The role of communities in care
The role of communities in care
Abstract and Keywords
What do people, including governments, mean when they expect communities to be involved in care? The answers which are given to that question depend on what communities are understood to be. This chapter therefore examines some of the problems about uses of the concept of community, particularly when it is related to care. What kinds of assumptions are made about what communities are, and how various subgroups and families are (or are not) embedded in them?
What do people, including of course particularly governments, mean when they expect communities to be involved in care? The answers that are given to that question depend on what communities are understood to be. This chapter will therefore examine some of the problems about uses of the concept of community, particularly when it is related to issues about care. What kinds of assumptions are made about what communities are, and how various subgroups and families are (or are not) embedded in them?
Community is a concept that is used very widely and very loosely. That is a topic the author explored many years ago in a book with Ruth Issacharoff (1971). We identified a range of problems with uses of the concept of community. We reported an American article that claimed to have identified 94 different definitions of community (Hillery, 1955) and we quoted Halsey as suggesting that usage of the concept of community tends to involve:
Since those days the water has been further muddied by the rise – and to some extent fall – of an official usage directly pertinent for this book, the use of ‘community’ in tandem with ‘care’ to describe, in effect, either all care outside institutional settings or, more confusingly still, all care outside hospitals. These usages carry with them meanings that it suits government to imply. As Means et al (2003, chapter 1), among others, have pointed out, the wider implication is that the ‘community’ (p.6) is intrinsically a better place for care, with the implications that it is cheaper for the government as far as possible obscured. Now of course that usage has largely been replaced by ‘social care’, but the questions remain about the caring capacity of the community (or perhaps more appropriately of the many different social contexts) and of the role of the government in supporting and sustaining this. Dawn Stephen and Peter Squires (in Chapter Seven) explore a related usage in the field of criminal justice, where the word ‘community’ is used similarly very loosely (in this case to describe control measures outside prison) but again carries implications of inclusion and care.
The persistent residue of a romantic protest against the complexity of modern urban society – the idea of a decentralised world in which neighbours could and should completely satisfy each other's needs and legitimate demands for health, wealth and happiness.
So has the concept of community reached the point at which at least we need to abandon it? Marjorie Mayo (1994) offers a good modern exploration of this issue, recognising drawbacks to its use like those outlined above. Having explored the use of the concept in sociological theory she argues that it remains important to recognise the notions of social solidarity embodied within it, as celebrated in Raymond Williams' (1976) emphasis on the quality of relationships where people ‘have something in common’. She also invokes the distinction made by the sociologist Toennies (1936) between ‘community’ and the more impersonal form which many modern social relationships take of limited ‘association’. Mayo (1994, p 58) also stresses the political dimension in which community struggles ‘may be seen in the context of wider alliances … to promote the empowerment of the disempowered to take more control over their own destinies’. Hence, for her:
This chapter takes it leads from Mayo's point of view, exploring some of its application in relation to issues about care (hopefully using the concept with as much precision as possible).
Despite all the ambiguities and contradictions inherent in the very concept of community, and in policies to promote community development, there remain strands that have continuing relevance in developing more democratic approaches to welfare.… (p 68)
Community and geography
A crucial problem about the use of ‘community’ concerns the fact that it is often given a specific geographical referent. This is particularly the case in discussions of public policy, inasmuch as government too (the topic of a later section) generally implies activities within the confines of a specified area (often, but not always, a nation state). The Chambers Dictionary starts by defining community as ‘a body of people in the same (p.7) locality’ but goes on to include ‘a group of people who have common interests’ among its later definitions (note also that Martin Bulmer, 1987, emphasises this as both a contrast and an overlapping usage). Clearly, for a great deal of discourse about community it is important to ask to what extent these alternatives are being conflated. Sometimes people in the same area have many interests in common, sometimes they have few. Several of the chapters in this book (particularly Six, Eight and Twelve) concern people who will often be very isolated from those who live around them. Conversely, interest ‘communities’ may have quite narrow geographical locations but sometimes very broad ones.
