Helping Older People in Residential Care Remain Full Citizens

New Labour’s project of modernization has involved thepromotion of interlocking ideas about active citizenship andnew modes of democratic engagement combining to produce whathas described as ‘participative governance’. Concernsabout legitimacy, a ‘democratic deficit’ and theneed to shift power and responsibility to the ‘citizen’have led to the emergence of a range of new deliberative foraand democratic processes. This has led to debates about howto ensure that social diversity can be represented in the decision-makingprocess. A challenge has been how to engage with the issuesof an ageing population and represent older people in all theirdiversity. In recent years, there have been growing calls toextend advocacy rights to older people living in residentialcare. Mostly, this has been to ensure that as consumers, theyhave a fuller say in how their service is run. Older care homeresidents are service users but, as persons, should not be reducedto this role only; they are also citizens in the broadest senseand should not be cut adrift from debates at the national, localand community levels on issues that concern them. This paperexamines how the moves to bring older people into deliberativedemocratic processes have tended to focus on those in their‘Third Age’. Those in institutional settings, beingin the ‘Fourth Age’, occupy a much more marginalposition. This effective disenfranchisement is yet another reasonwhy, for many, the move into residential care—a difficulttransition for a variety of reasons—becomes regarded asthe ‘last refuge’. It contributes to the sense ofloss of identity, lowering of self-esteem and a reduced senseof personhood. This article accepts that there should be moreeffective involvement of care home residents in decision makingabout their personal care. However, there are dangers in adoptinga too narrowly consumerist approach. This can reinforce a reductionistview of care home residents simply as ‘service users’—aform of ‘othering’ in itself. As citizens and membersof a wider community, they should be included in consultationsabout any community and wider political debates that affectthem. Such a proposal implies a widening and deepening of advocacyservices available to this group. As most older people in residentialcare are there following the intervention of a social care professional,then ensuring that they have access to advocacy must surelybe a key task. This paper argues that this is frustrated bythe lack of suitable services. Without a significant investmentby the Government in independent advocacy services, not onlyis the social work task with one of social care’s coreclient groups rendered impossible, but the Government cannotdeliver on its own agenda of empowerment, active citizenshipand inclusion.     

Professional Perspectives on Decision Making about the Long-term Care of Older People

With the increasing pressure on social and health care resources,professionals have to be more explicit in their decision makingregarding the long-term care of older people. This groundedtheory study used 19 focus groups and nine semi-structured interviews(99 staff in total) to explore professional perspectives onthis decision making. Focus group participants and intervieweescomprised care managers, social workers, consultant geriatricians,general medical practitioners, community nurses, home care managers,occupational therapists and hospital discharge support staff.The emerging themes spanned context, clients, families and services.Decisions were often prompted by a crisis, hindering professionalsseeking to make a measured assessment. Fear of burglary andassault, and the willingness and availability of family to helpwere major factors in decisions about living at home. Serviceavailability in terms of public funding for community care,the availability of home care workers and workload pressureson primary care services influenced decision ‘thresholds’regarding admission to institutional care. Assessment toolsdesigned to assist decision making about the long-term careof older people need to take into account the critical aspectsof individual fears and motivation, family support and the availabilityof publicly funded services as well as functional and medicalneeds.     

Would Palliative Care Patients Benefit from Social Workers' Retaining the Traditional 'Casework' Role rather than Working as Care Managers? A Prospective Serial Qualitative Interview Study

Social workers have made a significant contribution to the developmentand delivery of palliative care. Both palliative care and socialwork are rapidly evolving but, given their changing contextsand increasing workloads, can they sustain compatibility? Advancesin treatment of life-threatening illness mean that people livelonger in a period of palliative care. Social work has undergoneradical change in the wake of the 1990 NHS and Community CareAct and subsequent local-authority modernizations, with socialworkers now given the role of care managers, rather than themore traditional ‘casework’ or therapeutic role.This paper aims to explore the current and potential role ofthe social worker in palliative care for people with cancerand other prolonged life-threatening illness. It draws uponevidence from a prospective qualitative, patient-centred researchstudy, which detailed the experiences of forty people with lungcancer and advanced cardiac failure, and their personal andprofessional carers (Murray et al., 2002). A total of two hundredand nineteen qualitative interviews were carried out. We found that social workers were conspicuous by their absencefrom the lives of these forty vulnerable adults, who were livingand dying in the community with many unmet needs which, potentially,could be met by social-work input. The study highlights sixareas of concern in which social-work assessment and interventioncould have impacted on dying patients’ quality of lifeand that of their carers: loss and dependency, family-centredissues, carers’ needs, practical tasks, emotional andspiritual struggles, and finally, support needs of staff. Theseareas are outlined to explore the territory which a social workermight inhabit if resources and policies permitted.     

