Building Care Management Competence in Services for People with Learning Disabilities

Correspondence to Paul Cambridge, Tizard Centre, The University of Kent at Canterbury, Canterbury, Kent CT2 7LZ, UK. Summary This paper examines care management arrangements in servicesfor people with learning disabilities. Its perspective is informedby research on the long-term outcomes and costs of care in thecommunity for people with learning disabilities (Cambridge etal., 1994) and by earlier experimental approaches to care managementin Britain. Building on arguments developed by the author ina position paper in 1992 (Cambridge, 1992), the focus here shiftsto the performance of mainstream care management in servicesfor people with learning disabilities, with an identificationand review of critical dimensions for reviewing competence.Lessons from earlier experimental and demonstration approachesare used to inform the analysis and to construct pointers forcommissioners or providers who are looking to assess the effectivenessof care management arrangements in learning disability withintheir own service systems.     

The Care Programme Approach: Dimensions of Evaluation

Correspondence to Barbara Hatfield, Mental Health Social Work Research Unit, School of Psychiatry and Behavioural Sciences, University of Manchester, 12th Floor, Mathematics Building, Oxford Road, Manchester M13 9PL, UK. Summary The study examined the first six months of implementation ofthe Care Programme Approach (the CPA) at a psychiatric unitof a district general hospital. From an analysis of the researchliterature on case management, and from current policy, a frameworkwas developed which was used to analyse the implementation understudy. The framework included such features as: a keyworkeroffering a continuous relationship and co-ordinated care; assessmentand intervention over a range of ‘needs’; multidisciplinaryworking in the community; and involvement of user and carer.The objectives were to ensure continuity of care and reducehospital admission. The targeted service users were to be thosewith severe and enduring mental health problems. The study showsthat most of these features were achieved in the implementation,although there is no evidence that hospital admission was avoided.A number of factors were found to be associated with re-admission,and these are discussed in the light of the findings of otherstudies.     

Practitioners' Documentation of Assessment and Care Planning in Social Care: The Opportunities for Organizational Learning

This paper analyses practitioners’ documentation of socialcare assessments and care plans for disabled adults of workingage. The data were collected in the course of an innovativeproject that introduced new outcome-focused documentation intoroutine social care assessment, care management and review processes.The project aimed to encourage practitioners to focus duringthese processes on the full range of outcomes that individualdisabled adults might seek to achieve; and identify the appropriateservices for realizing those outcomes. Analysis of the new documentationprovides insights into the diverse range of priorities and outcomesthat service users aspire to achieve as a result of receivingservices, and the service inputs that were agreed between practitionersand service users. However, despite the new documentation, themajority of both outcomes and services that were recorded tendedto cluster around a fairly narrow range of conventional socialcare service functions. Moreover, the emphasis of both outcomesand service inputs differed between different groups of socialcare professionals. In the context of current policies to makesocial care services more individualized and outcome-focused,each of these findings has major organizational implications.The opportunities for using routine practitioner documentationto identify areas of organizational and professional changeand learning are discussed.     

User-Practitioner Transactions in the New Culture of Community Care

Correspondence to Nicky Stanley, Lecturer in Social Work, University of Hull, Hull HU6 7RX, UK. Summary This article describes the findings of a research project whichexamined the views and practice of social workers undertakingassessments in one local authority following the implementationof the NHS and Community Care Act 1990. While the assessorsexpressed dissatisfaction with some aspects of the new systemof care management, overall they appeared to be taking the newculture on board. Managers were consistently more enthusiasticthan practitioners. Both groups saw needs-led assessment, userchoice and keeping users in their own homes as central objectivesof care management. The shadowing of ten community care assessmentsallowed the degree to which these objectives were realized inpractice to be explored. Users' experience of the new culturewas also studied. The user-practitioner transactions observedsuggest that those users who were able to articulate their ownneeds forcefully were most likely to be able to exercise choice.It is argued that the new culture of community care embodies‘consumer choice’ rather than ‘user choice’.     