It is important to recognise that both ‘locality’ and ‘interests’ in those two dictionary quotes are open to multiple interpretations. Locality may be interpreted very narrowly or quite broadly, and in each case there will be very different ways of drawing boundaries. Interests – as the use of the plural implies – may be multiple, and overlapping in complex ways. Loose usages of either approach to defining communities often disregard these problems.
Clearly, however, what is involved in very many cases where community is discussed in geographical terms is an implication that it is possible to define a relatively specific area within which people with closely shared interests are located. There are then, however, difficulties in delineating such areas, something that is complicated by questions about how many people there can be in such an area. Work carried out in the 1960s in connection with English local government reform got into considerable difficulty in the search for ways of defining appropriate geographical units (HMSO, 1969).
A great deal of contemporary analysis of community as a geographical concept has suggested that the extent to which this is the case is diminishing in modern societies. These analyses often go on to explore the factors that influence variation in this respect. It does seem important here to be very sensitive to interest diversity, and the factors that may enlarge or reduce this. Relatives of the author used to live in a very anonymous suburban estate under threat from flooding. That clearly gave everyone in that locality a shared interest. Fortunately, that was not tested severely; had it been it would have been interesting and important to see to what extent solidaristic responses to emergencies occurred and to what extent they enhanced other collaborative actions. As far as the topic of this book is concerned the issue is about the extent to which the presence in such a location of some people with rather specific care needs would have been given special attention (but see Chapter Eleven by Marylynn Fyvie-Gauld and Sean de Podesta (p.8) for an account of some very positive developments on a geographical basis).
On the other hand, leaving behind the geographical dimension, the alternative questions are about the extent to which interest links lead to solidaristic action despite the distances between people, which, in the case of care, may impose severe practical limitations on action. This is an issue pertinent to the retirement decisions of many betteroff people where locations are chosen – in the remote countryside or even abroad – where relatives are far away and care networks, let alone services, are rudimentary (Hardill et al, 2005).
Studies of occupational groups (including professions) have drawn distinctions between ‘cosmopolitans’ with widespread reference groups and ‘locals’ for whom attachments are primarily to the colleagues – and indeed the organisations – with whom they are working (the distinction originates from Merton, 1957, chapter 10). This issue is clearly pertinent to the professional ethics discussed by Marjorie Mayo and her colleagues in Chapter Five. While occupations may differ in their orientations, and thus the relative importance of a cosmopolitan perspective, it seems also to be the case that individual preferences and personality characteristics influence the choice between these orientations. Inasmuch, then, as these alternative orientations influence other lifestyle choices – the characteristics of friendship networks and even residential locations – people may to some extent choose whether their ‘community’ is or is not geographically constrained. Such choices will then have an impact on the way potential care networks are constructed.
Community and diversity
However, it is inappropriate to see networks as simply matters of choice. They are influenced by cultural, ethnic and linguistic characteristics too. This brings us back to the assumptions discussed above about the extent to which there are communities, formed of people with strong shared characteristics. And, closely related to this are issues about the extent to which the processes that form these communities are imposed on them by the attitudes of others, engaging in various forms of discrimination. Relevant here is not only the obvious case of racial discrimination but also the extent to which people may be excluded from interaction with others because of their lifestyles (or assumptions about their lifestyles).
Hence, in the absence of actual pressures towards residential segregation (ghettoisation) the extent to which these kinds of (p.9) community bonds will have a territorial dimension will vary greatly. Several important points follow from this.
The use of the concept of community is particularly problematic in contexts where it to all intents and purposes stereotypes a group to which the speaker does not belong. If we consider the various subgroups in society – whether identified by class, ethnicity, sexual orientation or other cultural identification – there will be differences in the extent to which those groups identify shared interests in the way implied by the concept of community. This is particularly evident in the way the concept of community is used with reference to ethnic groups. On the one hand, shared experience of discrimination and of difficulties in settlement in a new land may bring some very diverse groups together with common awareness and common action. On the other hand, other factors may divide. Consider, for example, the diverse island societies that first-generation immigrants from the Caribbean came from (the bigger islands of Jamaica, Trinidad and Barbados far apart – unwilling to participate in a federation and often even uneasy partners on the cricket field – and then alongside them the many from small islands often regarded contemptuously by people from the bigger islands but also with very different cultures themselves). Furthermore, they brought with them views about gradations of colour and class (Andrea Levy's novels illustrate this brilliantly) and wider ethnic divisions (illustrated in V. S. Naipaul's early novels). Even more seriously we regularly hear members of that vast, complex and diverse world religion – Islam – described in terms in which they are seen as belonging to a common ‘community’ and with, worse still, a limited number of identifiable ‘community leaders’.
