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.     

Hunting the gowk?--Psychiatric community care in Scotland.

The implementation of the community care changes throughout the United Kingdom from 1 April will mark the culmination of a series of major health and social care reforms. The avowed aims of achieving value for money and improved consumer choice through the introduction of competitive internal markets have yet to be tested. The political complexion of Scotland means that any proposed change to the NHS has tended to be greeted with a mixture of suspicion and resistance. As a result very few self governing trusts and fundholding general practices exist north of the border. And although Scotland has not had a wide reaching policy of moving psychiatric patients out of hospitals, community care for mentally ill people has advanced spontaneously.     

Madness and care in the community: a medieval perspective.

Care in the community for insane people today is more a matter of expert provision than communal support. In consequence, although they are no longer confined to hospital, mentally ill people largely remain marginalised in a society that does not have the resources, nor often the inclination, to take responsibility for their care. The experience of insane people in medieval England seems to have been of a different order, as shown by a particularly well documented case dating from 1383. From the late 13th century congenital idiots were protected by law. Care of lunatics, by contrast, was primarily the responsibility of the family. However, where the family could not or was unwilling to provide, provision was made by the crown. Through the instrument of the inquisition, the diagnosis and social circumstances of each case were determined by commissioners in consultation with a local jury and all interested parties, including the subject himself or herself. The best interests of the subject remained a prime concern, and the settlement that was ordained was tried and enforced in law. The process was confined to those with real or personal estate, but it encompassed poor as well as rich and proved, through the close identity of the local community with the process, to be a sophisticated and effective mechanism for maintaining and sustaining insane people. Unlike today, care in the community was a communal activity that ensured a truly public provision for those who could not look after themselves.