Trust as a Means of Bridging the Management of Risk and the Meeting of Need: A Case Study in Mental Health Service Provision

Shifts in public policy towards an increasing focus on risk have been deemed problematic at a number of levels, particularly the tendency for concerns over reputational risk to institutions to trump the interests and needs of service‐users. This article explores the tension between these two dimensions, of risk and need, in a case study of local mental health services – a setting where conflicting objectives to manage risk and meet need are apparent. Media‐driven pressure to ward against the ‘risk’ represented by service‐users tends towards more coercive policy which may obstruct the meeting of need, which in turn may undermine service‐user engagement and hinder risk management. Drawing on qualitative data from interviews with service‐users, professionals and managers, the article explores the process of trust and its facilitative role in meeting need and managing risk. Findings suggest that while existing foci on risk are at times counter‐productive, trust plays a significant role in service‐users' initial and ongoing engagement, communication and co‐operation with professionals. Yet inherent obstacles to trust within mental healthcare contexts remain, due to cultural pressures on professionals, the nature of the illness experience and negative past experiences of in‐patient care.     

Models of 'ordinary' and 'special' daily living: matching residential care to the mental-health needs of looked after children

This paper proposes a set of distinctions between ‘ordinary’ and ‘special’ modes of everyday living in residential settings for young people in the ‘looked after’ system. The paper begins by reviewing both quantitative and qualitative evidence on the mental‐health needs of the young people, arguing that there is evidence of very high levels of mental distress and disturbance within this group, and that this distress is often undiagnosed and untreated both by psychiatric professionals and within the residential care system itself. There follows a commentary on the tacit assumptions underpinning much residential practice, especially the emphasis in some policy and legal documentation on the young people’s need for ‘ordinary’ everyday experience. The concept of the ‘ordinary’ is problematized, and it is argued that while young people do need to be supported towards mainstream ‘ordinary’ everyday living, they also need specialized everyday care in which their emotional and psychological needs can be recognized and responded to. Four models of ‘special everyday living’ are proposed, based upon existing literature on residential practice, and it is argued that residential care programmes should be based upon a mix of these special and ordinary provisions if the young people’s emotional needs are to be met.     

“The Poor Carer”: Ambivalent Social Construction of the Home Care Worker in Elder Care Services

In this article, we examine the social construction of the home care worker from the perspective of various professionals in the elder care sector in Ireland. The research, using the Grounded Theory method, involved focus groups with 31 participants comprising health and social work professionals as well as care agency managers and policy planners. The social construction of the elder care worker is characterised by ambivalence. We connect the concept of ambivalence at the micro level of human relationships to structural factors that are driving the ambivalence. Ambivalence towards home care workers is shaped by structural factors including the precariousness of care work, the commodification of time, and the stipulated personalisation of services. The irreconcilable contrasts between portrayals of care workers as both ‘good’ and ‘bad’ are indicative of deep contradictions in the expectations that contemporary care systems direct at paid caregivers. Ambivalence arises from the commodified and dispensable status of care workers, and fundamental transformations in their training, working conditions and pay are required to move away from this ambivalence and towards care workers’ equal status with professionals in the care sector.     

Overcoming barriers to effective practice in child care

This paper describes the work of three Action Learning Sets – two groups of child care social workers and one group of health visitors. Given the substantial investment in child care research and its dissemination, we wanted to examine barriers to effective practice from the vantage point of workers themselves. Our core question was: ‘What can we do about the things that get in the way of effective practice?’ The method, based on that of ‘co‐operative inquiry’, sought to engage front‐line practitioners as active collaborators in the research. While several of the barriers can be seen as part of the common predictable experience of professionals working in large public sector organizations, a key message is the importance of re‐invigorating models of supervision that can sustain high quality practice. What emerges is a contemporary picture of the pressures on child care workers and of the struggles to make sense of professional roles in different organizational landscapes. We are committed to evidence‐based practice, practice that is derived from the best knowledge available. We would simultaneously stress the importance of ‘holding environments’ to promote effective learning. Our experience suggests that Action Learning offers a constructive method for encouraging such environments and facilitating better practice.     

