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1990 10: 58Critical Social PolicyMary Langan

Community care in the 1990s: the community care White Paper: 'Caring for People'  

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Community care in the 1990s: thecommunity care White Paper: ’Caring forPeople’MARY LANGAN

Abstract

This article summarises the main proposals of the government’s November1989 White Paper Caring for People. It traces the background to the cur-rent drive towards community care, emphasising the phase of austerityand privatisation inaugurated by the 1988 Griffiths Report. It assesses thelikely consequences of the White Paper, now incorporated into a joint par-liamentary bill with the government’s plans for the health service, givingparticular attention to the consequences for women, ethnic minorities andvoluntary organisations

The much delayed White Paper on community care - Caring for people: com-munity care in the next decade and beyond - was finally presented to Parliamentby the Secretaries of State for Health, Social Security, Wales and Scotland inNovember 1989. In its main proposals it follows the report Community care: anagenda for action produced by Sir Roy Griffiths in 1988, which in turn was aresponse to the 1986 Audit Commission report, Making community care areality. Griffiths was appointed by the Prime Minister to investigate theAudit Commission’s complaints that care in the community was fragmentedand poorly co-ordinated between health and social services authorities. Hewas also charged with finding an alternative to the way in which social secur-ity payments were providing a ’perverse incentive’ to private residential carefor older people. Though Mrs Thatcher was thought at first to lack enthus-iasm for Griffiths’ proposal to give local authorities a central role in adminis-tering community care and in rationalising expenditure on residential homes,she finally endorsed his approach, which permeates the recent White Paper.The White Paper reaffirms the government’s commitment to promoting

care for the older people, people with mental illness, disabilities or learningdifficulties in the community, preferably in their family home or in a ’homelyenvironment’. It recommends a transformation in the role of local authoritysocial services departments from that of service providers to that of ’enablingagencies’, concerned with assessing need, planning services and promoting

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consumer choice among a range of public, private and voluntary organisa-tions. It proposes a new funding structure which removes the financial incen-tive towards residential care and gives local authorities financial responsibilitythrough a ’single unified budget’ for the care of older people whether theyare in residential care or remain in the community.The White Paper emphasises that the government’s aim is ’to promote choice

as much as independence’, and to ensure this local authorities are instructed ’tomake maximum use of the independent sector’. They are also instructed to pro-vide the Secretary of State with whatever reports and information he requires sothat he can ’issue directions and give guidance over the full range of personalsocial services activities by local authorities’. They are warned sternly that ifthe minister is displeased, he ’will not hesitate to intervene in order to stim-ulate improvements’. The White Paper thus offers a striking Thatcheritesynthesis of the principles of the free market and the attitudes of a strong state.The community care White Paper has been welcomed by many social ser-

vices directors and health authority managers, by entrepreneurs in the bur-geoning private welfare sector and, in more qualified terms, by some of thelarger charitable voluntary organisations. However among professionals atthe sharp end of care in the community, workers in the more grass rootsvoluntary organisations, groups representing women, black people and eth-nic minorities, and groups including service users and carers, the WhitePaper has been greeted with apprehension. For these groups the crucial fea-ture of the White Paper is that it proposes changes in the administration andfunding of community care without recommending any increase in the overallresources available - at a time when demographic factors are conditioning asteady increase in demand for all forms of social care. There is also a generalconcern that the White Paper has made little concession to demands to makecommunity care more accountable to users and carers and more open topopular participation. Black and ethnic minority organisations have identi-fied a continuing failure to make the provision of community care moreresponsive to the particular needs of black and ethnic minority communities.However, the government has characteristically paid little heed to critical

voices and has already introduced a joint parliamentary bill, bringingtogether the main recommendations of the community care and health ser-vice White Papers. However, in July 1990, the Secretary of State bowed topolitical expediency and the financial exigencies of the poll tax, and deferredthe introduction of the whole scheme until April 1993. Before looking inmore detail at the likely consequences, it is useful to put the current debate oncommunity care in a historical context.

