Who pays for community care? The same old question.

Trends in mental health service funding over the past 40 years show that the programme of hospital closures has not resulted in a significant release of resources to fund community based services. Far from being excessive, the current provision of residential services (both NHS and non-NHS) for mentally ill people is now below levels recommended as sufficient by the government, the Royal College of Psychiatrists, and the National Schizophrenia Fellowship. What clinical research evidence there is suggests that more rather than fewer residential places are required. This situation is likely to be compounded by the recent transfer of responsibility for funding private and voluntary residential care from the Department of Social Security to local authority social services departments.     

Difficult relationships--interactions between family members and staff in long-term care

Staff of long-term care facilities and family members have a common responsibility to ensure the best course of treatment and everyday care for residents who often cannot speak for themselves. Understanding the difference between instrumental and preservative care, and who the proper agent is to provide care in each category will not only improve staff/family interactions, but residential care in general. The Resident Enrichment and Activity Program improves the family/staff relationship obliquely by involving family in social activities; the Family Involvement in Care program, and the Patterns in Caregiving program directly target the relationship and involve the facility's administration to effect policy change.     

Allocating resources for health and social care in England.

The fair allocation of resources for health and social care in relation to the needs of the population in different parts of the United Kingdom has become particularly important since the implementation of the new arrangements for community care in April 1993. These depend on close collaboration between health authorities and local authority social services departments. Yet funding reaches these authorities by different means and according to different criteria. Most health authority funds come through a weighted capitation formula that overemphasises the effects of age, while family health services funding is largely not cash limited and hence demand led. Funds to local authorities for community care are being transferred from the social security budget but on a basis that partly reflects past provision of residential and nursing home care. None of these mechanisms responds to underlying needs that give rise to demands on the health and social care system as a whole, and none makes any attempt to compensate for defects in the others. The solution includes better research and a unified weighted capitation system for all sources of funding.     

LOCAL ATTITUDES, MORAL OBLIGATION, CUSTOMARY OBEDIENCE AND OTHER CULTURAL PRACTICES: THEIR INFLUENCE ON THE PROCESS OF GAINING INFORMED CONSENT FOR SURGERY IN A TERTIARY INSTITUTION IN A DEVELOPING COUNTRY

The process of obtaining informed consent in a teaching hospital in a developing country (e.g. Nigeria) is shaped by factors which, to the Western world, may be seen to be anti-autonomomous: autonomy being one of the pillars of an ideal informed consent. However, the mix of cultural bioethics and local moral obligation in the face of communal tradition ensures a mutually acceptable informed consent process. Paternalism is indeed encouraged by the patients who prefer to see the doctor as all-powerful and all-knowing, and this is buttressed by the cultural practice of customary obedience to those 'above you': either in age or social rank. The local moral obligation reassures the patients that those in authority will always look after others placed in their care without recourse to lengthy discussions or signed documentation, while the communal traditions ensure that the designated head of a family unit has the honor and sole responsibility of assenting and consenting to an operation to be carried out on a younger, or female, member of the family. Indeed it is to only a few educated patients that the informed consent process is deemed a shield against litigation by the doctors. This paper later addresses the need for physicians to update their knowledge on the process of informed consent through the attendance of biomedical ethics courses, which should highlight socio-cultural practices that may make this process different from the Western concept, but perfectly acceptable in this setting.     

Community care and social services.

The aim of community care is to enable people with various types of disability to live in their own homes, rather than in institutions. This involves the provision of support and services at home by various agencies. After a critical report in 1986 identified problems with coordination and flexibility of community care services, the white paper Caring for People (1989) stated the government''s aim to provide a "needs led," responsive range of services, promoting maximum independence of those wishing to live at home rather than enter institutional care. New arrangements were introduced in 1993, involving a formal assessment procedure and the production of a personalized care plan for each individual, incorporating services provided by private and voluntary agencies as well as by social services departments. This article describes the components of community care services supplied by local social services authorities, including housing adaptations, equipment, telephones and alarms, home care, meals, and respite care.     