‘Creating NHS Local’: The Relationship between English Local Government and the National Health Service

Following recent reforms of both local government and the National Health Service, there is significant emphasis in both services on improving inter‐agency collaboration, user involvement and strategic commissioning. In response, this article reviews historical debates about the relationship between local government and health care, before arguing that these two ‘partners’ need each other now more than ever. If local government is to be a ‘place‐shaper’, then it needs significant influence over local health services, while the NHS needs to learn from the best of local government if it is to gain sufficient local legitimacy to take the difficult decisions it needs to take. Against this background, the article reviews different options for future joint working, exploring various options for enacting a new relationship between local government and the NHS.     

Promoting Healthy Routes Back to Work? Boundary Spanning Health Professionals and Employability Programmes in Great Britain

Between 2003 and 2011, the Pathways to Work (PtW) initiative was established across Great Britain, as policymakers sought to address the ‘health‐related, personal and external barriers’ faced by people who were out of work and claiming incapacity benefits (IBs). In the first 18 districts that PtW was rolled‐out, the Public Employment Service (Jobcentre Plus) and National Health Service (NHS) organizations worked in partnership to deliver ‘condition management programmes’, which helped IB claimants to cope with health problems. Evaluation research has identified significant health benefits associated with these condition management programmes, but there has been less discussion of the role of frontline NHS professionals in ensuring that services worked effectively on the ground. This article deploys the concept of ‘boundary spanning’ to explore the role of NHS professionals within PtW. Drawing on more than 50 in‐depth interviews, the article concludes that these NHS staff played a key boundary spanning role in facilitating partnerships, based on an ability to engage with the values/practices of other partner organizations (especially Jobcentre Plus) and a willingness to challenge established professional boundaries and ways of working. The article notes that recent policy initiatives have abandoned the PtW partnership approach in favour of more familiar models of contracting out, and that NHS professionals have been excluded from the delivery of health/employability services. It is argued that these recent changes may negatively affect the quality and range of health‐related services available to people on IBs.     

The proof of the pudding: What difference does multi‐agency working make to families with disabled children with complex health care needs?

More than 20 years of research with disabled children, young people and their families has highlighted the need for the different professionals and services that support them to work more closely together. The British policy and legal framework for ‘joined up working’ has never been stronger. However, there has been an assumption that multi‐ or inter‐agency working will inevitably be a ‘good thing’ for families. This paper discusses findings from a 3‐year research project which looked at both the process and impact of multi‐agency working on families with a disabled child with complex health care needs. Interviews with 25 parents and 18 children and young people who used six developed, multi‐agency services were carried out. Findings suggested that the services had made a big difference to the health care needs of disabled children but were less able to meet the wider needs of the child and the family – particularly in relation to social and emotional needs. Multi‐agency working appeared to make some positive, but not significant, differences to the lives of families.     

Accepting and Negotiating Service Users' Choices in Mental Health Transition Meetings

Across Western welfare regimes, policies emphasize that service users should have more choices regarding their services. This article examines how service choices are presented, responded to and decided in interactions between service users and professionals in mental health transition meetings. Choice is often associated with consumerist user involvement ideas, but in mental health choice also relates to the democratic user involvement approach and to shared decision making between professionals and service users. The results of the study show that professionals construct service users as consumers by offering service options in choice making sequences, expecting users to make appropriate choices. Service users mostly act like consumers by responding to these choice options. However, the study also demonstrates that the professionals do not always accept the user's first choice but respond to them as non‐preferred. Sometimes, they also suggest choices on behalf of the users. In these ‘non‐accepting’ sequences, choices are negotiated in interaction between the parties, rather than users acting as autonomous choice makers. The sequences are based on two kinds of professional reasoning: first, the professional‐led needs assessment and, second, the structure of the service package that the user is being offered. This negotiation has elements of shared decision making and the ‘logic of care’. But it also has elements of paternalist control which challenge both consumerist and democratic service user involvement and suggests consideration of more collectively oriented service user actions.     