Much of the literature on communities within Britain has explored issues about class differences and homogeneities. In some of the literature there is a tendency to romanticise a working-class past characterised by high degrees of solidarity. There is little point in getting here into a discussion about the extent to which this involved an idealised vision. What is clearly evident is that such solidarity is now hard to find. However, an important aspect of that literature, as Mayo (1994) shows, is the extent to which such solidarity derives from a need to work together in the face of shared impoverishment and shared oppression.
Another feature of the debate about class and community is the extent to which there is (or has been) a strong connection between class solidarity and the geographical concentration of people with shared class characteristics. There are some pertinent issues here about the relationship between social mobility and geographical mobility. It (p.10) may be the case both that the most deprived are the least mobile – in either sense – and that such upward social mobility as occurs tends to increase homogeneity among those left behind. Once upon a time social engineers sought to create cross-class community identifications through deliberate mixing of people (witness the early ideal for the new towns and Aneurin Bevan speaking of creating in council estates ‘the living tapestry of a mixed community’, quoted in Foot, 1975, at p 76). Such ideals have long been abandoned, undermined if nothing else by the popularity of owner-occupation. However, while highly homogeneous communities can often be observed, accidents of history have also created some unexpectedly mixed neighbourhoods (particularly where the partial gentrification of old residential areas has occurred).
A more serious challenge for efforts to engender community feelings has occurred in areas where concentrated social housing has become what can only easily be described pejoratively as ‘dumping grounds’ for diverse groups of people – those who are desperate for housing, those evicted from preferred areas because of failures to pay rents or anti-social behaviour, those forced to turn to social housing because of disability, ex-prisoners and so on (Lee and Murie, 1998). Again, differential mobility out of such areas can add to this ‘dumping’ effect, note, for example, the way in which opportunities for owneroccupation, including of course the subsidised sale of social housing, play a part. Can community solidarity develop among a diverse group of people who have nothing to share but their deprivation? Brave social crusaders like Bob Holman have devoted much of their lives to trying to help it to develop, but in most cases surely the outlook is fairly bleak. Perhaps the most hopeful developments occur among subgroups within such neighbourhoods – here again is perhaps a reason for holding on to the notion of the feasibly of communitarian developments without there necessarily being a strong geographical connection.
Community and families
There are obviously connections between patterns of family life and community relationships. The issues about the relationship between family life and community life are relevant to the concerns of this book inasmuch as families are very important for social care.
Family connections are the building blocks of the more cohesive communities (although even here, as Shakespeare reminds us in Romeo and Juliet, families can divide as well as unite communities!). The family/community connection may be seen in a particularly strong (p.11) form in the Confucian model of family life, in which kin ties are traced widely and far back and are, in Chinese rural societies, in many respects the lowest tier of government. Conversely, therefore, it may be quite difficult to separate out in situations in which traditional communities are seen to be being destroyed or in decline – as explored in the classic studies of East London by Willmot and Young (1957, 1960) – issues about disappearing neighbourhood ties and issues about the dispersal of extended families. As far as issues about care are concerned there must surely be similar reinforcing interactions.
As far as the policy issues are concerned, however, the fact that families go to considerable trouble to maintain links despite geographical separation is a matter deserving of attention, but it may be doubted whether similar considerations apply to attenuated non-kin ties. It is appropriate to note here that one of the characteristics of the issues about care is that they involve particularly sensitive interactions between people – both in terms of physical tasks and psychological difficulties. There is perhaps a paradox here that there are difficulties about relationships that lie in the middle ground between the impersonality of paid service by strangers and the intimate relations between family members. We return to this below.