Collaborative Care for Depression in Primary Care: How Psychiatry Could “Troubleshoot” Current Treatments and Practices

The bulk of mental health services for people with depression are provided in primary care settings. Primary care providers prescribe 79 percent of antidepressant medications and see 60 percent of people being treated for depression in the United States, and they do that with little support from specialist services. Depression is not effectively managed in the primary care setting. Collaborative care based on a team approach, a population health perspective, and measurement-based care has been proven to treat depression more effectively than care as usual in a variety of settings and for different populations, and it increases people’s access to medications and behavioral therapies. Psychiatry has the responsibility of supporting the primary care sector in delivering mental health services by disseminating collaborative care approaches under recent initiatives and opportunities made possible by the Affordable Care Act (ACA).     

Falling rate of provision of residential care for the elderly.

The rapid increase in the number of very aged people has not been accompanied by appropriate expansion of local authority residential facilities. The rate of provision in 1976 was already acknowledged to be inadequate, but data are now presented to show that since then there has been an effective fall in the rate of provision of some 9000 places equivalent to, say, 180 old people''s homes of 50 places each. The prospects for the future are even gloomier: public spending cuts and local authority priorities suggest a continuing fall in the rate of provision that can be expected to have a profound effect on the National Health Service, on the burden on families, and on the condition in which old people are obliged to remain "in the community" (where support services have likewise failed to keep pace with demographic change).     

Mental health law: civil liberties and the principle of reciprocity.

At a conference organised by the Law Society, Mental Health Act Commission, and Institute of Psychiatry possible reform of mental health legislation in England and Wales was discussed. It was concluded that radical legal reform was required, and that the law should be designed specifically for provision of care in both hospital and the community. Reform should be based on principle rather than pragmatism, particularly the principle of reciprocity--patients'' civil liberties may not be removed for the purposes of treatment if resources for that treatment are inadequate. Protection of society from nuisance or even violence is insufficient reason for detention. Legal provision for compulsion of patients, whether in hospital or the community, must be matched by specific rights to treatment.     

Contextualizing mobility during the Ebola epidemic in Liberia

Based on findings from focus groups and key informant interviews conducted at five sites in Liberia between 2018 and 2019, we explore some of the key factors that influenced people’s motivation to travel during the 2014–2016 Ebola Virus Disease (EVD). We discuss how these factors led to certain mobility patterns and the implications these had for EVD response. The reasons for individual mobility during the epidemic were multiple and diverse. Some movements were related to relocation efforts as people attempted to extricate themselves from stigmatizing situations. Others were motivated by fear, convinced that other communities would be safer, particularly if extended family members resided there. Individuals also felt compelled to travel during the epidemic to meet other needs and obligations, such as attending burial rites. Some expressed concerns about obtaining food and earning a livelihood. Notably, these latter concerns served as an impetus to travel surreptitiously to evade quarantine directives aimed specifically at restricting mobility. Improvements in future infectious disease response could be made by incorporating contextually-based mobility factors, for example: the personalization of public health messaging through the recruitment of family members and trusted local leaders, to convey information that would help allay fear and combat stigmatization; activating existing traditional community surveillance systems in which entry into the community must first be approved by the community chief; and increased involvement of local leaders and community members in the provision of food and care to those quarantined so that the need to travel for these reasons is removed.     

Equity in community care.

The implementation of the NHS and Community Care Act 1990 made local authority social services departments responsible for the organisation and funding of support and care in the community. This development took effect at the same time as a blurring of the boundaries between health and social care. One consequence is that the relevance of equity (a guiding principle of the 1946 National Health Service Act, but relatively lacking from the 1948 National Assistance Act, the foundation of many social services) has come to be more keenly appreciated within personal social services. Equity questions arise in community care over the distribution of public resources between different client groups, income groups, generations, and localities. Moreover, no mechanisms exist to monitor the trends that emerge from different ways that people get access to care. Yet there is a risk that substantial divisive consequences may occur, particularly between generations.     

