Community health choice and social services are undergoing the most substantial changes since the beginning of the post-war welfare state.
Specifically, the idea that market efficacy rather than collective planning mechanisms is the best way of ensuring efficiency, accountability and choice in community care is at the heart of government health care policy. To achieve this, the 1990 NHS and Community Care Act introduced the separation of purchasing and providing functions in health and social care agencies. Notions such as the ‘quasi-market’ and the ‘mixed economy of care’ have begun to inform the organization of community care services. Two concerns one financial and the other organizational inform these general changes. First, the government, under pressure to control growing pu;llic spending on health and social care, was concerned with using existing budgets more ‘efficiently’. Consequently, ‘value for money’ and the preventicn of waste and inappropriate targeting of resources, identified by various reports, emerged as central aspects of government policy. Second, government policy had questioned the responsiveness ,tnd accessibility of community care services. Griffiths’s agenda for action on community care, for example, argued that community service deliver). was poorly reiated to need.
This echoed the concerns of the earlier Audit Commission report, which emphasized the importance of ‘a flexible service response’ that offered a wider range of options. The report concluded by calling for ‘the adjustment of services to meet the needs of people rather than thc adjustment of people to meet the needs of services’.
Ensuring that provision ‘Race’ and community care: an introduction 3 was tailored to more systematically assessed needs and preferences of individual users and their carers became a fundamental policy goal for future community care services. Ideals such as citizenship, consumerism, participation and choice have emerged as key objectives in attempts to empower recipients of health and social services.
Within this context, the policy guidance and reviews associated with the 1990 NHS and Community Care Act argue that ‘good community care’ must recognize the circumstances of minority communities, be sensitive to their needs and be planned in consultation with them.
The present restructuring of community care and some recognition of the multiracial nature of British society provides opportunities to improve provision to black and ethnic minorities. The introduction of needs-led care, the opening of consultation and planning processes to direct local influence and a new awareness of carers’ needs are all potentially helpful developments. These opportunities, however, arise in the*context of resource constraints and existing demands community care for minority ethnic communities fits into this broader context.
The introduction of the current community care reforms cannot be divorced from the existing disadvantages facing minority ethnic communities, especially since empirical evidence suggests that community services do not adequately recognize and respond to the needs of people from ethnic minorities.
Problems of access to, and appropriateness of, community health and social services have been well documented. Three themes emerge as significant and their impact is evident throughout the book. First, community service provision often ignores the needs of black and minority ethnic groups. For example, structural barriers to access are not taken into account when in the organization of services. Often service managers will say tha:- services are ‘open to all’ regardless of ethnic background. Yet racial inequalities and poverty disadvantage minority ethnic people and can create additional barriers to gaining service support; and the dietary, linguistic and caring needs of minority ethnic communities are often disregarded because services are organized to white norms.
Examples include the inability of health and social services to provide support for people who do not speak English or, more specifically, the unavailability of vegetarian food or halal meat in day care and domiciliary services. ‘Specialist services’, a popular response to these problems, although often beneficial, are too often a euphemism for shortterm and inadequately funded provision.
Yet, at the same time, mainstream services use the existence of specialist services to absolve themsek es of responsibility for ensuring access and appropriateness of services.
It should also be remembered that ‘special provision’ often leads to internal divisions within the minority ethnic communities who compete with each other on the basis of 7 4 Waciar I. U. Ahmad and Karl Atkin ‘culturally distinctive needs’.
Second, community care services often misrepresent the needs of ethnic minorities because of a preoccupation with cultural differences.
The emphasis on cultural practices means that many service organizations blame the potential client group for either experiencing specific problems or not making ‘appropriate’ use of services, rather than examine the relevance of the service being provided. The onus for change is thus on minority groups rather than purchasers and providers of services. For example, minority ethnic communities are frequently characterized as being in some way to blame for their own needs because of their supposedly deviant and unsatisfactory lifestyles.
Indeed, there is a history of defining health and social problems faced by minority ethnic communities in terms of cultural deficits where a shift towards a ‘Western’ lifestyle is offered as the main solution to their problems.
More recently, a variety of congenital malformations as well as higher deaths among Pakistani babies are being attributed to consanguineous marriages.
Reductionist approaches to minority cultures abound, and although their simplicity and rigidity hinders rather than helps service delivery, they remain popular with professionals.
Third, racist attitudes On the part of service providers have been reported in a number of studies in health and social services.
Health and,social service pr(sf,- sionals exercise considerable discretion an.: their views about users anc ! carers can influence the nature of service provision.
Local authorities often list black people as ‘high risk’ clients, ‘uncooperative’ and ‘difficult to work with’.
Similarly, stereotypes of minority ethnic group patients, as ‘calling out doctors unnecessarily’, ‘being trivial complainers’ and ‘time wasters’, are common.
These racist attitudes deprive minority ethnic communities of their full and equal rights to services. Despite the current restructuring of community care provision, there remains widespread uncertainty, puzzlement and ignorance about what should be done to meet the community care needs of minority ethnic communities.
Policy remains underdeveloped, comprising little more than bland statements in support of racial equality, while the mechanisms that might achieve race equality, and the principles that underlie them, remain unexplored. Devices such as the internal market, the separation of purchaser and provider roles, the mixed economy of care and the enabling role of social services do little to acknowledge, let alone alter, the unequal structuring of opportunities and are, therefore, unlikely to deal with the fundamental disadvantage faced by ethnic minorities. None the less, it is important not to lose sight of the opportunities created by the w community care’. The critical emphasis of the literature ‘Race and community care: an introduction 5 is understandable and has successfully highlighted racism, marginalization and unequal treatment. By focusing on disadvantage there is a danger, however, of adopting a ‘victim-orientated’ perspective that undervalues the significance and contributions of the struggle of minority i-thnic people and their organizations. Change can be pushed through by com.nunity action, as shown for services for sickle cell disorders and thalassaemia. As Walker and Ahmad (1994) have argued, community care offers a potential window of opportunity, although exploiting this opportunity requires resources and organization, which many minority community groups lack. On the part of purchasers and providers, more appropriate approaches to needs assessment and community consultation may facilitate improved purchasing and contracting, and the increasingly fashionable ethnic monitoring may also prove a useful tool for monitoring progress. Future work in this area needs to acknowledge the possibility for change rather than merely describe the problems faced by black and ethnic minorities.