Prison Welfare and Voluntary After Care

Summary Some findings of a survey into the experiences of men releasedfrom prison are reported, where they relate to their use ofprison welfare and after care services. These are discussedin the context of issues such as through-care, rate of take-up,and the factors which may be influential in determining whethera man makes use of after care on release from prison. It isproposed that for more isolated men the probation service shouldadopt a ‘reaching-out’ strategy.     

Poverty, Social Exclusion and the Politics of Disability: Care as a Social Good and the Expenditure of Social Capital in Chuadanga, Bangladesh

People labelled with disabilities in Chuadanga, Bangladesh, are denied equitable access to social networks and formal services. In terms both of funding future formal service programmes and of designing community‐based outreach programmes, this lack of access is not a simple reflection of one's impairment but a facet of the social exclusion and stigma that is culturally ascribed to disability in Chuadanga. We utilize a social model to focus on the cultural processes initiated by the onset of illness or impairment. Our participants are drawn from four types of diagnosed disability: blindness, orthopaedic impairment, hearing impairment and mental disorder. Although this inquiry is in line with Daly's focus on how future spending on formal services to promote care and equity in Europe can be helped by searching out information that is often ignored, the particular focus of this study is Chuadanga and the research questions incorporate a disability studies perspective. The authors consider care as a social good and an expenditure of social capital, in reviewing findings from a recent empirical study of disability and employment in the Bangladesh district of Chuadanga. Regardless of disability, poverty can be a morally and socially devastating ordeal. However, the authors conclude that the added loss of social solidarity and equitable access, due to the social exclusion and stigma of disability for the families concerned, make it statistically far less likely that they will access formal services or be able to escape poverty.     

The Ties that Bind: Support from Birth Families and Substitute Families for Young People Leaving Care

This paper draws on findings from a study of outcomes for youngpeople leaving care funded by the Department for Education andSkills. It explores the informal support networks availableto a sample of 106 young people over a period of 12–15months after leaving care. It examines patterns of contact withbirth families and caregivers, the support that emanated fromthese links and the strategies of leaving care professionalsto strengthen these connections. It also considers the new familiescreated by many young people through relationships with partnersand the onset of parenthood and discusses the continuing supportneeds of young parents. The paper situates the needs and experiencesof care leavers in a wider youth transitions framework and highlightsthe need for continuing professional attention to be given tostrengthening family links as one strategy for helping careleavers to negotiate the transition to adulthood.     

Integrating Health and Social Care at the Micro Level: Health Care Professionals as Care Managers for Older People

A common problem in the provision of coordinated long‐term care is the separation of health and social care. The present government has been increasingly concerned with promoting convenient, user‐centred services and improving integration of health and social care. One arrangement that could contribute to this for some older service users is for health care staff to act as care managers, coordinating the provision of both health and social care. This paper presents the findings of a survey of arrangements in place in local authorities for health staff to work as care managers for older people. This was designed to provide details about the range and scope of care management activities undertaken by health care professionals. Key areas of enquiry included: which kinds of health care staff undertook care management and in what settings; how long the arrangements had been in place and how widely available they were; whether there was a distinction between the types of cases and care management processes undertaken by health care staff compared with their social service department counterparts; and what management and training arrangements were in place for the health care staff.     

Community Care for the Elderly -- Rhetoric and Reality

Correspondence to A.C. Bebbington, Assistant Director, Personal Social Services Research Unit, Cornwallis Building, The University, Canterbury, Kent CT2 7NF. Summary This paper investigates the management and delivery of carefor 176 elderly people receiving both community health and socialservices. These people represent a crucial group if the communitycare policy is to become a reality, and they receive high serviceslevels. The study provides both quantitative and qualitativeevidence of inadequate case management and lack of co-ordinationin providing care. Assessment, determining services, and reviewwere all inefficiently managed. Liaison was non-existent forthe majority, and opportunities for substitution were missed.There could be conflict over role, particularly in relationto personal care. Innovations designed to tackle these problemsremain limited in scale. These difficulties are recognized andaddressed by the 1989 White Paper ‘Caring for People’which makes a number of proposals to clarify responsibilitiesand accountability. The different professional assumptions andwork practices among the plurality of agencies providing carewill need to be resolved if community care is ever to offera realistic alternative to care in institutions for increasingnumbers of people with high levels of dependency.     

