Table of Contents
The Core Definition: Shifting from Institutions to Domiciled Care
The policy known as Care in the Community (often referred to interchangeably as Community Care or Domiciled Care) is a fundamental British policy of deinstitutionalization. Its central mandate is the provision of treatment, support, and long-term care for individuals with physical or mental disabilities within their own homes or local community settings, rather than within large, geographically isolated long-stay institutions. This policy represents a profound philosophical shift in welfare provision, prioritizing individual autonomy, quality of life, and integration into society over the standardized and often criticized environment of residential establishments. The fundamental principle underlying this concept is the belief that maintaining individuals in familiar surroundings is not only morally superior but also promotes better psychological and social outcomes than institutional confinement.
The core objective of the Community Care policy has consistently been to minimize the use of long-stay institutions and maximize the capacity of domiciliary services. This objective was rooted in both humanitarian concerns and the perceived economic advantages of decentralized care. Early assumptions, such as those summarized by the Guillebaud Committee in 1956, suggested that developing robust domiciliary services would constitute both an ethical measure—allowing people to lead preferred lives—and a genuine measure of economy. However, the eventual implementation of the policy revealed complex tensions between these moral aims and the financial constraints imposed by government reforms, particularly concerning the boundary between free National Health Service (NHS) care and means-tested social care.
Three key structural objectives dominated the implementation of the Community Care policy in the late 1980s and early 1990s. First, there was an overriding need to cap public expenditure, particularly on independent sector residential and nursing home care, which was achieved by transferring budgetary responsibility to cash-limited local authorities. Second, the policy aimed to develop a mixed economy of care, actively promoting a variety of providers including independent organizations, voluntary groups, and private entities, alongside residual public provision. Third, a crucial, and often contentious, objective was redefining the boundaries between health and social care, shifting much of the continuing care responsibility for elderly and disabled populations from the NHS to local authority social care departments.
Historical Context: The Drive for Deinstitutionalization
The political momentum for deinstitutionalization gathered significant pace following widespread criticism of institutional conditions during the 1960s and 1970s, which exposed issues of neglect, abuse, and poor standards of care within long-stay hospitals. Despite these criticisms, significant policy change did not materialize until the 1980s, under the Conservative government led by Prime Minister Margaret Thatcher. A pivotal moment occurred with the publication of the Audit Commission report, “Making a Reality of Community Care,” which provided a clear blueprint advocating for the advantages and feasibility of domiciled care, thereby giving the necessary bureaucratic and financial justification for adopting the new policy.
The shift was heavily influenced by the prevailing political ideology of managerialism, which sought to solve public sector problems through strong, effective leadership, management structures, and the application of business principles. This ideology suggested that the inefficiencies plaguing the Welfare State could be rectified by clearly defining responsibilities, separating purchaser and provider roles, and devolving budgetary control. This context set the stage for a systematic examination of the disorganized state of long-term care, particularly the ambiguous “no-man’s land” situated between the NHS and local authority social services.
The resulting policy architecture sought to resolve this ambiguity by assigning clear leadership. The government aimed to move away from a model where the state was simultaneously funding, providing, and purchasing care, towards a model where the state acted primarily as an enabler, commissioning services from a diverse range of independent providers rather than being the direct provider itself. This separation was intended to foster competition, increase efficiency, and ultimately lead to better outcomes, although these expectations were met with considerable skepticism and challenges during implementation.
Operationalizing the Policy: The Mechanism of Financial Restructuring
The practical application of Care in the Community relied fundamentally on a restructuring of how care was financed and allocated, which serves as a critical real-world example of the policy’s mechanism. Before the reforms, the long-term care of dependent groups was often provided directly by the NHS or funded through the social security system, leading to uncapped expenditure and a lack of local accountability. The new mechanism, formalized by the 1990 Act, transferred the responsibility for assessing individual needs and commissioning tailored packages of care to local authority Social Services departments.
The application of this principle can be illustrated through the following operational steps:
Needs Assessment: An individual requiring long-term support (e.g., an elderly person needing assistance with daily living) is assessed by a local authority social worker, rather than solely by a health professional. This assessment determines the specific level and type of support required, focusing on whether the need constitutes health care (free via NHS) or social care (potentially means-tested).
Care Management and Package Design: Based on the assessment, the local authority Social Services department, acting as the purchaser, designs a “flexible package of care.” This package might include domiciliary visits, day care, or respite care, utilizing the cash-limited budget allocated by central government.
Commissioning from the Independent Sector: The local authority then commissions these services from the most appropriate provider, which is often a private company or a voluntary organization. This mechanism promotes the mixed economy of care by ensuring public funds flow to independent sector providers, reinforcing the state’s role as an enabler rather than the primary provider.
Financial Consequence: Crucially, since the care is defined as social care and is provided by the local authority, the recipient often faces means-testing and may be required to contribute financially to their care package, a significant distinction from the free-at-the-point-of-use principle of the NHS.
