementation. These changes would have to include a shift in the social value of care as a commodity and a vocation through educational and legislative efforts so as to divorce the image of care from the image of woman-as-natural-carer. Also, as an interim measure, adequate state provision and welfare support network would have to be provided so as to prevent a situation wherein care standards are falling as a result of tucking them away from public notice.
Whether these changes are likely to occur is a matter of skeptic speculation.
REFERENCES
[1] Pascall, G. (1986), Social Policy, London: Tavistock Publications, p. 19. [2] Ramon, S. (1988), 'Community Care in Britain' in A. Lavender and F. Holloway, Community care in Practice, Chicester: John Wiley & Sons. [3] Goffman, E. (1961) Asylums, Harmondsworth: Penguin. [4] Philipot, T. (1989), 'Birth of a Nation', in Social Work Today, 30th November 1989, p. 1. [5] Hall, C (1992), 'Ministers Act on Mental Care' in The Independent, 20th January, 1992, p. 1. [6] Leat, D, and Gay, P. (1987) Paying for Care London: Policy Studies institute. [7] Ungerson, C. (1987) Policy is Personal, London: Tavistock. [8] Graham, H. (1988), 'Caring: a Labour of Love' in J. Finch and D. Groves (eds.) A Labour of Love, London: Routledge. [9] Pascall, G. (1986), pp. 30-31. [10] Pascall, G. (1986) p. 87. [11] Parker, G.(1990), With Due Care and attention, London : Family Policy Study Centre. [12] Dawney, R. (1990), 'Plans equal exploitation' in Social Work Today, 13th June 1990, p. 5. [13] Fry, A. (1990), 'The perils of Griffiths', in Social Work Today, 29th March 1990, p. 7. [14] Downey, R. (1990), 'Ready, Steady - Stop?' in Social Work Today, 13th July, 1990, p. 9. [15] Heptinstall, D. (1990), ' Residential Privation' in Social Work Today, 2nd August, 1990, p. 9. [16] Booth, W. (1990), 'Dependent, Frustrated and Devalued' in Community Care 13th December, 1990, pp. 23-25. [17] Wilson, E. (1983), 'Feminism and Social Policy', in M. Loney, D. Boswell and J. Clarke, Social Policy and Social Welfare, Milton Keynes: Open University Press, pp. 33-47. [18] Pidgeon, J. (1991), 'Unseen Benefits' in Social Work Today, 28th November, 1991, pp. 24-27. [19] Leiberman, S. (1991), 'At Sea Without a Captain', in Community Care, 25th July, 1991, pp 9-10. [20] Pelikan, C. (1991), 'A Marriage of Convenience?' in Community Care, 19th September, 1991, pp. 17-20. [21] Ward, L. (1991), ' Having a Say in Community Care' in Community Care, 11th April, 1991, p. 19. [22] Finch, J. (1990), ' Community Care in Britain' in C. Ungerson (ed) Gender and Caring,New York:Harverster Wheatsheaf, pp. 34-57.
Written in 1992
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