Community and government
While it may seem to be taking us rather far from the issue of communities and care it is in fact not irrelevant to recognise that the modern concept of the nation state – as enshrined in the perspectives of many nationalist movements and given sustenance by the way in which national self-determination has (intermittently) been taken into account in determining territorial boundaries since 1919 – embodies a view of the desirability of equating a broad concept of community with the idea of democratic self-government. Indeed, that is implicit in the concept of citizenship. We are, of course, continually reminded of this in situations in which this ideal cannot be or has not been attained, as for example in the case of the Balkans or Northern Ireland. Of course, in most cases the community ideal in relation to nationhood involves population and geographical units much too large for notions of close caring networks, but it is appropriate to start from this point inasmuch as the legitimation of the assumption of a collective responsibility for care on the part of the government stems from this notion. This will therefore be explored a little more before proceeding to issues about smaller – local – units of government.
(p.12) So the issue here is about the extent to which notions of solidarity through citizenship can be effectively seen to legitimise a consistent set of government policies for care holding across a specific area. Clearly, such a view is implicit in expectations that government has a key role in the provision of care, often reinforced (and not merely by politicians) by concerns about territorial justice – often given popular form in assertions that who gets what should not be a ‘postcode lottery’.
Such a perspective seems, then, to come into conflict with an increasingly widespread view that a single government for a large territory (however defined) cannot realistically claim to represent us all. Leaving aside for a moment issues about more localised alternatives within a nation state, the general thrust of this argument requires a search for new approaches to self-government. That search tends to involve two alternative lines of argument.
One of these takes an individualistic character, stressing the need for consumer choice. This gives government the role of regulator of markets in which individual purchasing decisions may be made. It is not appropriate in this chapter, then, to go into the issues about the extent to which markets are non-existent, or rigged, or about the large number of situations in which consumers lack the resources to make choices of their own. Those deficiencies of markets can be addressed, notably through income maintenance measures. In some countries (see particularly the contributions on Germany and Japan in Chapters Fifteen and Sixteen respectively) care insurance offers another approach to this, although in the field of care – as these chapters show – it is impossible to escape forms of rationing through official need determination. In the UK the provision of ‘direct payments’ to people in need of care similarly extends individual choice to some extent.
It is, then, the other approach to the problem of the increasing irrelevance of the representative government approach to citizenship that particularly embodies a search for communitarian approaches to the government of caring services. Inasmuch as attention is paid to the geographical dimension of community this involves the exploration of ways to coordinate and consult on services at the local level, and at the same time therefore to strengthen locality-based networks. But perhaps their more concrete manifestations have been the growth of user groups – both as self-help groups and as participants in (or aspirants to participate in) policy processes at the local level. Such developments, important for the growth of the participatory ethic of care advocated by Marian Barnes in Chapter Four – although often locality specific – are likely (particularly as far as an issue like social care is concerned – by contrast with, for example, tenants' movements) to (p.13) be less geographically concentrated and thus to involve highlighting some interests and concerns that will not be shared with others in the same locality. Inasmuch as this is the case, such movements may be more appropriately seen as ‘consumerist’ – perhaps connecting up with developments like direct payments in which market notions are present – rather than ‘communitarian’. The consumerist emphasis may indeed be destructive of community approaches to serve organisation and control, interestingly a point made both by Alison Petch (Chapter Three) in her discussion of the importance of local government services in Scotland and by Frank Bönker (Chapter Fifteen) in exploring the replacement of non-profit organisations ‘with deep roots in the local community’ by commercial providers in Germany.
So far, this section has tended to pose two extremes for community involvement – one based on citizenship and oriented to the generally very large nation state, the other based on micro-level involvements. But, particularly given the extent to which interests may be expressed through movements that are localised in a broad rather than a narrow and very specific sense, is there a middle-level alternative? From the formal organisational point of view the obvious candidate for such a role is local government.