COMMUNITY CARE IN THE POST-WAR PERIOD

We can identify three broad phases in the evolution of community care in

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Britain: the period of consensus and slow expansion up to the late 1970s, theperiod of retrenchment and stagnation from around 1979 up to the late 1980s andthe phase of austerity and privatisation inaugurated by Griffiths in 1988/89.During the long post-war expansion of the Welfare State there was a grad-

ual decline in the popularity of institutional care of all sorts, from children’s shomes to homes for older people, and a growing consensus of support forcommunity care. The 1962 Hospital Plan and the 1963 report Health andWelfare both linked the contraction of hospital provision for older people,people with mental illnesses, disabilities and learning difficulties, with theexpansion of local authority services. The White Papers on the mentally han-dicapped and the mentally ill, in 1971 and 1975 respectively, both empha-sised community care. The personal social services expanded rapidly in the1970s. Sheltered housing and warden-attended housing schemes encouragedthe old and disabled to remain in the community. Local authorities providedmore home helps and meals-on-wheels as well as more day centre places.The consensus in favour of community care was supported by the demands ofmany service users themselves that they be allowed to live more independentand ’normal’ lives.As many commentators have observed, the planning and provision of

resources in the community always lagged far behind the political rhetoric(Titmuss, 1968; Jones, 1989). Mentally ill people were often discharged intothe care of relatives who received little in the way of support or additionalresources. Many mentally handicapped people remained in long-stay insti-tutions. The predicament of the physically disabled was exposed in a numberof reports which culminated in the 1970 Chronically Sick and DisabledPersons Act. There was evidently no comprehensive strategy or central allo-cation of resources for care in the community, and the institutional lobbyremained effective in commandeering funds. Yet the steady increase in thefunding of social services allowed some progress to be made: the share ofnational income allocated to personal social services increased fivefoldbetween 1955 and 1976 and its share of all public expenditure increased morethan threefold (Judge, 1978). In a recent article Walker has contrasted theaustere climate of today to that reflected in the 1968 Seebohm report on localauthority social services which devoted only 2 out of 706 paragraphs tofinance, ’because everyone assumed that the money the services neededwould be found’ (Walker, 1988 p 18).

In view of the current emphasis on voluntary organisations, it is worth

noting that the voluntary sector remained marginal for most of the post-warperiod. While the national or local state provided the vast bulk of welfareservices, voluntary organisations were mainly involved in initiating newareas of provision or acting as pressure groups around particular issues ofconcern, such as homelessness, single parenthood, or drug dependency.The period of retrenchment began with Labour’s public spending cuts in

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1976 and gathered momentum in 1979 after the election of a Conservativegovernment committed to rolling back the Welfare State as a matter of prin-ciple (Clarke, Langan and Lee, 1980 p 188-92). The official emphasisshifted from ’care in the community’, to ’care by the community’, in themuch quoted epigrammatic couplet formulated by Michael Bayley in 1973.Bayley’s couplet was proclaimed as the central theme of government policyin the 1981 White Paper on services for the elderly, Growing Older. Thegovernment’s object was no longer to expand publicly provided services inthe community, but to encourage ’informal networks’ of family, friends andneighbours to take on more of the burden of caring. Writing in 1978, Bayleyhimself had emphasised the link between promoting community care and theshortage of public resources:

’If we are concerned that adequate services should be provided for those whoneed them, there is no choice but to seek to develop a new style of provisionthat interweaves statutory and informal care.’

(Bayley, 1978)

A series of DHSS initiatives in the early 1980s, including Care in the Com-munity and Helping the Community to Care, showed the government’s deter-mination to push ahead. Ministerial statements by Patrick Jenkin and hissuccessor Norman Fowler indicated that the government was planning topush local authority social services departments into a residual ’long stop’role, while promoting family, voluntary, neighbourhood and self-helpschemes (Walker, 1989 p 212-3). As Janet Finch and Dulcie Groves haveobserved, community care, particularly that provided ’informally’ bywomen in the home, was a ’low cost solution’ to the continuing lag of resour-ces behind rhetoric (Finch and Groves, 1985 p 221-4).

It is important to note, however, that taking the 1980s as a whole, therewas still a slow increase in spending on social services. Despite the steadycentral squeeze on local government expenditure, personal social servicesremained a relatively protected area: between 1979/80 and 1987/88 currentspending increased by 36 per cent and capital spending by 17 per cent(NALGO, 1989 p 10). However, the slow growth in the expenditure onsocial services was not enough to ensure that the provision of services likeday centres and domiciliary care kept up with the needs of an ageing popula-tion. For example, the number of home helps per thousand of the populationover 75 declined from 20.6 in 1975/76 to 14.5 in 1987/88 (LGIU, 1990 p 3).There was also a relative decline in the availability of day centre places forthe physically handicapped (NALGO, 1989 p 12).