Mental Health and the Asian Communities: A Local Survey

Correspondence to Barbara Hatfield, Lecturer in Psychiatric Social work, Department of Psychiatry, 12th Floor, Mathematics Building, Manchester University, Oxford Road, Manchester M13 9PL Summary The survey of people from the Asian communities in ‘Milltown’included people who used mental health services, family membersof service users, and members of the Asian general public. Personaland social stresses of the group were explored, as were theirperceptions of the ‘causes’ of mental ill-healthand appropriate responses. Although most people saw family andsocial stress as central, a religious dimension was also prominent,in terms both of causes and treatment of mental ill-health.There was no evidence of rejection of mainstream services becauseof a choice on the part of Asian families or communities tobe self-servicing. A range of issues identified by respondentssurrounded the cultural acceptability of services in ‘Milltown’to Asian people. A lack of knowledge of service availabilitywas also apparent, with a heavy reliance upon GP services formental health care in the community. The findings of the surveyare compared with similar studies, where available, which focuson indigenous white British service users. Some findings arecommon; other issues are specific to this Asian group.     

The State of Care Management in Learning Disability and Mental Health Services 12 Years into Community Care

This paper reports on the organization of care management froma longitudinal study of community care for people resettledfrom long-stay learning disability and psychiatric hospitals.The findings from a 12-year follow-up of care management arrangementsin 12 learning disability and eight mental health study siteservices are described. The diversity of care management arrangementsfound at earlier points in the evaluation remained evident.Also, many of the former ‘care in the community’service users were excluded from mainstream care managementarrangements in their localities. The difficulty of developingperson-centred arrangements in learning disability and the lackof integration of the Care Programme Approach and care managementwere evident. The findings and observations are placed in thewider policy and practice context, with suggestions for takingcare management forward nationally and locally.     

Care Management and Professional Autonomy: The Impact of Community Care Legislation on Social Work with Older People

Correspondene to Mark Lymbery, Centre for Social Work, School of Sociology and Social Policy, University of Nottingham, University Park, Nottingham NG7 2RD, UK. e-mail: Mark_Lymbery{at}nottingham.ac.uk Summary The 1990 National Health Service and Community Care Act appearedto herald a new dawn for social work with older people, whichhad previously been a relatively neglected and undervalued areaof social work practice. The legislation proposed a new rolefor social workers as ‘case managers’, with considerableautonomy and flexibility about the way in which the ‘casemanager’ responded to need. By the time community carepolicy was implemented, the role of ‘case manager’had been transformed into that of ‘care manager’,with a focus which emphasized procedural and managerial requirementsrather than a more flexible professional practice. This paper explores the extent to which this shift has substantivelyaltered the nature of social work practice with older people.It outlines key theories of professions and their applicabilityto social work, and critically analyses the impact of the ‘newmanagerialism’ within social services departments. Thepaper also examines the nature of social workers' practice witholder people following the impact of community care legislation,and concludes that the impact on the social work professionhas been to locate an increasing control of practice with socialwork managers, with potentially serious consequences for thecontinuation of a distinctive social work role in relation toservices for older people.     

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.     

The Single Assessment Process in Primary Care: Older People's Accounts of the Process

Recent government policies have been active in addressing socialinclusion and active participation of older people in many aspectsof societal life. Independence and well-being animate thesedevelopments and are evident in the emphasis on person-centredservices within the single assessment process for older people(Department of Health, 2002b). Drawing on a feasibility study of the Single Assessment Processas a ‘case-finding’ approach, this paper presentsfindings drawn from older people’s accounts of this experience.These accounts indicate the potential of the process for identifying‘low-level’ need, whilst raising issues of accessto formal services and resource constraint; also they underlinethe importance of understanding how older people seek ways ofmanaging their own health and well-being, whilst continuingto contribute to the social cohesion of society by providingsupport to their peers and to younger generations. Interdependence, it is suggested, rather than dependence shouldunderlie any approach to assessing older people’s needs,if we are to appreciate and build upon the complexity of olderpeople’s strategies for actively managing their lives.     