Revisiting children 'home on trial' in the context of current concerns about the costs and effectiveness of the looked-after children system: findings from an exploratory study

Statute and practice relating to s.31 part IV of The Children Act 1989 allow children subject to care orders to be placed at home with their parent(s). It is not uncommon for the courts to accept a plan for children to return home at the final hearing of care proceedings at which full care orders are granted. In such instances, children retain looked‐after status but, in terms of their day‐to‐day care, are looked after by parent(s). Whilst there are a small number of studies conducted in the 1990s relating to children ‘home on trial’, there is a much more limited recent literature. It is important to revisit this population of children, given current concerns about the burgeoning costs of child care proceedings and the looked‐after children system (LAC). This paper reports on a small‐scale exploratory study in one north‐west local authority area. Consisting of a file study and interviews with parents and professionals, the study examines the factors that contributed to initial removal of children to public care, the impact of the LAC system for children ‘home on trial’, stability of placements at home, as well as issues to do with the discharge of care orders. Particular attention is drawn to lone father headed households, a social group over‐represented in our sample. The study aims to inform further multi‐location studies.     

Inter‐agency Cooperation and New Approaches to Employability

This article examines the role of inter‐agency cooperation, which is one form of ‘partnership’, in new approaches to employability in the UK. The article articulates a ‘model for effective partnership working’ on employability. This model is applied first in a general review of employability policy and then to discuss case study research on the recent ‘Pathways to Work’ and ‘Working Neighbourhoods’ pilots. It is argued that successful partnerships need a clear strategic focus based on a necessity for inter‐agency cooperation and institutional arrangements that allow for shared ownership, trust and mutualism, and flexibility in resource‐sharing. While some of these factors are apparent in UK employability services, an over‐reliance on contractualism and centralized organizational structures may undermine partnership‐based approaches. Many of the success factors associated with effective partnership working appeared to be in place, even though the role of the Public Employment Service was fundamentally different in each case (as a key actor in implementing the first pilot, but largely withdrawing from the implementation role in the second). The article concludes by outlining the relevance of this model and the case study findings to discussions of the future development of employability policies and related partnership working.     

Externalizing an ‘Asset Model’ of Activation: Creative Institutional Work by Frontline Workers in the Norwegian Labour and Welfare Service

The past two decades have brought significant shifts in Norwegian activation policy towards a joined‐up and employability‐enhancing approach to labour market inclusion in order to promote return‐to‐work despite health problems or disabilities. Utilizing a concept from health promotion, we term this approach an ‘asset model’ of activation. The Norwegian Labour and Welfare Service (NAV) and its local offices are the main agents implementing the new policy. This article aims to investigate the strategies that the frontline workers of NAV engage in, in order to externalize an ‘asset model’ in the adjacent medical field and to the general practitioners (GPs) in particular. We analyze these strategies as forms of creative institutional work – the purposive actions undertaken to change existing presumptions and opinions among relevant actors. We argue that although the new activation policy is not theirs to develop, in order to bring about changes in practice, ‘creating’ institutional work by the frontline workers is required. Our findings show that the frontline workers develop strategies in order to externalize an asset model to the GPs, as part of operationalizing an ‘activation’ reform into practice. We identify four forms of ‘creating’ institutional work undertaken by the frontline workers: ‘defining’ – enacting legislation and regulation in relation to GPs; ‘constructing normative networks’ – creating a more collaborative relationship with the GPs; ‘educating’ – teaching the GPs about the rules and regulations, and the opportunities and assistive measures they can offer to the injured; and thereby also ‘changing normative associations’ of GPs towards the activation policy.     

‘Doing it right?’– accessing the narratives of identity of newly qualified social workers through the lens of resilience: ‘I am,I have,I can’

Using narrative enquiry, this paper accesses the construct of identity through exploring resilience in newly qualified social workers based in statutory children's services. In seeking to avoid deficit‐based models of this role, this paper aims to present inductively the ‘voice’ of three social workers in a semi‐rural authority, storying the positive ways in which resilience has developed during their first year. Using the Grotberg resilience framework (1995) –‘I am, I have, I can’– as an analytical tool at the interface of personal, professional and organizational identities, we conclude that ‘I am’ and ‘I have’ are more important than the skills dimension of ‘I can’. Positive role models, trust, ‘managed’ optimism, flexibility of support in and beyond induction, and, crucially, self‐efficacy and space for reflexivity, are more prominent as sources of resilience and strong identity. The reflexivity, inspired by the process of narrative enquiry, is an important contributor to self‐efficacy. We propose that a positive view of growth and identity is preferable to deficit models in the context of the transition between the two ‘communities of practice’ and of the challenges of the workplace. Organizational approaches based on this view will be more likely to promote a sustainable workforce.     

