Care management in social and primary health care: the Gateshead Community Care Scheme
International Journal of Integrated Care, 5 June 2003 - ISSN 1568-4156
Book review
Care management in social and primary health care: the Gateshead Community Care Scheme
Edited by Challis David, John Chesterman, Rosemary Luckett, Karen Steward, Rosemary Chessum, Aldershot, et al
Ashgate: 2002, pp xii, 262
ISBN 1 85742 206 6
Frederike Jörg, PhD, Researcher at the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands

In many countries, long-term care policy aims at providing integrated and co-ordinated care for vulnerable older people who prefer to remain at home rather than move into an intramural setting. Flexible and convenient user-friendly services that allow elderly people to remain independently at home are necessary. This book describes and examines the Gateshead Community Care Scheme, which is a system of co-ordinated, integrated and flexible community services for a vulnerable group of elderly living independently in the community. The Scheme is set up around care managers, who co-ordinate various social and health services and who are able to arrange flexible care that is also responsive to changes in the care needed. The authors of the book examine the outcomes of the Scheme by comparing a group of 101 vulnerable elderly receiving the social care scheme with a group of 144 comparison cases receiving standard social care services. The outcomes are compared in terms of quality of life and quality of care for the elderly, burden or stress for informal carers and in terms of costs for social services, the NHS and society.

In Chapter 1, current issues in care management are discussed and the Gateshead study is briefly described. The authors claim the study is important because it is one of the studies of care management for highly vulnerable people that were influential in shaping some of the UK community care reforms. The study also was cited as an exemplar of care management in the White Paper Caring for People (CM 849, 1989). The main goals of the Gateshead Social Care Scheme were to provide a realistic community alternative to institutional care and to provide more effective and efficient long-term care for vulnerable people. The devolution of control of resources to individual care managers made it possible to respond more flexibly to need and to integrate fragmented services into a coherently planned pattern of care.

Chapter 2 describes the service context and the research design for both the social care and the health and social care scheme. The latter scheme consists of integration between community social services and primary health care services and operated in one group practice. For the social care scheme, as stated above, the aim of the research was to examine the kinds of care arrangements that are necessary to maintain frail older people in their own homes. The aim also was to compare the impact of the scheme with standard provision on older people and their carers and to compare costs. The Gateshead Borough was effectively divided in two parts, the western half being eligible for the experimental service and the eastern half serving as comparison population. The matching procedure for the social care and comparison groups is extensively discussed.

Chapter 3 gives an elaborate picture of care management in the Social Care Scheme, including its tasks, responsibilities, characteristics, and characteristics of recipients. It is a very interesting chapter because it also describes implementation difficulties, such as resistance of existing social services and the fear of budget competition. Furthermore, the chapter informs about the assessment process and the care planning process. It introduces the new form of help that was required, the so-called ‘helpers’: people who could work flexibly at different times throughout the day to undertake a wide variety of tasks that often fall outside traditional services. The chapter concludes with paragraphs about monitoring and reviewing of care, supervision and managing the care management service.

In Chapter 4 the role of the aforementioned helpers and their experience of the scheme is extensively discussed. This is by far the largest chapter and it widely portrays the helpers' motivation. Also discussed are their tasks in working with older people, their relationships with the older persons and their role in bridging formal and informal care. It offers an interesting discussion about whether the job of helper is an opportunity or rather exploitation of the fact that women (most helpers are female) tend to care for others. It is stated that on the one hand it gives women the chance to work in a fashion that permits them to keep caring for their own household and family but still provides them with some extra money. But on the other hand, their hours and pay are uncertain, the work is relatively low paid and their status is casual, all of which does not strengthen their position on the labour market. The chapter concludes with the examination of clusters of motivation and rewards experienced by the helpers and reasons of dropout.

Chapter 5 examines the ways in which the scheme provided care to older people with different needs. Six need areas were identified: the four I's that were identified earlier, Immobility, Incontinence, Instability and Intellectual Impairment; one “I” was added: Informal carer stress; and lastly the sixth need area was presence of depression. Most elderly people experienced needs in two or three of these areas. Care scheme cases are compared with the comparison cases on all problem areas; cases having problems in one area are compared with all cases; and costs are given of care scheme cases and comparison cases whereby cases having problems in one area are compared with all cases.

In Chapter 6 the outcomes of care for older people who received the care scheme are compared with the outcomes for those receiving standard services. The scheme appeared to have enabled older people to remain in their own home for longer and, in most cases, avoid entry to long-stay care. Different factors associated with remaining at home are examined. Furthermore, quality of life and quality of care are measured and compared, and the factors associated with higher levels of both are examined. Interestingly, many older people, both from the care scheme group as well as the comparison group, experienced benefits from entry into a long-stay facility. The worst option from the point of view of the older people was to remain at home and receive standard domiciliary services.