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’.     

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.     

For the Sake of their Health: Older Service Users' Requirements for Social Care to Facilitate Access to Social Networks Following Hospital Discharge

Facilitating older service users’ requirements for accessto or re-engagement in social networks following hospital dischargeis recognized in social care analysis and policy as criticallyimportant. This is because of the associated benefits for restoringphysical health and psychological well-being. However, it tendsto be a neglected dimension of current social care/intermediatecare. Our paper draws on a qualitative study of voluntary sectorhospital aftercare social rehabilitation projects in five UKlocalities, which focused on addressing this issue. Throughexamining older service users’ feedback and experience,our study confirms the health benefits of social care facilitatingaccess to social networks at this crucial juncture. By providingsensitive interpersonal interaction, advocacy and ‘educational’assistance, social care workers supported older service users’re-engagement in a variety of networks. These included friendship,recreational and family groups, health care treatment programmesand locality based contacts and organizations. As a result,material, interpersonal and health care resources were accessed,which contributed to restoring and sustaining physical healthand psychological well-being. The process of such social carealso emerged as critical. This included ensuring that objectivesreflected service users’ priorities; integrating ‘low-level’home care; offering befriending; and challenging the pre-settime frame of intermediate care.     

A Role for Anyone? A Description of Social Work with the Elderly in Two Area Offices

Summary This article analyses information from Case Review Forms completedby social workers on 199 allocated elderly clients. These peoplewere very frail, most were considered to be ‘at risk’and to require regular, reliable and frequent care. The questionof the client moving to a tafer setting arose in two-thirdsof the cases, concerning which there was often some dispute.It is argued that social workers require a high level of professionalskill in dealing with clients, and others involved, faced withsuch questions and that this requirement will remain with thedevelopment of ‘community social work’.     

Advocacy for Black and Minority Ethnic Communities: Understandings and Expectations

Recent policy has promoted ‘advocacy’ as a meansof promoting social justice for many disadvantaged groups. Yet‘advocacy’ is a contested concept, and the understandingsthat members of disadvantaged groups themselves have of advocacyhave rarely been explored. Previous research indicates thatunderstandings may vary considerably. Using empirical evidencefrom research conducted in Glasgow, Scotland, this paper examinesthe understandings and expectations of ‘advocacy’held by black and minority ethnic (BME) service providers andpotential service users. The BME service providers believedthat they were offering advocacy, and did so in the contextof a marginalized position for their services. The BME communitymembers supported the development of advocacy services, buttheir own marginalization was in many ways reinforced by servicesthey were already using. They had clear ideas about appropriateadvocacy services for their situation. These ideas were groundedin their current situation, and did not necessarily conformto dominant ideas about advocacy. In conclusion, the prospectsfor successful advocacy are assessed.     

Social Care and the Modern Citizen: Client, Consumer, Service User, Manager and Entrepreneur

Since coming to power, New Labour has embarked on a programmeof modernization. Few areas of state activity have been morevisibly subjected to New Labour’s modernization agendathan the personal social services. Local authority social servicesdepartments have largely ceased to exist as separate organizationalentities. However, modernization has also required that therelationship between state and citizen be reconstructed. Thisis evident in New Labour’s vision for adult social carewhich envisages a move towards individual budgets. The individualizingnature of such schemes may be thought hard to reconcile withthe discourse of integration and partnership prominent elsewhere.However, a key linking concept is that of ‘person-centredness’.It is often assumed that this simply means that public servicesbecome more flexible to meet the needs of ‘the person’.This paper uses the example of direct payments to demonstratehow modernization also requires flexibility of ‘the person’.It would appear that inherent in New Labour’s projectof modernization is the assumption that the modern citizen shouldbe both managerial and entrepreneurial. What were once publicresponsibilities are being transferred to the individual. Theimplications for the users of adult social care are discussed.     

