Community Care for Substance Misuse | Evaluation
From a service users perspective, critically evaluate people with substance misuse who live in supported housing.
Introduction
This paper discusses some salient aspects of community care of people with substance misuse who live in supported housing in the UK. Some of the issues that would be discussed include community care provisions with reference to legislative enactments; policy and practice initiatives in service sectors; a short review of the developments of community care policy and practice; an evaluation of the experiences of community care in a district and on different service users and carers– all these keeping in mind the requirement of anti-oppressive practice in working with service users and carers in community care.
To keep the arguments within the ambit of the meaning and implications of the topic of discussion, and to impart clarity and precision to them, it is thought prudent to define at the outset the terms and concepts used in the course of discussion. A contextual definition of ‘service users’ adopted from the one given by Hanley et al in their 2003 INVOLVE report is that ‘service users’ are ‘patients; unpaid carers; parents/guardians; users of health services; disabled people; members of the public who are the potential recipients of health promotion/public health programmes; groups asking for research because they believe they have been exposed to potentially harmful circumstances, products or services; groups asking for research because they believe they have been denied products or services from which they believe they could have benefited; organisations that represent service users and carers” (Hanley, B et al, 2003, p.13). The words or the phrase “substance misuse” means the use of illegal drugs, or the improper use of alcohol, or prescribed medication, or over-the-counter medicines, or volatile substances such as aerosols and glue. ‘Substance misuse’ has become as much a serious problem among older adults as among the young; causing physical and mental health problems for them. Substance misuse has also the wider impact of affecting not only the lives of those directly involved but also those of their families and the communities in which they live. Gavin defines supported housing as “accommodation wherereceipt of housing supportservices is a condition of residence” (Gavin, n. d.) He continues to say that such “accommodationcan be grouped individual self-contained flats, or may be shared housing, with or without shared communal facilities. Support staff may be based on-site or be visiting staff. This type of housing is usually provided for groups of people with similar needs, e.g. older people, homeless people, people with mental health problems or those recovering from alcohol problems. People can live in supported housing for varying lengths of time, dependent on their individual needs and the type of service” (Gavin, n.d).
Government Policy in respect of service and care
In one of its published documents (DH 2002), the Department of Health has given detailed guidance about the regulation on ‘Supported Housing and Care Homes’. The document begins by saying that “Government policy for community care aims to promote independence, while protecting service users’ safety” (DH 2002). Contextually, here ‘independence’ would obviously imply the freedom for individuals to choose on their own the housing, the care and support, including the embedded choices in respect of risk and protection. One objective of the Care Standards Act, 2000 has been to ensure high standards of care and to protect vulnerable people. The Act, however, has not changed the definition of a care home and matters implicit in that definition. “In respect of “personal care” the specified types of care include assistance in physical activities such as feeding, bathing, toileting, and dressing; in non-physical tasks such as encouragement, advice and supervision relating to physical activities; and emotional and psychological support in social functioning, behaviour management, and assistance with cognitive functions” (DH 2002).
Anti-oppressive stance in service users and carers in community care
In a multi-racial and multicultural society such as that of the UK, it is imperative that service users and carers should rise above common prejudices and discriminatory practices to be true to the requirements of their profession. To assist voluntary adherence to such practices, the UK has enacted legislation mandating anti-discriminatory practices in the provision of ‘social services’ and care facilities. This requirement is incorporated in the Sex Equality Act 1975, the Race Relations Act 1976 and the Children Act 1989; and reinforced by other legislations such as the Disability Discrimination Act 1995, the Race Relations Amendment Act 2000 and the Human Rights Act 1998. Anti-oppressive practice demands knowledge of the legislation and an understanding of the personal values of service users. An Open University document says that some of the ways in which anti-oppressive practice enter into practice include “‘colour-blindness’ (or blindness to other aspects of identity): ‘multi-culturalism’: thinking that it is enough to learn about other people’s culture and to celebrate diversity without examining our own attitudes; concentration on one aspect of identity to the exclusion of others; failing to ask service users how they like to be thought of, in other words asking them to define their own identity; cultural relativism: excusing abusive or criminal behaviour on the grounds of culture or other aspects of identity; failing to act for fear of being thought racist (or sexist, ageist or disablist). Social workers need to examine and question the sources and nature of their own power and the ways in which this is exercised in their relations with children and families and service users” (OUL, p. 107). It is also necessary to encourage the use and implementation of the GSCC’s Codes of Practice to social care workers, service users and carers (GSCC, 2002).
