British home and community care: Research-based critiques and the challenge of the new policy

The policy of the British central government is among the most coherent and pervasive of those in countries at the leading edge of reform. One perspective is its attempt to match resources to needs. Starting from a summary of the official statement of the logic of the policy and the way in which it reflected policy critiques of the previous decade in Section 1, Section 2 reviews the propositions of the arguments of the mid-1980s in the light of results of research on the nature and causes of patterns of resources, needs and outcomes and their interrelationships, particularly the results of a stream of 'production of welfare' studies focused on who gets what resources and with what effects. Evidence shows that applying some of the assumptions of the new policy dramatically changes the basis for judging the degree to which a cost-effective targeting of resources to needs could in principle be accomplished within the then level of public funding of the services. It shows a higher degree of consistency of allocations than some of the criticisms had implied, but the evidence did not allow a rejection of the proposition that allocations were biased against some kinds of potential beneficiary. Discussing the proposition that community-based services had a low impact on the probabilities of unwanted and inappropriate admission to institutions for long-term care, the evidence shows that low proportions of recipients were subsequently admitted; that as a consequence of assumptions and processes which have been extensively researched, the cost of care in the community approached cost of care in institutions for too few persons for the resources to have been most effectively used to make admission unnecessary, so that resources have not been focused on those for whom the impact is greatest; that generally, providing more rather than less service tended to have a small impact on the probability of admission to institutions. Section 3 discusses what changes in the relations between resources needs and outcomes will be necessary, and what the results of evaluated new models suggest about how to achieve them, discussing the improvement of targeting and increasing the impact of resources on outcomes in the context of the logic and results of care management experiments in the U.K., the U.S.A. and elsewhere, concluding that there is a need to adopt longer time horizons in the implementation of the new policy.