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Book Reviews: Community care in perspective: care, control and citizenship

Despite the wide-ranging title, Community care in perspective is in fact a detailed study of services for people with learning difficulties since the foundation of the National Health Service in 1948. Its mission is to explore the “extraordinary historical transition”, which saw community care “transmuted, at least in rhetoric, from an adjunct to the institution to the means for inclusion and rights”. Its methodology is the “stakeholder approach” where life histories, oral histories and autobiography, together with documentary sources, are used to construct plural accounts of service development and impact that reject the quest for a single “authoritative” history (pp. 2–3). 
 
The book is divided into four parts. Part 1 consists of two chapters which unpick the ‘Ideology and ideas’ that underpinned policy before and after 1971. Part 2 conducts a similar exercise for ‘Organizations and structures’, with the addition of a third chapter that commendably examines the implications of devolved government. Part 3 places the UK experience in international context through a discussion of the USA, Canada, Scandinavia, and Australia. And Part 4, entitled ‘Experiences’, tells the story from the viewpoint of people with learning disabilities, their families, the workforce, and the voluntary sector. There is also an interesting chapter that teases out the implementation of community care in two contrasting locations—urban Croydon and largely rural Norfolk. Finally, the conclusion offers an excellent summary of the book's two key themes: the “forces for change” in which campaigning families, “an individualistic human rights ideology”, the scandal of abuse, and rising costs featured prominently; and the shifting balance between care, control, and citizenship, in which staffing, “the emphasis on industrial work rather than education and rehabilitation”, and “the reality of social interaction” were uppermost (pp. 233–7). 
 
In assessing the dynamics of these processes, Jan Walmsley argues that the social model—which attributes disability to oppressive material and attitudinal environments—has been less influential for people with learning difficulties than for those with physical impairments. Correctly, she criticizes a simplistic rights-based response to this discrimination that stresses “individual rather than collective wellbeing” (p. 55) and hence threatens a market-based orientation endangering citizenship. However, there are also risks in over-emphasizing the positive conceptual changes that have occurred since the Second World War. For, whilst not “passive victims” (p. 3), intellectually impaired people remain the recipients of defective services. As a recent report from the Healthcare Commission confirmed, problems continue with major institutional failings in hospitals, treatment centres, and secure facilities that deprive residents of their human rights and dignity (December 2007). 
 
The gap between theory and practice is a product of the separation between ideology and service delivery that Community care in perspective embodies. The division of chapters also has other spin-offs, in particular a certain amount of repetition. But this is a minor worry. On the whole, the editors succeed in overcoming many of the weaknesses that beset edited volumes and only the omission of a national backdrop to the case study of community care in the Australian state of Victoria suggests that a brief has not been fulfilled. 
 
Though straddling the boundary between student text and research monograph, the book's fluent style and coherent arrangement ensure that it will appeal to a wide readership. The evolution of policy is made more accessible by an international timeline, which compares the trajectory of significant events in the countries under consideration. However, it is the oral testimonies that are especially telling. May they realize their potential to achieve a better understanding of disabled people's lives.