In the same period, social services departments acquired more and morestatutory responsibilities, notably in relation to children, and were obliged todevote more resources to training. They also came under more pressure as aresult of rising long-term unemployment, deteriorating housing conditions

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and deepening poverty. Cuts in social security, notably in housing benefit tothe young, not only produced more hardship and homelessness, but moredemands on social services to cope with the consequences, especially forfamilies with young children. The result was a general decline in services anda demoralisation of staff (Langan and Lee, 1989).The expansion of the voluntary sector in the 1980s parallelled, and to some

extent compensated for, the decline of public provision. National organisa-tions like Age Concern and the Spastics Society began to play a more activerole in providing basic services as well as running campaigns and organisingexperimental and innovative projects. Smaller, more localised groupsfocussed on the needs of those increasingly neglected by the mainstream,such as the homeless, and also those of women, black people and ethnicminorities, running play groups, day centres and other community facilities.Humble and Walker estimate that by the late 1980s the voluntary sectorincluded around 180,000 paid workers (Humble and Walker, 1988 p 250).Some of the major casualties of the period of retrenchment were the long-

stay mental hospital patients who were discharged en masse into ’the

community’. The result of the accelerated closure of a number of largeasylums without adequate preparation or provision of appropriate hostels,day centres or other supportive facilities rapidly became a national scandal.Between 1982 and 1986 the number of hospital beds occupied by thementally ill declined by 10,000; in the same period the number of day centreplaces increased by 543 and the number of residential places by 399 (Healthand Personal Social Services Statistics, 1988). In 1985 the House of Com-mons Social Services Committee was sharply critical of the government’s saction in forcing through its mental hospital closure programme withoutsufficient planning or provision of alternative resources in the community(HCSS, 1985). The report noted that existing community services were’underfinanced and understaffed’ and emphasised that a decent community-based service for mentally ill or mentally handicapped people could not beprovided without additional expenditure (Jones, 1989 p 112-3).The growing burden on carers in the community for these and other

victims of the run-down of institutional care became an increasing focus ofconcern, especially among women who were forced to do most of the work,despite their much increased participation in the labour market over theseyears (Langan, 1985). Finch and Groves observed that ’current communitycare policies cut across a legislative commitment to equality between thesexes’ (Finch and Groves, 1985 p 219).The inadequacy of provision for the special needs of black and ethnic

minority communities has enforced a particular burden of care on thesecommunities. As David Johnson has observed, welfare professionals ’tend toassimilate generalisations about the extended Asian family supporting itsindividual members, the matriarchal nature of society in the West Indies, and

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the role of the village elder in an African village’ rather than finding outabout the specific experiences and needs of minority communities (Johnson,1979 p 14). Ratna Dutt has noted that, as a result of such prejudices, socialservices departments have been slow to provide home helps and meals-on-wheels for black elderly people (Dutt, 1989 p 34). Other reports have notedthe failure of existing community services to cater for the specific needs ofyoung black people and black psychiatric patients leaving institutional care(Morgan and Taylor, 1987; Kay and Legg, 1986; Connelly, 1988).The most significant change in the context of community care in the late

1980s was the announcement in the report of the House of Commons SocialServices Committee in 1988 that current expenditure on the personal socialservices was projected to fall by 0.7 per cent between 1989/90 and 1990/91;capital expenditure was also expected to fall for each year of the planningperiod (HCSS, 1988). This expectation of the first decline in social servicesspending in the post-war period, at a time when a steady increase is anticipat-ed in the demand for social support from an ageing population, overshadowsthe whole debate about community care provoked by the Griffiths report andthe White Paper. One London Borough has estimated that if it is to conformwith poll tax regulations it will have to cut spending on social services by 30 percent, for example by abolishing its home help and meals-on-wheels provision(LGIU, 1990 p 3). Unfortunately the central concern of the government isnot to improve the quality of community care, but to reorganise communitycare in the interests of reducing overall social services expenditure. How thiscan be achieved in a period of rising demand without reducing the quality oravailability of service is the circle the White Paper sets out to square.