Perceptions of Difference Between Aging and Disability Service Systems Consumers: Implications for Policy Initiatives to Rebalance Long-Term Care

This study explores service professionals' perceptions of how and why older adults and younger persons with disabilities are different consumers and clients within the long-term care service sector. Data are from 2004, early in the history of federal long-term care rebalancing initiatives, reflecting perceptions at that time. Findings suggest professionals working within aging, developmental disability, and physical disability service networks believe significant distinctions exist related to age of clients and nature of service required and how it is delivered. Overall need for greater professional and organizational capacity to support provision of service to both aging and disability populations is reported.     

Implementing Care Management: Issues in Relation to the New Community Care

Correspondence to Professor Jane Lewis, All Souls College, Oxford OX1 4AL Summary The official guidance on the new policy of community care emphasizedcare management as the means of securing needs-led services,together with user empowerment and choice. This paper uses datafrom eighteen months intensive fieldwork in five local authorities,first, to examine the very different interpretations of caremanagement in these authorities; secondly, to examine two majorsources of difficulty in the implementation of care managementsystems—the simultaneous development of purchaser/providersplits, and the tension between needs and resources—and,finally, to draw some conclusions about the implications ofcare management for social workers.     

The Case for a New 'Case' Management in Services for People with Learning Disabilities

Micro-organization is currently fragmented in services for peoplewith learning disabilities. Care management, person-centredplanning (PCP) and direct payments have developed through separatepolicy strands, with tasks and agency responsibilities blurred.A wide diversity of care management arrangements currently operate,with the relationship between care management, PCP and directpayments imprecisely defined. PCP and direct payments have alsobeen variably implemented. This paper argues for a new ‘person-centredcase management’, with these different devices betterintegrated and decision-making and action more person-centred.Drawing on practice experience from the original British casemanagement experiments, the new ‘case’ managementwould be centred on the needs and wants of individuals, be conductedindependently from assessment, operate outside the public sectorand be able to access personal budgets. It would consequentlyhave the capacity to further de-institutionalize services andsupport and transfer more control to people with learning disabilities.     

Outline of a Critical Best Practice Perspective on Social Work and Social Care

Correspondence to Harry Ferguson, Faculty of Health and Social Care, University of the West of England, Blackberry Hill, Stapleton, Bristol BS16 1DD. E-mail: harry.ferguson{at}uwe.ac.uk Summary This article seeks to lay the foundations for a new, more positiveperspective on critical practice, research and learning in socialwork and social care. A ‘critical best practice perspective’seeks to move the literature beyond a ‘deficit approach’where the focus is on what does not get done (well), to createa perspective where learning occurs in terms of best practicewhich is set out as a model for developing systems and practicecompetencies. This requires a focus on the actual critical practicesthat are ‘best’ demonstrating the very practicethrough which positive outcomes were achieved. A detailed case-studyis offered drawn from a large scale research study which typifieshow a critical best practice perspective can provide for learningin key areas such as how to engage service users, advocate ontheir behalf, promote protection, establish empowering relationshipsand conduct longer-term therapeutic work in an antioppressivemanner. The research method uses critical theory as an interpretativeframework for reaching an operational definition of 'excellence’and what is ‘best’, which is drawn from the perspectivesof the range of stakeholders who construct practice. This requiresa broadening of the concept of evidence-based practice to includequalitative research methods and the experience of professionals,service users and the production of ‘practice-based evidence’.     

