Publication
Health promotion and community care: the perceptions of users, purchasers and providers of community care services
Introduction
Purpose and background
This research set out to assess the potential for strengthening the relationships between health promotion and community care and to understand what relevance, if any, the ideas and practice of Health for All may have to such developments.
At first sight the links between these areas may seem relatively unproblematic. There are clear needs for health promotion support for particular community care groups - for example encouraging mobility and preventing falls and other accidents in older people. The values which are central to community care practice - particularly autonomy and empowerment - would be acknowledged also by practitioners in health promotion. Health for All provides a framework for linking policies and players across sectors which would seem of considerable relevance to the attempts to develop ways of joint planning and ways of working to meet the needs of community care users.
Thus, these potential linkages can be located at a number of levels including:
- needs
- values
- policies
- ways of working
- outcomes
There were also many reasons why information and reflection was seen to be required as a basis for the development of work around this challenging boundary of health promotion, community care and Health for All. Many of the core concepts are contested. Organisational boundaries, budgetary responsibilities and professional remits may overlap but do not coincide. Health promotion may be seen both as a service and as a way of working. Health for All aims to provide a holistic framework for comprehensive strategic action which may at first appear hard to reconcile with the specific concerns of community care as defined in legislation and practice.
Community care embraces a very wide range of needs and formally designated ‘health promotion’ is not a limitless resource. How and where should this expertise be directed within community care and, more broadly, what are the possibilities for enhancing the contributions of those who give everyday and specialist care to community care groups including care assistants, home care workers, district nurses and occupational therapists? The issue of how specialist input could best be used and where generic skills are appropriate is important to this area, as in many aspects of community care. There are also very difficult issues of definition and of the translation of those definitions across professional and organisational boundaries. What do we mean by ‘health promotion’ and, more importantly, how is it understood by people working in community care as they go about their work of commissioning services, assessing people for community care services or providing support to them? Seeing connections between several areas of policy and practice is not the same as knowing that people working in those areas speak the same language and are ready to get on with the business of sharing information, solving problems together and collaborating in what they do.
To understand how to develop a framework in an area which is at the interface of various fields of practice requires both understanding of the (often contested) conceptual issues and knowledge of the strategic, policy and practice context. At the conceptual level there are tensions as well as opportunities in attempting to link the ideas underlying health promotion, community care and Health for All into a common framework. Perhaps the single most important difficulty is that community care refers to a relatively clearly defined (if not fixed) set of needs, people and services, whereas Health for All in particular would tend to be concerned potentially with all the policies and services that might impact on a community. The point here is not to make judgments about which set of ideas or practices is the most holistic, but rather to point out that one obstacle to a common framework is that each set of ideas and practices has overlapping, but not common, populations or ‘communities’ in view. This has real problems for the development of a common voice in this area. Yet while policy aims, remits, and professional terminology may vary, there is nonetheless the possibility that areas of good practice may develop.
When we consider the current strategic context there is a danger that the area of work in question could become the victim of some of the central conflicts in this area of policy and practice. The area of well-being in community care users potentially overlaps the boundary between health and social provision, described by Twigg as ‘the principal fault line of community care’ (Twigg, 1997), with all the divisions of professional culture, organisational responsibilities, financial and policy tensions that the boundary implies. The question of who should pay for long-term care costs is likely to dominate debates about priorities and responsibilities for caring, extending it not only to the appropriate uses of health and social care budgets but also to the respective responsibilities of the individual, the family, the taxpayer and the state.
In terms of priorities there is an obvious risk that the needs we are concerned to highlight could be doubly marginalised, a low priority both within health care expenditure and within the demands being made upon community care as a whole, exacerbated by any possible reduction of public responsibility for paying for care. For example, it is clear within the field of mental health that the care of those with long-term and enduring mental health problems is increasingly accepted as a legitimate priority. In this context, what are the prospects for the key agencies also paying greater attention to positive mental health promotion or to tackling stigmatising attitudes to people with mental health problems amongst the general public?
This research is intended to form part of a process of clarification and development. The aims shaped the methodology of the study which sought to ground the debate in people’s experiences and to understand differences in perceptions by finding out the views of users, carers, purchasers and providers of community care services and of people involved in health promotion and Health for All. This full report develops our analysis and makes extensive use of the words and experiences of research participants.