An interesting paper by Hellmut Wollmann (unpublished) explores the extent to which the roots of local government in European countries lay in notions of the representation of local communities, but later diverged from that ideal in many countries. The alternative competing notion was of local government as an administrative activity, with powers dictated by central government, with boundaries influenced more by concerns about the most efficient units for policy delivery rather than by communities of interest. This has taken its most striking form in the UK with the consequence that the ratio of population to local government unit is much higher than in most other countries. In particular, the UK has been reluctant to go down the French road of accepting that units may remain – at least in the rural areas – as representative bodies even when they have to accept that most services will have to be provided through combinations with other authorities or bought in from outside.
In this sense, local authorities in the UK are not seen as fora for the exploration of community concerns, a fact most dramatically demonstrated by low electoral turnouts to vote for candidates most of whom come from the national political parties and with results that are seen by the media as indicators of the popularity of the central government.
(p.14) However, there is within local government scope for rectifying this deficiency – although probably not in electoral terms – through the provision of facilities within individual local authority areas, for consultation closer to local communities. In the field of social care the interest in notions of integrated ‘patch’ teams in the years after the Seebohm reforms involved a search for ways to do this (Hadley and Young, 1990). Within local authorities as a whole there was a corresponding interest in integrated local offices, with perhaps appropriate local consultative committees, and in some places the organisation of the business of the authority itself through area committees (Hoggett and Hambleton, 1988). That impetus was subsequently lost; this may be attributed to a combination of the abandonment of integrated approaches within social services in favour of divisions along client group-based lines, the impact of privatisation in fragmenting integrated approaches to services and the emergence of more centralised approaches to local decision making through ‘cabinet’, ‘city mayor’ and ‘city manager’ initiatives. Contemporary approaches to consultation with the public are much more individualised, seeing citizens as separate consumers who should hopefully be in a position to make consumer choices and whose opinions may be sought by way of questionnaires. In Chapter Two, Susan Balloch explores other dimensions of this change of emphasis, particularly the difficulties involved in integrated approaches at the community level.
There is one other alternative here – that the voluntary sector can operate in this social ‘middle ground’. It is embodied in notions of subsidiarity, particularly in the traditional approach to much social care and education in the Netherlands and Germany (although note the comments on the decline of this in Chapter Fifteen) of leaving service provision to faith-based community organisations. This does to some extent separate the geographical dimension from the community of interest dimension. But it is pertinent to note that this has been observed to be of diminishing importance with the declining importance of religious affiliation within Christendom. It has re-emerged on the agenda because of the establishment of significant minority groups from outside Christianity, but is then the subject of much controversy inasmuch as separate services may imply forms of discrimination and may enhance divisions within a society. This implies a need to balance universalism and communitarianism, the topic of the next section.
(p.15) Universalism versus communitarianism?
The heading for this section opposes the concepts of universalism and communitarianism but adds a question mark, to indicate that the concepts are not necessarily in opposition. Running through the discussion so far are two key points – one that those links between people that are seen as important for the maintenance of ‘community’ are very likely (indeed, probably increasingly likely) dispersed across large areas, the other that organising principles for government (and also correspondingly for key representative groups that link people's interests and convey them to governments) are likely to involve large units of a kind to which the application of community notions cannot be more than symbolic. But while the justification for these large units has often been in terms of efficiency, there is another justification that is important for public policy: the case for territorial justice, ensuring if not equality of treatment at least compatibility of treatment across large areas.
The question is, then, how large should these areas be? As suggested in the last section, the 19th- and 20th-century concept of the nation state suggested the importance of a communitarian notion spreading across a nation. The reality has been, and remains, that many so-called nations have sharp divisions running through them. But now in the 21st century, notions of interconnectedness between nations are very much on the agenda, reinforced not merely by global economic ties but by massive population movements between states. In political science one of the justifications for talking of ‘governance’ rather than ‘government’ is that complex political and institutional connections run across traditional state boundaries (Pierre, 2000).
The recognition of this complex interconnectedness seems to conflict with efforts to define and work within quite narrow communities of interest, particularly ones that are defined in narrow geographical terms. But there is nothing new about this. For the Christian world the recognition of a universal caring responsibility is embodied in the parable (perhaps more honoured in the breach than the observance) of the ‘good Samaritan’, while there are similar universalist propositions within Islamic thinking. In more modern times, issues about a common humanity have been an important ingredient in humanistic thinking, offering a challenge to the more atavistic nationalist notions.