Malaria-related health-seeking behaviour and challenges for care providers in rural Ethiopia: implications for control

A range of activities are currently underway to improve access to malaria prevention and control interventions. As disease control strategies change over time, it is crucial to understand the health-seeking behaviour and the local socio-cultural context in which the changes in interventions operate. This paper reflects on how people in an area of seasonal malaria perceive the causes and transmission of the disease, and what prevention and treatment measures they practise to cope with the disease. It also highlights some of the challenges of malaria treatment for health care providers. The study was undertaken in 2003 in Adami Tulu District in south-central Ethiopia, where malaria is a major health problem. Pre-tested structured questionnaires and focus group discussions were conducted among men and women. Malaria, locally known as busa, was perceived as the most important cause of ill health in the area. Respondent's perception and knowledge about the cause and transmission of the disease were relatively high. The newly introduced insecticide-treated nets were not popular in the area, and only 6.4% of households possessed at least one. The results showed that patients use multiple sources of health care for malaria treatment. Public health facilities, private clinics and community health workers were the main providers of malaria treatment. Despite higher treatment costs, people preferred to use private health care providers for malaria treatment due to the higher perceived quality of care they offer. In conclusion, effort in the prevention and control of malaria should be intensified through addressing not only public facilities, but also the private sector and community-based control interventions. Appropriate and relevant information on malaria should be disseminated to the local community. The authors propose the provision of effective antimalarial drugs and malaria prevention tools such as subsidized or free insecticide-treated nets.     

Lessons learned in developing community mental health care in Latin American and Caribbean countries

This paper summarizes the findings for the Latin American and Caribbean countries of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. It presents an overview of the provision of mental health services in the region; describes key experiences in Argentina, Belize, Brazil, Chile, Cuba, Jamaica and Mexico; and discusses the lessons learned in developing community mental health care.     

Frequency and associated factors for care giving among elderly patients visiting a teaching hospital in Karachi, Pakistan

Objective

To study frequency and associated factors for care giving among elderly patients visiting a teaching hospital in Karachi, Pakistan.

Methodology

A cross sectional questionnaire-based study was conducted at the Community Health Centre (CHC), Aga Khan University Hospital (AKUH) Karachi, Pakistan from September to November 2009. All individuals, visiting the CHC and aged 65 years or above were interviewed after taking written informed consent.

Results

A total of 400 elderly completed the interview. Majority were females, 65–69 years age, More than half of the individuals ie: 227 (85%) had received Care Giver experience for assistance and among these 195(72%) had care provided by an immediate family member. A large proportion of them stated that their Care Givers managed to provide less than four hours in a day for care giving. Around 37% showed substantial improvement in their relationship with the care givers. About 70% of the respondents stated that the care provided by the Care Giver improved their quality of life.

Conclusion

Elderly care is provided by majority of the family members resulting in increased satisfaction level, however small number still not satisfied due to unfulfilled need of these older people. This demands that efforts should be made to strengthen the family support by increasing awareness regarding elderly care and arranging support system by the government.     

Community care for the elderly 1976-84.

The aging of the elderly population is of crucial importance as people who are over 80 make far greater use of health and social services than any other age group. Government guidelines on the provision of services, which are generally related to the whole population aged 65 and over, fail to take account of this change in the age structure of the elderly population and are no longer appropriate. Recent trends in the provision of domiciliary services, day care, specialist housing for the elderly, and residential care have been related to changes in the number of potential consumers. Ironically, despite the government''s stated commitment to "community care," the chief growth area has been private institutional care. The number of day care places and sheltered housing units has also increased in real terms, but the provision of domiciliary services, such as home help and health visitor visits to the elderly, has either fallen behind or barely matched the increase in the number of very old people. If community care is to be made a reality and if the present inadequate levels of service are to be maintained, let alone improved, then additional resources, greater cooperation among agencies, and a more imaginative approach to the development and delivery of services are urgently needed.     

