Personal Views

The new Victorians: community care in the 1990s

BMJ 1998; 317 doi: (Published 19 December 1998) Cite this as: BMJ 1998;317:1738
  1. Jill Chaloner, consultant psychiatrist
  1. BrentwoodEssex

    Just before Christmas 1997 my mother, 88 years old and suffering from Alzheimer's, was admitted to the geriatric ward of her local hospital. She had managed successfully in her own home with brief input four times a day from home care workers, who were subcontracted from a private nursing agency by the local social services.

    After three days on oral antibiotics she was well. The ward sister commented that the social worker seemed to have been waiting for things to break down in order to shift my mother into a unit for the elderly mentally ill. When I telephoned the nursing agency I was told that the social worker was not “happy with the package” but the agency was vague about details.

    The social worker admitted to me that they are trying to cut costs

    Although my mother was now medically fit for discharge, the weeks rolled on due to the social worker's insistence on arranging what was rather mysteriously referred to as an “assessment.” Deprived of all personal belongings, including her outdoor clothes and door keys, my mother became angry and uncooperative. It was at this point that the so called assessments were organised. A senior registrar in psychiatry was shipped in with the (mis)information from the social worker that my mother was violent, suicidal, and at risk in the community. Fortunately, the ward sister told the psychiatrist to contact me for background information, and the fuller picture emerged. An occupational therapist, even when armed with biased information, still felt that my mother could manage in the community. The psychiatrist recommended a return home with the same care package as on admission.

    A discharge date was set and at this point the social worker revealed the truth. Months before the hospital admission, the social services had made an internal decision not to finance the previously existing care package solely on cost grounds. The social worker admitted to me that they were trying to cut costs for the most expensive—that is, the most needy clients. She said that they thought that it would be less cruel to move my mother to hospital, then to a psychiatric unit, rather than straight to the unit from home. It is illegal to move people from their home against their wishes or the wishes of their nearest relative. This attempt to bypass civil rights is particularly blatant since I am a consultant psychiatrist. It could be attempted only if the person was very old, nearly totally deaf, and cognitively impaired.

    I wrote to the local director of social services as well as to the chairman of the local authority, threatening to go public. A telephone call followed immediately, claiming “a terrible misunderstanding.” My mother was discharged with the same home based package as before. One year later she is still managing, and not a single crisis of even a minor kind has occurred.

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    Cost driven care: Victorian style

    There was no single villain of this piece. The social worker who had played such a major role in the game plan was apologetic about what she had felt compelled to do. She later told me that she thought that the spirit of community care had been abandoned. The care system which we operate is made up of a large and complex patchwork of different disciplines and professions. Any individual working within it may perceive themselves as merely a cogin a larger wheel. A decision to cut costs may seem morally neutral at the higher managerial level at which it is first made. Further down the system the human costs of such a decision are felt keenly, but without the perceived power to alter it.

    In my mother's story a sequence of different professionals yielded to a political rather than a medical imperative. They failed to realise this because the requests for intervention were cloaked in politically correct terminology such as needs led assessment, mental health assessment, and daily living skills assessment. The ward sister was the only individual who spoke out honestly and so allowed me to address openly an issue which would otherwise have remained concealed.

    We mock the Victorians for using religiose language to mask cruelty towards people in the form of the workhouse system and the lunatic asylum. These systems were created with an attitude of patronising superiority towards those who were to be helped. They were not “one of us”; they could, therefore, make do with less than us—be herded into institutions capable of providing only the bare necessities. These institutions were cost driven and closed to public view. We claim to be willing to finance a system of community care driven by the needs of the individual. Instead we too have created a cost led system of care in which it is a crime to need too much, and which morally resembles the Victorian approach we affect to despise. Moreover, the public is led to believe that humane principles predominate.

    The new religion of community care has its own platitudinous language which holds no more guarantee of moral rightness than that of the Victorian philanthropists. It may, on the contrary, merely mask what is politically expedient.

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