Public Satisfaction with the Health System and Popular Support for State Involvement in an East Asian Welfare Regime: Health Policy Legitimacy of Hong Kong

The legitimacy of social policies has gained increasing attention in the past decade, against the backdrop of fiscal austerity and retrenchment in many nations. Policy legitimacy encompasses public preferences for the underlying principles of policies and the actual outcomes as perceived by citizens. Scholarly knowledge concerning the legitimacy of health policy – a major element of modern social policy architecture – is, unfortunately, limited. This article seeks to extend the scholarly debates on health policy legitimacy from the West to Hong Kong, a member of the East Asian welfare state cluster. A bi‐dimensional definition of health policy legitimacy – encompassing both public satisfaction with the health system and the normative expectation as to the extent of state involvement in health care – is adopted. Based on analysis of data collected from a telephone survey of adult Hong Kong citizens between late 2014 and early 2015, the findings of this study demonstrate a fairly high level of satisfaction with the territory's health system, but popular support for government responsibility presents a clear residual characteristic. The study also tests the self‐interest thesis and the ideology thesis – major theoretical frameworks for explaining social policy legitimacy – in the Hong Kong context. Egalitarian ideology and trust in government are closely related to both public satisfaction with the system and popular support for governmental provision of care. However, the self‐interest thesis receives partial support. The findings are interpreted in the context of Hong Kong's health system arrangements, while implications for the territory's ongoing health policy reform are discussed.     

Towards Neo-Bismarckian Health Care States? Comparing Health Insurance Reforms in Bismarckian Welfare Systems

Germany, France and the Netherlands all have specific ‘Bismarckian’ health insurance systems, which encounter different and specific problems (and solutions) from those of national health systems. Following a relatively similar trajectory, the three systems have gone through important changes: they now combine universalization through the state and marketization based on regulated competition; they associate more state control (directly or through agencies) and more competition and market mechanisms. Competition between insurers has gained importance in Germany and the Netherlands and the state is reinforcing its controlling capacities in France and Germany. Up to now, continental health insurance systems have remained, however, Bismarckian (they are still mainly financed by social contribution, managed by health insurance funds, they deliver public and private health care, and freedom is still higher than in national health systems), but a new ‘regulatory health care state’ is emerging. Those changes are embedded in the existing institutions since the aim of the reforms is more to change the logic of institutions than to change the institutions themselves. Hence, structural changes occur without revolution in the system.     

Person‐centredness in the community care of older people: A literature‐based concept synthesis

‘Person‐centredness’ is a ubiquitous term, employed in modern care services to signify policies and practices that attend to the uniqueness of each individual user. Despite being highly regarded in older adult community care services, there is much ambiguity over its precise meaning. Existing reviews of person‐centredness and its attributes have tended to focus on the medico‐nursing literature, neglecting other interpretations, such as those relevant to community social care. A new literature‐based concept synthesis reported here identified 12 common attributes within the broad themes of ‘understanding the person’, ‘engagement in decision‐making’ and ‘promoting the care relationship’. The review also contrasts how these attributes are applied across different interpretations of person‐centredness. The article argues that not all attributes necessarily pull in the same direction, and that older adults may require them to be delivered in different ways than they are to younger people. Thus, a ‘one‐size‐fits‐all’ approach should be discouraged in community care. Key Practitioner Message: ? ‘Person‐centredness’ is open to multiple interpretations, causing difficulties for services trying to gauge performance and quality; ? Three themes are central to person‐centred services: ‘understanding the person’, ‘engagement in decision‐making’ and ‘promoting the care relationship’; ? A ‘one‐size‐fits‐all’ approach to applying person‐centredness is to be discouraged.     