CONSEQUENCES OF THE WHITE PAPER

How the new community care system will work in practice remains unclear.This is particularly the case in the sphere of finance, where only the broadprinciples of the new policy are outlined in the White Paper and keyquestions have yet to be answered. How much of the social security budgetwill be transferred to the local authorities? How will funds for communitycare be worked out in the complex negotiations between central and localgovernment that are likely to rage over the poll tax over the next year? Willlocal authorities be forced to charge for day care and domiciliary services aswell as for residential care? The only things that are clear are that the govern-ment will provide ’no new money for community care’ and that the adminis-trative and accountancy costs of getting the new system going will be enor-mous. While these uncertainties are likely to continue for some time, we canalready anticipate the impact of the new community care framework on thedifferent agencies and interests in the field.At the centre of the new community care structure stands the local authority

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social services department. This is no longer to be the familiar ramshacklebureaucracy condemned in the White Paper as a ’monopolistic provider’ ofservices. It is to be bom again with stronger management and financial control,as an arranger and purchaser of services, as an ’enabling authority’, assessingneeds (and ability to pay!), designing community care ’packages’, securingservice delivery, and monitoring quality. The enabling authority is to be thespearhead of the entrepreneurial revolution in welfare, choosing ’whereverpossible’ voluntary and private providers, only ’insofar as this represents acost-effective care choice’. The enabling authority is charged with stimulat-ing ’competition between providers, resulting in better value for money and amore cost-effective service’. On these points the White Paper faithfullyfollowed the principles of the Griffiths report, which was, as one reviewernoted ’written in the codes of Thatcherism and the language of &dquo;managerial-ism&dquo; ’ (Trevillian, 1988/89 p 67).The government claims that its aim is to develop a ’mixed economy of

care’, but as many commentators have pointed out, the logic of the WhitePaper proposals is to privatise much of local authority social services, reducingthe role of the social services department to that of managing the remainder.The end product will be a two tier welfare system in which the private andvoluntary sectors look after anybody who can raise the required funds and thelocal authority deals with a residuum of the poorest, the most disturbed andthe most difficult, those the White Paper describes as having ’challengingpatterns of behaviour’. The result is likely to be a decline in the accountabil-ity of service providers who operate at one remove from an overburdenedauthority and a permanently under-resourced directly managed service;unregulated private affluence and directly attributable public squalor.The record of competitive tender elsewhere in local government and the

health service suggests that ’cost-effectiveness’ is achieved largely throughcutting staff numbers (or hours) and reducing their pay and conditions of ser-vice. As Walker has pointed out, market forces are not a reliable regulator ofquality in the sphere of welfare: ’contrary to the market perspective, thelowest price is not necessarily in the &dquo;best interests of the user&dquo; ’ (Walker,

’

1989a p 22). In the welfare sector there is an inherent conflict between ’costefficiency’ and what he terms ’care-effectiveness’, for which the training andcommitment of staff are at a premium. Furthermore the process of encourag-ing competition among providers is likely to increase the fragmentation ofservices and reduce the collaboration and communication that the White

Paper elsewhere recognises is essential to good community care. The effectof contracting out services to large scale providers with the aim of cuttingcosts is likely to diminish choice for users and reduce the overall responsive-ness of the community care system (LGIU, 1990 p 5-6).The White Paper assumes the readiness of the private sector to provide

welfare services in competition with existing local authority services. But

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while there is a flourishing private residential sector, the viability of privateenterprise in other spheres of welfare, such as meals-on-wheels, day centres,home helps, etc. remains uncertain. Even in the residential sector, privateprovision is uneven: it predominates in the South East, for example, where itmay be considered a monopoly supplier, and in suburbia, but in the innerLondon Borough of Hackney there is not a single private residential ornursing home for the elderly. (The City and Hackney Health Authority,1990). It is ironic that while the White Paper opposes public monopoly, inpractice it encourages private monopoly.When it comes to the practicalities of community care the irrationality of

the government’s application of free market principles to welfare becomesincreasingly apparent. The key factors that determine the admission of an oldperson into residential care, private or public, for example, are location,domestic circumstances, and availability of a place, not market considera-tions. As Walker observes, in most circumstances, ’shopping around for analternative is not a realistic proposition’ (Walker, 1989a p 23). While thechoice created by privatisation is illusory, the loss of independence resultingfrom care through under-resourced public provision or from overstretchedfamily members is only too real.One of the key recommendations of the White Paper is that ’authorities

