Policy context

The community care reforms introduced by the 1990 UK National Health Service and Community Care Act provide an important context for understanding the relevance and application of mental health service evaluations. They also generate or consolidate a number of demands for cost information and a better understanding of cost-effectiveness.

The 1990 reforms comprise a number of strategic changes (Social Services Inspectorate, 1992; Wistow et ai, 1994). They seek to alter the balance between institutional and community care, moving the emphasis away from long-term hospital provision in favour of care in the community and away from residential and nursing homes towards support in domiciliary settings. They stress the importance of decisions which are purchaser dominated rather than provider dominated and needs led rather than supply led. Care management and care programmes should be important elements in the new system, comprehensive assessment procedures should be adopted and users and carers given greater influence and choice. There will also be some shifting of responsibilities for decision-making and funding from the National Health Service (NHS) to local government. This will make it harder, for example, for health authorities to discharge hospital inpatients to residential or nursing homes without the agreement and funding of local authorities. Greater pluralism within the ‘mixed economy of care’ is encouraged.

These reforms are being introduced in pursuit of familiar, broad policy aims. For example, the community care White Paper, Caring for People (Cm 849, 1989), argued that these changes would improve user choice, service innovation and quality. It was also unequivocal in its emphasis on system cost-effectiveness.