Parents' involvement in care order decisions: a cross‐country study of front‐line practice

This article examines parents' involvement in care order decision‐making in four countries at one particular point in the care order process, namely, when the child protection worker discusses with the parents his or her considerations regarding child removal. The countries represent different child welfare systems with Norway and Finland categorized as ‘family service systems’ and the USA as a ‘child protection system’, with England somewhere in between. The focus is on whether the forms and intensity of involvement are different in these four countries and whether the system orientation towards family services or child protection influences practice in the social welfare agencies with parents. Involvement is studied in terms of providing information to parents, collecting information from parents and ensuring inclusion in the decision‐making processes. A vignette method is employed in a survey with 768 responses from child protection workers in four countries. The findings do not show a consistent pattern of difference regarding parental involvement in care order preparations that align with the type of child welfare system in which staff work. The goal in each child welfare system is to include parents, but the precise ways in which it is carried out (or not) vary. Methodological suggestions are given for further studies.     

‘Undeserving’ mothers? Practitioners’ experiences working with young mothers in/from care

Although teen pregnancy is on the rise in Canada, and while adolescent mothering in general has received considerable recent attention from researchers, there is a paucity of information about the particular experiences of young women who become mothers while in government care. Emerging out of a study guided by a grounded theory methodology to address this knowledge gap, this paper examines the experiences and perspectives of government‐based social workers who work with young mothers in/from care. Our findings indicated that social workers reflect prevailing middle class values, including norms about ‘good’ and ‘bad’ parenting, and centred around the belief that adolescent pregnancy is, in and of itself, bad. One of the most significant ramifications of workers’ values was their belief about the inevitability of ‘the cycle’: of children in care begetting children who ultimately came into care. Ironically, though workers and young mothers were both preoccupied by the concept of ‘the cycle’, and each were determined to break it, the two groups had very different ideas about what the cycle was all about and what perpetuated it. Unfortunately, this disjunction in perspectives, along with major recent shifts in the direction of child welfare policy and practice and related constraints in the resources at workers’ disposal, conjoined to create significant barriers to what workers and young women both recognized as supportive practice with youth in care.     

Ticking Boxes and Changing the Social World: Data Collection and the New UK General Practice Contract

The new General Medical Services contract was introduced into general practice in the UK in 2004, and it links pay to performance far more than in the past. As a result, accurate data collection about patients and the care that they receive is now not only important for good patient care but also to prove that targets are being met. The use of electronic records and information technology has thus become much more sophisticated. This article reports the results from an ethnographic study of the early stages of the new contract in two general practices. As expected, electronic data collection had increased in importance in both practices, with consequences both for clinician–patient interactions and for the structures and processes in the practices, as uniform data collection instruments are put in place that privilege ‘hard’ biomedical data that can be easily coded above ‘softer’, more patient-centred information. Roles and responsibilities had been changed to reflect the needs of the new systems, and new software applications allowed increased surveillance of both doctors’ and nurses’ performance; both of these had an impact on patterns of authority in our study practices. Furthermore, the structural changes that were found acted to embed the new ways of working, ensuring their reproduction in the future. In spite of these effects, we found little opposition to or critical reflection on the changes, and the doctors in our study continued to view their improved computer systems as neutral recording devices. The implication of these findings is discussed.     

Perceptions of Reconciliation and related Indigenous Issues among Young Residents of Shepparton

It has been argued that reconciliation between Indigenous and non‐Indigenous Australians requires non‐Indigenous Australians to change their attitudes. Some suggest that this process is occurring and that younger people hold more positive attitudes towards Indigenous Australians. This paper explored the perspectives of 86 young people from Shepparton, Victoria in relation to reconciliation and related Indigenous issues. The study found that young participants' views of reconciliation varied, and while some supported reconciliation, many opposed a national apology and indicated that they were not very informed about or interested in Aboriginal issues. Many distinguished between ‘good’ and ‘bad’ Aboriginals based on behaviour. Their talk was embedded with notions of special privilege, ‘sameness’ and social hierarchy but excluded attention to cultural difference. Findings suggest that these young people have embraced discourses of sameness, individualism and ‘practical reconciliation’ and that they are reluctant to reflect on their position of White privilege.