should move towards contractual funding in partnership with the voluntarysector’. The central role of the voluntary sector in the government’s com-munity care plans marks the culmination of more than a decade of growingofficial interest in promoting this sphere of activity. In 1978 the WolfendenCommittee undertook a major review of voluntary activity and a number ofsocial policy analysts recommended the voluntary sector as a social demo-cratic middle way between state monopoly and privatisation (Gladstone,1979; Hatch, 1980). In the early 1980s the Conservative government wasquick to recognise the potential of the voluntary sector and set about

discreetly promoting it, providing grants through a number of ministries andquangos (the Manpower Services Commission’s Voluntary Projects Pro-gramme was one example). Growing income from local authorities and fromcharity contributed to an expanded role for voluntary organisations. In West-minster, for example, Age Concern became a major service provider in the1980s, with 80 staff, 10 day centres, 3 local offices and an annual budget ofmore than £1 million (Thackray, 1989 p 6).The aim of the White Paper is to build on experiments like that in West-

minster and to encourage voluntary agencies to expand their role from thatof supplementing public provision to substituting for it. Representativesof the voluntary sector have been quick to point out that voluntary servicescan only be made cheaper by reducing pay and conditions below thestandards of local authority workers - and that this would be no guarantee ofquality (Thompson, 1989 p 2). Indeed others have insisted that for voluntary

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organisations to play a constructive role in developing policy initiatives incommunity care, they would need more funding in the short-term:

’Any shift of policy like that towards community care requires higher expendi-ture in the first instance. The government has failed to show how the voluntarysector could significantly increase its funding to take on the extra burden.’

(Humble and Walker, 1988 p 265)

Given that voluntary groups at present receive less than one per cent of localauthority social services budget their capacity to substitute for establishedservices remains very limited (Leat, 1986 p 36).One effect of increasing reliance on the voluntary sector will be to

exacerbate existing inequalities in service provision. It is well known that

voluntary activities are not so readily available in working class areas whereneed is high. Hence voluntary services tend to be distributed in inverseproportion to need (Leat, 1986 p 33). Another effect of an expanded role forthe voluntary sector will be a growing gap between the big establishednational charities, which see some scope for extending their own role in res-ponse to the community care white paper, and the smaller, local community-based voluntary groups, which are in a much weaker position. In his 1988lecture to Islington Voluntary Action Council, Stuart Hall anticipated theemergence out of the voluntary sector of a small number of ’highly profes-sionalised, private, welfare corporations’ while the great majority of

organisations experience ’something closely resembling a collapse’ in theirestablished sources of funding (Hall, 1989 p 2).Take, for example, the response of Age Concern representative Gordon

Lishman to the White Paper at a seminar organised by the National Councilfor Voluntary Organisations (NCVO) in January 1989 (Lishman, 1989 p 4-7).Lishman began by emphasising that Age Concern had been involved in agree-ing contracts with local authorities since 1953 and welcomed the trendtowards making them more detailed and more formal. He described therange of Age Concern’s activities from its involvement in a consortium withhospital consultants to provide long-stay psychogeriatric care to plans forday and domiciliary care facilities. The charity had set up a contracts unit toadvise local groups on negotiations with local authorities. Lishman remindedhis audience, mainly made up of representatives of smaller voluntary sectororganisations, that Age Concern regarded itself ’first as a charity, second aspart of the care sector and only third as a voluntary organisation’. Lishmanconcluded by emphasising that his concern was to help old people, ’not toprotect the jobs and conditions of local authority staff. Whether Age Con-cern can provide decent standards of care for old people in the community oneven worse pay and terms than local authorities remains to be seen.

Representatives of more grass roots voluntary organisations have express-ed grave reservations about the government’s plans for them in the new

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community care system (Hall, 1989; Thompson, 1989). They are concernedthey will lose their traditional role as innovators, as advocates of theinterests of service users and as campaigners against the authorities who arenow set to become their managers. The transition from the status of ’grant-aided’ to being under contract will allow local authority managers to dictatethe terms for longer periods (usually three years, rather than 12 months) andin much greater detail and formality. Many smaller organisations are con-cerned at the loss of independence and local initiative, as well as beingworried about the burden of acquiring further managerial and financialskills. It is possible that the voluntary organisations most threatened by thesedevelopments will be those that pose a radical challenge to conventionalforms of welfare practice. Such groups, particularly those involving womenand black people are concerned to promote the participation, control andultimately the empowerment of the individuals involved. Either such groupswill be forced to discontinue or the terms of grant contracts will curb theirradical emphasis on user control, empowerment, participation and