Parental Rights Assumptions, The Passage of Time and 'Natural Justice': The Use of Section 3(1)(d) of the Child Care Act 1980

Summary This paper reports a study carried out in two Social ServicesDepartments, of 63 children in care under Section 2 of the ChildCare Act 1980, in respect of whom parental rights had been assumedunder Section 3 on the ground that they had been in Section2 care for three years or more. Some of the arguments put inthe debate about ‘natural justice’ in relation toparental rights assumptions are briefly considered in the introduction;recent changes in such assumptions are then outlined. The studyand its main findings are then presented, with reference tothe findings of other studies of parental rights resolutionswhere appropriate, Finally, the implications of the study forthe ‘natural justice’ debate are discussed. Theauthor's main conclusion is that the existing procedure is anomalousalthough Departments' use of it may be acrupulously careful.The grounds for assuming rights should be revised and the procedureshould be carried out by a family court.     

A Long‐Term Disability Care and Support Scheme for Australia: Opportunities for Disability Sector Reform

Social insurance schemes in Australasia have a long‐standing involvement in leading systemic change as well as funding services for eligible scheme participants. Establishing a long‐term disability care and support scheme for Australia provides opportunities to remove barriers to community access and improve the employment participation of all Australians with a disability, and to increase the use of evidence in policy development and in the delivery of disability supports. Using the examples of successful models in Australia and New Zealand, the authors will propose a model for the development and management of a long‐term disability care and support scheme that enables sector reform in employment participation, barriers to access and participation in all aspects of community life, and funding of disability research to benefit all Australians with a disability.     

Asian Carers' Perceptions of Care Assessment and Support in the Community

Within a study of the use of carer assessment forms, Asian carerswere given the opportunity to describe and comment on theirperceptions and experiences of community care assessment andsupport. Although their confidence in community care workerswas not exclusively related to ethnicity, they relied a greatdeal on semi-informal contacts with minority ethnic workersthrough their own local communities. The concept of ‘friendship’with professionals was important to many Asian carers. In commonwith the findings of other carer studies, many Asian carerswere uncertain about their experience of formal assessment andunclear about their entitlements and availability of communitycare support. ‘Outreach’ contact and ‘befriending’support was greatly appreciated. Day-care and sitting supportwere seen as a priority for formal services. Apart from contactwith general practitioners, there was limited awareness or experienceof community health-care support. Most of these Asian carerswere involved with carer support groups. They spoke of the benefitsin terms of social interaction and mutual support, counteractingfeelings of isolation, and access to information and formalsupport.     

Managing the Care Home Closure Process: Care Managers' Experiences and Views

This paper reports case study research that set out to identifywhat care managers do during independent care home closures.Little research has focused on the way in which care homes forolder people are closed in England, or what those involved thinkabout the process. This paper reports the activities and viewsof care managers directly involved in helping older people relocatefrom care homes that were closed by their owners. During suchclosures, residents and their families have no choice but tomove, usually to a deadline, and with little control over theprocess. Care managers have a responsibility to help arrangealternative care for those current residents who are publiclyfunded, and to offer information and support to those fundingtheir own care (the ‘self-funded’). Closure relatedactivities could involve considerable staff time. Care managementarrangements, including the organization of teams and provisionof needs assessments, varied across authorities. The care managersdescribed drawing on emotional counselling and inter-personalskills, as well as practitioner knowledge and experience, particularlywhen offering support and advice about finding appropriate newhomes. Tensions between aims, constraints on their actions andviews of good practice are identified.     

Care Proceedings: Exploring the Relationship Between Case Duration and Achieving Permanency for the Child

The 1989 Children Act in England and Wales and the derivative1995 Children (NI) Order in Northern Ireland provide the legislativeframework within which issues pertaining to the care and supervisionof children that come before the Courts are examined. Both piecesof legislation were intended to address a number of problemswith the way that such issues were dealt with by the Court,particularly the tendency for proceedings to become protractedand for children to ‘drift’ in care as a consequence.The imposition of the ‘No Delay’ principle in bothjurisdictions was designed specifically to address these concerns.However, since the introduction of both the 1989 Children Act(implemented in October 1991) and the 1995 Children (NI) Order(implemented in November 1996), there has been a steady increasein the average duration of proceedings and concerns remain aboutthe impact that this may be having upon the children involved.This paper presents the findings of a research study (McSherry et al., 2004)that explored the complex relationship between the durationof care proceedings and costs to children in terms of the likelihoodof achieving permanency.