Service users relation with anti-oppression practices (AOP) need a little further elaboration, as it is a much debated issue and an equally ‘sore’ one in the repertory of the social workers’ kitty. It can be said that in recent years public conscience has been outraged at an all-pervasive emergence of AOP in the work of service users and a simultaneous emergence of the ‘philosophy of ‘anti-oppressive practice’ in social work challenging discrimination in all forms and along all lines of disparity, including race or ethnicity, culture, sexuality, gender, disability and age. It is to the credit of ‘social work providers’ to have pioneered this development and to come in for the brunt of much criticism (Wilson and Beresford, 2000). We find that in 1970 an influential document, The Client Speaks did not include in its sample service users people not born in the UK “since the reaction of ‘non-natives’ to social work are likely to be complicated by cultural
differences, language problems and so forth” (Meyer and Timms, 1970). However, despite social work’s ‘commitment’ to AOP policies and practices, equal access to services and support, and the provision of “culturally appropriate services and support have continued to be qualified” (Watson and Riddell, 2003). Inadequate access, or repeated denial of it, to important social work and social care services were reported by minority ethnic service users, who also said to have been ‘pushed’ as it were to the use of less valued areas of intervention in care services (Beresford and others, 1987; Vernon, 1996). Morris (1996) says that there is a wide prevalence of ‘inappropriate assumptions about BME (Black and Minority Ethnic) service users’; “for example, the levels of informal support available to them, continue to be reported (Morris, 1996). Some issues relating to refugees and asylum seekers, “where social work may be expected to be part of the policing and control processes introduced where citizen rights have not been granted or have been refused” were also said to worrying issues. (Shah, 1995). Other issues pointed out by service users in which they experience problems relate to their social work practice on the basis of gender, disability and age (Morris, 1991).
Another issue concerning community care, although not directly related to AOP, has been the ‘inordinate pressure’ for people to be placed in residential care. Large number of people is estimated to be living in such provisions and they include older people and disabled people of younger age, who according to service users could be supported to live in their own homes n accordance with the objectives of the community care paradigm. Along with the increase in the number of people in supported housing, another development has been that the service users have been able to impact on policy (Thompson, 1991). This has been evident from the introduction of direct payments schemes with new legislation in 1997 (Glendinning and others, 2000). People receiving direct payments have steadily increased in number along with the expansion of the range of service users receiving direct payments. (example, Newbigging with Lowe, 2005). It may be recalled that direct payments were pioneer by the disabled people’s movement. The aim was to put the individuals who received support to be in charge of the cash that the support would cost; and for them to decide on what support they wanted; from where to have that support (from disabled people’s organizations, for instance); to initiate and run such schemes; and for the support to be sufficient to make it possible for them to have ‘independent living’; that is to say for people to live their lives as far as possible on equal terms to non-disabled people or non-service users (Barnes, 1993). Direct payments scheme, however, met with serious problems and obstacles which undermined it. Local Authorities officials opposed it because they in the scheme a steep erosion of their control over their own services. In many instances the prescribed budgetary limits have meant that direct payments have often not been sufficient to ensure independent living. Further,
“frequently there has not been equity between service users; the process of assessment has continued to be dominated by traditional professional values, direct payments appear often to have been understood officially in consumerist terms (as if people were just buying services), rather than as a means of empowerment, requiring infrastructural support; and contracts have increasingly been placed away from disabled people’s organisations to commercial organisations which have undercut them and offered an inferior service. The cumulative effect has been to subvert direct payments as a truly different approach to personal and social support (Beresford and others, 2005). The government has reiterated its policy of individualised approaches to support a central plank in social care policy by bringing together different funding agencies to provide support for service users (Duffy, 2004, 2006).
