Introduction

SRV's most significant impact occurs in the field of intellectual disability. The fundamental changes in this field since the 1960s reveal those key elements that need to shift in service systems in order to begin to remediate social devaluation. Central to restructuring these service systems is the conviction that institutional models are intrinsically flawed and unnecessary for classes at risk of social devaluation. The aim of this chapter is to envisage an ideal palliative care system by applying the key elements of SRV-based systems to the palliative care context.

This chapter argues that service systems can evolve beyond the institutional model to a dispersed services model. In the intellectual disability sector, SRV-based models have made substantial progress toward a dispersed, non-institutional service system. Following the same route, the first step required is to gradually close all palliative care institutions, replacing them with non-institutional or, at least, quasi-institutional alternatives. The second step required is to disperse the services delivered by palliative care organisations. All services should be dispersed among generic providers whose clientele mostly include people who are not similarly devalued, that is, people who are not dying. Case management should be separated from direct care to work against the concentration of services within one organisation. Specialist palliative care professionals should retain the case management role or its recently developed, more individualised, user-oriented forms, such as service broker.

Beginning with a discussion of the evolution of systems beyond institutional models, this chapter then looks at how a dispersion of service provision allows institutions to be closed. After examining the feasibility and effectiveness of non-institutional models of care, the chapter gives a description of the closure of a disability institution, a significant proportion of whose residents require palliative care. The chapter concludes by outlining a reconfiguration of case management that can work towards a dispersion of service provision.

Beyond institutional models

The intellectual disability services system has been reinvented to respond to the ethical demand to close all institutions. This evolutionary process is continuing. Although far from perfect, intellectual disability service systems in various countries have operated for a couple of decades in broad terms, without the need for any significant institutional expression except the small group home.