This step-by-step process demonstrates the policy’s central aim: shifting the financial burden and responsibility for long-term care away from the centrally funded NHS and social security system toward locally managed, cash-limited, and means-tested social service provision, thereby capping public expenditure while theoretically offering more personalized care.
The Griffiths Report and the Call for Action
The catalyst for the structured implementation of these reforms was the 1988 report by Sir Roy Griffiths, titled “Community Care: Agenda for Action,” commonly known as the Griffiths Report. Griffiths, who had previously advised the government on NHS management, was deeply influenced by the managerialist conviction that organizational problems could be solved through effective leadership and clear lines of responsibility. He was tasked with examining the entire system of community care, which he famously described as “everybody’s distant cousin but nobody’s baby,” highlighting the lack of clear accountability for dependent groups such as older people, the disabled, and the mentally ill.
To resolve this organizational paralysis, the Griffiths Report made six key recommendations designed to define ministerial and departmental authority. These included establishing a Minister of State for Community Care to ensure implementation, and fundamentally assigning the key role in community care to Local Authorities—specifically the Social Work/Services departments—rather than Health Boards. This clearly delineated the roles: Social Services would handle long-term and continuing care, while Health Boards would focus on primary and acute care.
The report also stipulated the specific duties of Social Service Departments, requiring them to assess the overall care needs of their locality, establish mechanisms for assessing individual needs, and, based on those needs, design the flexible packages of care mentioned above. Furthermore, it strongly advocated for promoting the use of the independent sector by mandating collaboration with and maximum use of voluntary and private welfare organizations. Although Griffiths intended to place community nursing staff under local authority control to consolidate responsibility, this specific recommendation was ultimately rejected by the government, indicating a tension between empowering local government and strengthening central control over health services.
Significance and Impact: Evaluating the Reforms
The significance of Care in the Community lies in its profound, yet controversial, restructuring of the UK welfare state, formalized by the National Health Service and Community Care Act 1990. This legislation fundamentally altered the relationship between the state, the individual, and the provision of long-term care. It successfully established the mixed economy model and the purchaser/provider split, which remain central tenets of UK public service delivery today, extending beyond just social care. The policy’s primary impact was achieving the goal of capping public expenditure on residential care by transferring the financial risk to local authorities and shifting costs onto individuals through means-tested social care charges.
However, the impact of the reforms, operational since 1993, has been highly contested. Critics, such as Hadley and Clough (1996), argued that the reforms created “care in chaos,” characterized by inefficiency, unresponsiveness, and a lack of equity and choice, largely due to chronic underfunding by central government. These authors claimed that while the idea was conceptually sound, the enthusiasm of local authorities was undermined by vested professional interests, poor collaboration between health and social services workers, and a service legacy that resisted radical change.
Means and Smith (1998) provided a more nuanced critique, suggesting that the new system of resource allocation was no better than the bureaucratic systems it replaced. They emphasized that the lack of commitment from social services, combined with the severe underfunding, prevented the policy from fulfilling its humanitarian promise. Despite these structural failures, the voluntary sector was often cited as the main beneficiary, as the drive to develop a mixed economy provided increased opportunities and funding streams for third-sector organizations to deliver domiciliary services. The political fallout culminated in 1998 when the Labour Health Secretary, Frank Dobson, declared that the “care in the community programme launched by the Conservatives had failed,” particularly in relation to vulnerable populations.
Connections and Relations: Mental Health and the Broader Category
Care in the Community belongs primarily to the subfield of Social Policy within applied psychology, though it has profound implications for Clinical Psychology and Community Psychology. It is intrinsically linked to the global movement of deinstitutionalization, a broad trend across Western nations aimed at closing large psychiatric hospitals and moving patients into community settings, beginning in the mid-20th century. In the UK context, the policy is inextricably tied to the structure of the National Health Service and the evolving role of local governance.
The policy’s connection to mental health care is particularly sensitive. Under the 1990 Act, individuals with mental health problems were expected to receive treatment while remaining in their homes, a significant step toward integration. However, this transition raised considerable public concern following high-profile acts of violence perpetrated by a small minority of former psychiatric patients, leading to intense scrutiny of risk management protocols. While the legislation mandated individual assessment and assignment of a specific care worker—and placement on a Supervision Register for those presenting a risk—system failures often resulted in vulnerable patients “slipping through the net,” leading to homelessness and inadequate ongoing support.
Furthermore, the policy is relationally defined by its critical distinction between health care and social care. The definition of whether a required service is “health” (free) or “social” (chargeable) determines the financial outcome for the dependent person. This definitional boundary creates systemic friction between Health Boards and local authorities, frequently leading to arguments over who should bear the cost of continuing care, a problem the Griffiths Report explicitly sought, but ultimately failed, to eliminate fully.