A Consumer Study of Young People's Views on their Educational Social Worker: Engagement as a Measure of an Effective Relationship

Correspondence to Colin Pritchard, Mental Health Group, University of Southampton, Royal South Hants Hospital, Brintons Terrace, Southampton, SO14 0YG, UK. Summary This, the first ever consumer study of education social workers(ESWs), uses qualitative material and quantitative analysisby examining the views of 110 users of a county ESW service.Most pupils belonged to families with long-standing disadvantage;e.g. 53 per cent had unemployed fathers; over 70 per cent hadparents with disturbed personal and social relationships, 39per cent had a single parent; 30 per cent plus had mental healthproblems; and 10 per cent of parents had been in care as children,i.e. more than ten times the national average. The young people also had considerable disruption in their lives:for example 78 per cent frequently missed school; over 50 percent had school and peer difficulties; 30 per cent offended;over 30 per cent experienced bullying; 5 per cent were the subjectof child protection enquiries, 10 per cent had previously beenin care and 2 per cent had had an incident of ‘attemptedsuicide’ (50 times the national rate). They averaged sixmajor difficulties each. Despite these antecedents, 91 per cent of the young people demonstratedan ‘engaged’ relationship with their social worktrained ESW, with many examples of practical psychosocial helpbeing received. The concept of ‘engaged’ was statisticallyvalidated in the comparison of views between the ‘engaged’and ‘non-engaged’ research participants. The resultsindicate the value and effectiveness of a supportive rapport/relationshipas a vehicle to reach and to be of practical assistance to disturbedand disturbing young people.     

Understanding 'Going Missing': issues for social work and social services

Correspondence to Malcolm Payne, Professor of Applied Community Studies, The Manchester Metropolitan University, 799 Wilmslow Road, Didsbury, Manchester M20 8RR. Summary Recent research about young people and adults who ‘gomissing’ raises important issues for social work and thesocial services. Large numbers of young people go missing eachyear, becoming vulnerable to exploitation and at risk of committingcrime and suffering from other social difficulties. Adults leavebehind families with practical and emotional difficulties. Adefinition of ‘going missing’ should focus on absencefrom social expectations and responsibilities. Five groups ofmissing person are identified: runaways, pushaways, throwaways,fallaways and takeaways, reflecting different social situationsin which going missing occurs. It is argued that going missingis one of a range of choices which people in difficulties maymake, depending on their approach to problems in their livesand the availability of opportunities. Effective local co-ordinationto focus on reasons for going missing, on reunions and returnsto residential care or home, and to provide emotional and practicalhelp to people ‘left behind’, are required, providedthat care is taken to protect people who go missing becausethey are subject to abuse and violence.     

Inter-agency Information Sharing in Health and Social Care Services: The Role of Professional Culture

This article uses a literature review to examine the ways inwhich professional culture might shape inter-organizationalexchange of personal information in a health and social carecontext. The aim is to explore a simplified model of possibleinformation-sharing behaviours (‘ideal’, ‘over-open’,‘over-cautious’ and ‘chaotic’) and tosuggest that patterns of information sharing may be influencedby a number of factors. It is proposed that these factors includenot only inter-professional differences in the approach takento information sharing but also the ways in which the professionsinterrelate.     

Group Work in Intermediate Treatment

Summary This article is concerned with the development of group workin a specialist intermediate treatment project. Using the techniqueof participant observation the author describes the use madeof groups over a six-month period with young people, all ofwhom presented problems of disturbance and/or delinquency. Thepractice portrayed is not ‘model’ but illustrativeof the dilemmas of practitioners beginning to work with groupsof young people for the first time. The evidence of the studypoints to the difficulties that an over-simplified view of participationand democracy can create, and indicates the need for group workersto define their purpose and objectives and to establish a contractor working agreement with group members. In relation to thedebate about ‘talking’ and ‘doing’ inintermediate treatment, it is suggested that a model of groupwork practice that distinguishes between ‘activity asan end in itself’, ‘activity as a means to an end’,and ‘focussed discussion’ may be helpful to groupworkers in conceptualizing the totality of their task. Socialwork with groups is still more talked about than practised.This article describes the attempts of a newly established teamof intermediate treatment workers to practise group work withyoung adolescents whose behaviour and social circumstances wereregarded as problematic. As a part-time researcher attachedto the project team, the author had access through participantobservation to groups over a six-month period and he also hadthe opportunity of listening to group workers discussing theirwork at review meetings.     

Regulation or fragmentation? Directions for Social Work under New Labour

Summary This article reviews the modernizing agenda of New Labour forsocial work which has been articulated in the various changesfor social work and social care announced in the ‘QualityStrategy’. Focusing predominantly on arrangements foreducation and training, the article argues that, rather thanpresenting a coherent strategy, the structures and proceduresare fragmented and unco-ordinated at many levels. A major weaknessis that New Labour has failed to clarify where it places socialwork in the structures of a ‘modernized’ welfarestate.     

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.