Politics, Practical Logic, and Primary Health Care in Rural Haiti

During the 1980s, an ambitious project for health development restructured medical services throughout rural Haiti. The "Rural Health Delivery System" (RHDS) pursued several goals of primary health care, including dispensary-based maternal and child health services and the provision of low–cost drugs. Based on fieldwork in a single village, this article examines how local residents pushed the project in unpredictable and ironic directions. People did not regard dispensary services—which were planned and financed by international health agencies—as essentially foreign elements in the local health–care system. They rather engaged with the dispensary according to long–standing local strategies for prestige and economic advance. Despite the dramatically new shape of biomedicine introduced by the RHDS, the dispensary remained for most people a recognizable arena to gain access to state resources or to contest state control over their lives. The "success" of clinic services, and the "failure" of the project to distribute essential drugs arose more from people's practical routes to symbolic and material power than from the formal plans of health planners or state bureaucrats. This practice-based analysis provides another dimension to both the liberal and neo-Marxist critiques of international health development, [primary health care, community participation, planned development, Haiti]     

Is the money following the clients with learning disabilities?

For the past decade patients with learning disabilities living in long stay mental handicap hospitals have been resettled in the community. Local authorities have also taken on the care of new patients who would once have been long stay residents. The imperfect data that are available suggest that in England about half the residents in mental handicap hospitals in 1981 are now the responsibility of local authorities; the figures for Wales and Northern Ireland are 38% and 33%. Data on revenue suggest that the savings to the health service are much less--perhaps 9% in Northern Ireland and 3.6% in England, although there have also been capital gains through the sale of hospitals. Existing methods of transferring money from health to local authorities--joint finance and "dowries" for individual patients--do not seem adequately to have compensated local authorities. Moreover, as patients still to be transferred are more severely disabled local authorities will require larger sums--about 26 000 pounds per patient per year plus 39 200 pounds in capital. If the government chooses not to transfer these resources from health authorities it will be switching funds away from learning disabled people to other care groups.     

The Karamazov complex: Dostoevsky and DNR orders

Families making difficult end-of-life decisions in the intensive care unit often do not exercise their autonomy in accord with the individualistic philosophic and legal models that currently prevail. Instead, they try to avoid responsibility and deny complicity, even for decisions that they ultimately approve. This paper examines two novels and a recent case from a neonatal intensive care unit that reveal how people actually make tragic decisions for family members. Dostoevsky's The Brothers Karamazov and Kenzaburo Oe's A Personal Matter explore the patterns of communication by which people in such situations test complicity and share or submerge accountability. The psychological similarities between the novelists' portrayals and the actual processes that families undergo in the ICU have practical clinical implications for the ways physicians approach discussions about do not resuscitate (DNR) orders with patients' family members.     

Demand for patient care.

A study was performed to determine the extent to which patients of all types were receiving inappropriate levels of care. The needs of patients in acute and supporting hospitals, people in residential homes, and patients cared for at home were assessed. A sixth of the hospital inpatients did not need hospital care, while 5% of those in residential homes and 5% of those at home did need hospital services. These findings indicate that a realistic provision of hospital beds would be 4 per 1000 population for all specialties except regional specialties, psychiatry, mental subnormality, obstetrics, and paediatrics. About a third of these beds need to be acute, while the rest may be in supporting or community hospitals. Thus the current provision of acute beds (2-0 to 2-5 per 1000 population) exceeds actual need.     

Possible home care in poliomyelitis

THREE MAIN PROBLEMS IN PROVIDING ADEQUATE HOME CARE MUST BE SOLVED: (1) the obtaining of necessary equipment for the patient such as bed, chair, hot pack materials, appliances and exercising apparatus; (2) the training of some responsible member of the family in the care that is required for the patient; and (3) the provision of adequate supervision by the physical therapist and the physician. The provision of these needs requires proper organization of all the persons and agencies in the community that have a contribution to make toward this care.