Care-service in Bradford
To examine a representative district-centred programme to tackle the ‘evil’ of alcohol misuse, a brief account of the Bradford district’s ‘alcohol harm reduction strategy’ is considered here. According to a ‘Draft Status Report’ on the subject, “Bradford is in the highest (worst) quartile for all three types of alcohol-related crime (all crimes; violent offences; sexual offences) included in the 2006 Local Alcohol Profiles for England (NWPHO). The number of all crimes in Bradford attributable to alcohol in both 2004-5 and 2005-6 was just over 12 per 1000, down from nearly 15 per 1000 in 2003-4; alcohol related violent offences for all three years was fairly stable at between 8 and 9 per 1000 population. Alcohol-related sexual offences increased significantly in 2005-6 to a three-year high of around 0.16 per 1,000 (NWPHO, 2006 – this data is based on the Government Strategy Unit’s formula for alcohol attributable fractions for each crime, which was developed from survey data on arrestees who tested positive for alcohol). 20% of Penalty Notices for Disorder (PNDs) issued by WY Police in 2004 to 16 and 17-year olds, and 24% of those to adults, were for alcohol-related disorders” (Smith, 2006). To tackle this problem of alcohol misuse Bradford District has put in place ‘the Bradford District Alcohol Harm Reduction Strategy’ based on the 2004 National strategy for the purpose. The Bradford Strategy has the objective of “continually reducing alcohol misuse and the personal and social harms it causes, so enabling ever-increasing numbers of Bradford residents and visitors to live healthy and fulfilling lives, free from crime, disorder, intimidation, anti-social behaviour and avoidable health problems” (Smith 2006). Specifically the strategy aims to “reduce the number of people who drink alcohol above recommended limits; to reduce alcohol-related crime, disorder, nuisance and anti-social Behaviour; to reduce the harm caused by alcohol misuse within families; to reduce the prevalence of harmful drinking by children and young people aged under-18; to reduce alcohol-related accidents and fires; and to ensure that Bradford City Centre and outer town and village centres are areas that the local population and visitors can enjoy without fear of alcohol-related violence and victimization” (Smith 2006).
The Bradford Metropolitan District Council APA Impact Analysis 2007, says that “134 young people in substance misuse treatment (April – Feb 07) shows 54 YP currently Receiving substance misuse treatment from Specialist CAMHS [Centre for Addiction and Mental Health Service]; 100% of young offenders are screened for substance misuse in 2006/07, and 92.9% of those testing positive were referred for specialist assessment, an improvement of 16.4% on the previous year. The figure for entry to treatment also increased by 9.6%. In 06/07 there have been 4 substance related admissions to hospital in young people aged under19 years mirroring figures for 2005/06” {Bradford Metropolitan District Council APA Impact Analysis, 2007).
Development of community care policy
The UK community care policy is based on three planks of ‘autonomy’, ‘empowerment’ and ‘choice’ (Levick 1992). There have been disputes going on since the introduction of the NHS and Community Care Act (1990). On the one hand, the Act and its policy guidance have been seen as a significant development in the care reform for older people.
Three factors have contributed to the enactment of the legislation: first ‘the marketisation’ of the public sector from 1979 onwards (Means and Smith 1997); second, in theory, joint planning between health and social services promoted integrated and multidisciplinary community services; in practice, such arrangements failed to realise such services and were criticised as pedestrian and ‘patchy’; and third, the government policy of privatisation encouraged people to enter private residential homes through a system of social security financing different from that of local and health authorities. (Mooney 1997). This policy essentially channelled public sector funds into the private institutional sector while leaving the domiciliary sector chronically under-resourced. It is the older people who were adversely affected in a serious manner by the policies of the 1980s in respect of community care. The Audit Commission (1986) pointed out the principal fallacy of the ‘perverse financial incentive’ which supported the development of private institutional care at the expense of community care, through the income support system. In 1989 government accepted the findings of the Griffiths Report of 1988 and came out with a three-pronged policy: user choice, non-institutional services promotion, and targeting. In 1990, the Community Care Act was put on the statute book.
Conclusion
In concluding this essay it may be recalled that this paper has been an exercise in delineating some important aspects and issues relating to people with substance misuse who live in supported housing in UK. In the course of discussion issues relating to the various concepts and concerns of the subject matter of the discourse have been explored and analysed. It was seen that service users want to see social work which will be non-discriminatory and which will intervene on their behalf, offer support to secure their rights and needs. It has also been seen argued that “social work could be more effective in safeguarding service users (both adults and children) from the risks that they currently encounter in the social care system, including serious risks of neglect, abuse, denial of rights, bullying, racism, etc” (Beresford and others, 2005; Branfield and others, 2005).
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