Chapter 7 discusses the outcomes for carers. It examines the extent to which the scheme was successful in alleviating the problems experienced by carers, so that their quality of life would improve and they could continue to care for the older person. The most important finding is that mental health pressures, recognised as the greatest cost to carers, are reduced for the carers receiving the scheme. The chapter furthermore examines factors precipitating breakdown of carer support. It appears that not only characteristics of the older person and the carer are important, but also the way they interact.

Chapter 8 deals with the costs and outcomes of care. Costs to the social services department, the National Health Service, and to society as a whole are distinguished. Social care scheme cases and matched comparison cases are compared. Also health and dependency, personality, physical environment or outcome factors are examined, associated with an increase in costs for both groups. Interesting findings are that the cost of improving quality of care and subjective well-being favoured the care scheme most at higher levels of outcome. Furthermore, care scheme cases had higher costs to the National Health Service and society as a whole, attributable to the lower personal consumption and housing costs of the comparison group, of whom more had moved into institutional care.

Chapter 9 describes a somewhat different care scheme: the health and social care scheme, in which social care and primary health care are closely linked in the delivery of community care. A group of 33 vulnerable older people were included in the scheme, of whom 29 cases were compared to the most vulnerable of the earlier mentioned 144 comparison cases. The processes of case finding, care planning and monitoring of care are described. With the help of examples from the case reviews, it is investigated how the scheme responds to the needs of the older people. The chapter concludes with outcome and costs of the scheme, of which the most important finding is that a far higher proportion of those receiving the health and social scheme were remaining in their own homes after 6 and 12 months at no greater costs than the usual services available to them.

The last chapter evaluates both schemes shortly and goes on to describe the rise and the ‘fall’ of these schemes, as they are integrated in mainstream service provision. In the first phase, the scheme was set up to offer an alternative to residential care and aimed to provide flexible and user-centred social care, and ran from 1981–1988. The health and social care pilot phase ran from 1985–1989. The third phase involved extension of the social care scheme to a wider geographical region under local management, until 1993. After the implementation of the Community Care and NHS Act in 1993, the scheme became part of the provider side of the social service organisation. This last phase introduced, if we may call it that, the ‘fall’ of the system, because the Act involved the separation of assessment from provision of care. This turned out not to work very well for complex cases where the roles of care management, assessment and care planning are not easily separated. Furthermore, in this chapter, different forms of linking social and primary care are discussed and in the last paragraph, the authors identify the lessons that can be learned from the Gateshead Scheme, in retrospect.

This book gives an elaborate picture of a very well worked-out system of horizontal and vertical integration of health and social care in the beginning of the 1980s in England, with an important role for care management. It is easily readable, and the evaluation of the outcome of the scheme for both cases and their carers in terms of improved quality of care, quality of life, reduced carer stress, reduced number of admissions to institutional care and costs is highly informative. A proper design of the study, whereby the experimental cases are compared with a group receiving standard care, provides reliable results in terms of outcome. However, without wanting to devaluate the scheme, it may not come as a surprise that the elderly in the scheme seemed to be better off compared with those receiving standard services, as the cases received so much extra attention and had flexible helpers resolving many problems.

A more important criticism of this book is the fact that it is outdated, as this scheme was introduced and evaluated in the mid-1980s. The question is why the evaluation of this scheme, almost 20 years after its introduction, including 101 cases and 144 comparison cases, deserves more than 250 pages. Challis et al. have extensively reported important findings of this scheme earlier, questioning not only the added value of this book, but also resulting in a high auto-citation. In the meantime, comparable schemes have been set up and evaluated, in England as well as in other parts of the world, with or without the Gateshead Scheme as a role model, and with or without comparable results. As it has been well established that integrated, small-scale care management projects improve the quality of care as well as the quality of life of vulnerable elderly people and their cares, it would have been far more interesting to go into the question of successful implementation of schemes like these. How can these projects be integrated into mainstream service provision without losing its small-scale advantages? How can the role of care managers survive in systems where assessment and care provision are separated? Although the authors of this book mention these themes shortly, they do not go into them in depth.

Concluding, this book gives very valuable information about the merits of a small-scale social care scheme and could be very useful for communities without any form of case management projects intending to set up such a scheme. For most communities however, the question is not whether these projects are beneficial to their vulnerable elderly, but how to implement such a scheme successfully within existing acts, laws and procedures.