Care Managers' Time Use: Differences between Community Mental Health and Older People's Services in the United Kingdom

Article excerpt

Since the community care reforms of the early 1990s, care management in the United Kingdom has become the usual means of arranging services for even the most straightforward of social care needs. This paper presents data from a diary study of care managers' time use, from a sample of social services commissioning organizations representing the most common forms of care management practiced in England at the end of the 20th century. It compares the working practices of care managers in community mental health service settings to the practices of those situated in older people's services. Evidence is provided to suggest that while the former follow a more clinical model of care management, those working with older people take an almost exclusively administrative approach to their work. In addition, the multidisciplinary nature of mental health service teams appears to facilitate a more integrated health and social care approach to care management compared to the approach to older people's services. Further enquiry is needed as to the comparative effectiveness of these different modes of working in each service setting.

Keywords: case management models; community care service settings; diary study; professional working practice

Case or care management can be seen as a key element in the development of long-term care services in many countries (Challis, 2003; Kraan et al., 1991), arising as a response to the initial failure of community-based services to meet the complex and changing needs of vulnerable people. A need for the coordination of these otherwise fragmented services was widely recognized if they were to offer a realistic alternative to hospital, nursing, or residential care (Audit Commission, 1986; Goldberg & Connelly, 1982; Intagliata, 1982; Melzer, Hale, Malik, Hogman, & Wood, 1991; Steinberg & Carter, 1983). In the UK, care management was introduced for all adult user groups in the policy document Caring for People (Cm 849, 1989), and it remains a central factor in the way in which services are organized and delivered (Cm 4169, 1998; Department of Health, 1999b, 2001).

There are considerable debates in the literature about the different models of care management and their relative virtues and appropriateness (see, for example, Challis, 1994; Meuser, Bond, Drake, & Resnik, 1998). These range from predominantly administrative approaches to more clinical forms of care management that combine care coordination with skills such as counseling and support in older people's services (Challis, Weiner, Darton, Hughes, & Stewart, 2001b) or psychotherapy in mental health services (Meuser et al., 1998). More intensive forms of care management in mental health services have also evolved from the early work of Stein and Test (1980), including "assertive community treatment" and "intensive care (or case) management" (Marshall, Gray, Lockwood, & Green, 2003; Meuser et al., 1998). In older people's services, similar models were employed in the U.S. by the Channeling series of demonstration projects (Brown & Philips, 1986) and in the UK by the early pilots of care management (Challis, 1993, 2003) cited in Caring for People (Cm 849, 1989, para 3.3.3). Assertive community treatment and intensive care management are targeted to the most severely mentally ill or highly dependent older people and aim to reduce inpatient episodes or provide an alternative to long-term institutional care.

In the UK, a lack of explicit guidance accompanying the community care reforms of the early 1990s resulted in wide variation in the interpretation of care management across local authorities, the principal commissioners of social care (Challis, 1999; Lewis & Glennerster, 1996). Of particular note is the relative absence of a differentiated approach to care management to ensure that different levels of response are consistent with different levels of need (Challis, Darton, Hughes, Stewart, & Weiner, 2001a; Department of Health, 1997b; Social Services Inspectorate, 1997). …