accountability.A part of the voluntary sector that is particularly concerned about the

implications of the community care White Paper is that which represents theinterests of the black and ethnic minority communities. Ratna Dutt of theRace Equality Unit of the National Institute for Social Work has criticised theWhite Paper for its failure to acknowledge the contribution of black

voluntary organisations to community care, especially in developing aholistic approach which could provide a model for the rest of society (Dutt,1989). She has emphasised the need for positive action to encourage theprovision of contracts to black and ethnic minority groups and for widerinformation and consultation about all aspects of the development ofcommunity care: ’Until packages incorporate the black and/or anti-racistdimension, then black communities will continue to be marginalized and’care’ will continue to be the sham it is now.’ The National Council for

Voluntary Organisations has echoed these points and has set up a CommunityCare Project with a particular concern to ensure that the concerns of blackand ethnic minority groups are taken into account (NCVO, 1989).The White Paper’s recognition of the importance of carers and the need

to support them is to be welcomed. However its references to carers aregeneral and repetitive. It offers bland promises about creating opportunitiesand emphasises the importance of respite care. But there are no specificrecommendations, particularly in the sphere of income maintenance orin relation to encouraging access to wider involvement in the life of society.After asking 80 carers from all over Britain - women looking after dis-abled parents, husbands and children; carers in different ethnic minorities;men looking after disabled wives and mothers; and gay men looking afterpartners with Aids - Cherrill Hicks recently summed up with they want.

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’What most carers want from the state is a system which genuinely encouragesdisabled and elderly people to lead independent lives within the community.This could be achieved by providing them with the health and social servicesthey and their carers require; by devising a system of cash benefits whichguarantee financial independence; and by policies which take account of theneeds of disabled people through the whole range of public and social life,including transport, education and employment. In short, the growing numberof carers need better support and more of it.’

(Hicks, p 221)

Recent changes in social security and welfare policy are more likely to makematters worse rather than to enhance carers’ capacities for an independentlife (Langan, 1988).Though the White Paper devotes some attention to the users of community

services, they appear only as the passive objects of official policy, withoutany active role in its formation or implementation. It is remarkable that aftertwo decades of criticism of public sector provision for its bureaucracy, itsbaffling complexity, its lack of responsiveness and flexibility, the govern-ment’s new structure for community care, by promoting ’consumer choice’is likely to reproduce these defects. We have seen that the market is not aneffective guarantee of consumer interests in the welfare sphere. Real choicerequires adequate funding and mechanisms to encourage user involvementparticipation and control, not an abstract ’choice’ but genuine empowerment(Beresford and Croft, 1986).The White Paper gives no real consideration to the question of how to

empower the consumer of services, how to guarantee and extend the rightsof all citizens to decent standards of care, how to ensure redress for the ser-vice user who is dissatisfied with the service provided, in the public or pri-vate sectors. One commentator has claimed that before the final draft of theWhite Paper was released a long paragraph stipulating that the consent ofthe individual, or carer, must be sought before a care assessment couldproceed, was erased (Redding, 1989 p vii). Yet, extensive research intocommunity services has shown that ’many people want to have more controlover the services they and other people receive’ (Beresford, 1988 p 43).Calls for more democratic participation in community care have goneunheeded.The White Paper virtually ignores the now widely acknowledged fact that

the vast majority of carers are women, and fails to take account of years ofdemands for alternatives which do not exploit women. The government hasremained deaf to Janet Finch’s plea that ’women must have the right not tocare, and dependent people must have the right not to rely on their relatives’(Finch, 1988 p 30).The White Paper makes the assumption that family care is always the best of

all possible worlds, when in the real world (Sheffield) surveyed by Qureshi

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and Walker, it is evident that the family provides both the best and the worststandards of care. (Qureshi and Walker, 1989). Giving a real choice to everyperson who needs social support, and providing support for every carer inthe community, demands above all the provision of adequate resources atevery level of the community care system. It is this fundamental failure of themarket system that destines the rest of the government’s market-led

proposals for community care to guarantee only greater hardship to thatsection of society that is least capable of bearing it.

Mary Langan is Lecturer in Social Policy in the Faculty of Social Sciences at the Open University.

AcknowledgementI would like to thank John Clarke and Fiona Williams for their helpful comments on a draft of this article.

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