In the field of care there are some very important transnational connections to which there is a need to be sensitive. Gough and Wood (2004), in a book on social policy in the poorer countries of the world, stress the importance of remittances from family members working (p.16) abroad for welfare in their countries of origin. It is, then, important to recognise that many of these remittances come from people who are carrying out paid care tasks in the countries within which they work. Looking at this from the other end of the telescope, then, Clare Ungerson (2004) has raised concerns about the exploitation of these workers.
In relation to social policy, universalist notions have been propounded, as already noted, in the concept of territorial justice, but also in the advocacy of policies that extend social rights in a non-discriminatory way. This universalism is thus crucial for the defence of tax-funded healthcare for all (Titmuss, 1974). Reference to the particularist needs of specific communities is, then, seen as in conflict with this principle.
The difficulty with social care is both the cost of universalist solutions and the fact that, even if that cost could be afforded, entitlement depends on far from straightforward decisions about need and on the formulation and implementation of very varied packages of care. The author's own preference here is for an approach to this topic by way of (a) good overall income maintenance packages and (b) supplementary cash benefits depending on relatively simple tests of need, which then leave the recipient with a choice about how to spend the money. In other words, much better state pensions and invalidity benefits, supplemented by benefits like Attendance Allowance uprated so that they pay the real costs of attendance and so on. But that is a utopian dream. Without that, much tailoring of state support to individuals' resources and circumstances including the care they can call upon from others is necessary. In which case, attention to issues about community are important and connect up with concerns about citizenship – not to enable the public burden to be pushed off on to others, but to enable those who receive care and their carers to participate in decision making about how the resources should be provided.
Many people need care from family members (and in the absence of this from communities, in the broad sense) simply because public services are inadequate. It is not appropriate to espouse an argument that these links should be neglected simply because of a belief that there should be more adequate public services. Looking at this issue from a comparative perspective, distinctions need to be made between systems where there has been a stress on delegating tasks seen hitherto as potentially public to the community, those where community organisation is traditionally strong and those where the public contribution is so little that inevitably governmental effort has been about trying to shore up community resources.
(p.17) There is a case for strengthening community caring networks, just as there is a case for strengthening family caring networks. On the whole that seems to be an issue for us, for civil society, since when the state does it there is an ulterior motive – to save it the cost and responsibility. We should distrust communitarian arguments emanating from the mouths of politicians (see also comments in Chapter Four by Marian Barnes and in Chapter Seven by Dawn Stephen and Peter Squires on this theme). Bo Rothstein (1998) develops an interesting argument about traditional Swedish communitarianism – as embodied in a doctrine coming from the Left about policies for the ‘people's home’ – inasmuch as while it led to the development of some universalistic benefits it also implied uniform services imposed from above (he uses, for example, the case of maternity services imposed on mothers without consultation). This is also related to an authoritarian view that people who are in need are in a dependency relationship, less than full citizens with entitlements but rather subservient to those who consider they know what is best for them (an issue explored by Marian Barnes in Chapter Four).
The argument here is thus about the importance of universalist principles, and a warning about the too eager espousal of communitarian alternatives, with an important reservation. That reservation is about the viability of integrating universality and choice in the absence of real alternatives. Choice in situations where there has been no participation to determine the conditions under which those choices are made – a current danger with the enthusiastic advancement of direct payments for care – carries similar dangers. In any case, treating care as a commodity carries with it potential problems, inasmuch as it involves complex relationships between people that cannot simply be commodified within contracts.
Rothstein (1998, p 214) argues that ‘every democratic system must strike a balance between a collectivist/communitarian and an individualistic/autonomist ideal of democracy’. Fair enough, but in relation to care the issues go beyond this dichotomy. Both universal services and choice within them are needed. But there are limitations to the solutions these offer, not merely because of finite resources, but also because caring relationships are needed as well as caring services. Hence there is need, too, for the nurturing of networks of care. But this cannot be done ‘top down’ by politicians, telling us what our obligations are to each other, but through the recognition of real communities of interest that, in our complex world, will not have a simple spatial identity.
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