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.     

Organizational support for evidence-based practice within child and family social work: a collaborative study

Research in Practice works in collaboration with over 50 English local authorities and voluntary childcare organizations, to explore new and dynamic ways to increase the use of quality evidence to improve services to children and families. One Research in Practice initiative was a two‐year collaborative project involving the social services departments of six local authorities. This paper reports on how the views of more than 100 professional staff involved with the provision of services to children and families have been gathered to offer insight into how evidence‐based practice can be supported or frustrated in social care organizations. The findings suggest considerable uncertainty about the nature of evidence in social care and its validity in relation to decision‐making, policy and planning. Mechanisms essential for the dissemination, implementation and adoption of research messages are underdeveloped and tensions exist around the explicit use of research evidence within reports and reviews. Many practitioners and teams may be excluded from making decisions based on the best available research evidence through lack of access to internet resources and adequate information dissemination mechanisms. The paper concludes that there remain considerable areas for further debate if evidence‐based practice is to become a reality in work with children and families.     

Evaluating Social Work and Medical Practice with Black and Ethnic Minority Groups Using the Clinical Audit Model

Correspondence to Kish Bhatti-Sinclair, Department of Social Work Studies, University of Southampton, Highfield, Southampton SO17 1BJ, UK. Summary This paper is based on the External Audit-Ethnically SensitivePractice (EA-ESP) project which was undertaken within six primaryand secondary health care settings. This project is used asan example of how the clinical audit model can be used to monitorand review health and social work practice in the UK. The paperexamines quality, compares approaches to evaluation, and suggeststhat audit can be a useful tool for agencies in obtaining userand staff views on many areas of practice but in particularon equal opportunities, anti-racism and anti-oppression. Attentionis drawn to audit within broader evaluative and review approachesalready employed by social work academics and practitioners.The issue of quality and how it can be measured is consideredthrough an analytical comparison with approaches which employaction research and other evaluative means in the process ofreview. Audit is explored in the context of a growing need for the developmentof monitoring and review systems which provide evidence to supportand develop professionalism within social work. External auditis explored and compared to internal audit. Finally, the needfor the development of quality services in anti-racist and anti-oppressivework is highlighted and it is suggested that audit can be acost-effective and efficient way of achieving this.     

Room to move? Professional discretion at the frontline of welfare‐to‐work

Outcomes of social policies have always been mediated by the discretionary agency of front‐line staff, processes which nevertheless have received insufficient attention in policy evaluation and in the social policy literature more broadly. This article takes the case example of the policy reforms associated with the Australian government's welfare‐to‐work agenda. Drawing on two discreet research projects undertaken at different points in the policy trajectory, the practices of social workers in Centrelink – the Commonwealth government's primary service delivery agency involved in welfare‐to‐work – is examined. Centrelink social workers have been and remain one of the core groups of specialist staff since the Department's inception in the late 1940s, working to improve the well being of people in receipt of income security. Their experiences of the recent past and their expectations of the future of their professional practice as welfare reform becomes more entrenched are canvassed. In summary, the discretionary capacity of the Centrelink social workers to moderate or shape the impact of policy on income security recipients is steadily eroding as this group of professionals is increasingly captured by the emerging practices of workfare.     

From communication to co‐operation: Reconceptualizing social workers' engagement with children

Communicating and engaging with children is a foundational component of child care social work practice, but all too frequently, in the wake of serious incidents, it is the focus of criticism. Drawing on findings from a large‐scale ESRC‐funded research project conducted in the four U.K. nations, this paper explores, through a psychosocial analytic lens, how social workers anticipate, enact and reflect on their encounters with both children and their families. Close analysis of what social workers said about their practice alongside what they were observed to do in practice revealed perceptions, patterns and processes of communication that, first, minimize emotions and the complexity of the professional task and second, overly privilege verbal interaction. Drawing on Sennett's (2012) ideas this paper offers a reconceptualisation of this professional task, from a communicative to a co‐operative one. It affords and creates a space in which social workers can develop more attuned communicative practices that include rituals, gestures and the minimal use of force. The theoretical insights and evidence‐informed practice recommendations arising from this research have conceptual significance for the social work discipline and practical significance for the child care social work profession, across national and international contexts.     

‘Street‐level Bureaucracy’ Revisited: The Changing Face of Frontline Discretion in Adult Social Care in England

This reassessment of the continuing significance of Lipsky's (1980 ) work on ‘street‐level bureaucracy’ for frontline decision making is based on a retrospective review of the author's research on assessment practice in adult social care in England. The studies span the past two decades during which time successive governments have restructured and modernized social services departments. When these were established in 1970, they represented the high watermark of bureau‐professionalism – a mode of administration which dominated social welfare at the time Lipsky was writing. The subsequent dismantling of bureau‐professionalism calls into question the validity of his findings, and the author draws on her own research to assess conflicting views about the impact of social care reforms on the discretion which social workers exercise as street‐level bureaucrats. She concludes that the distinct types of discretion to emerge from her findings, represented in a taxonomy, are shaped by the differing micro environments of frontline practice which, in turn, affect the relative force of managerialism, professionalism and user empowerment in countering the defensive exercise of discretion described by Lipsky. Whilst her analysis affirms the continuing significance of Lipsky's analysis, it also points to the need for some revision to accommodate major shifts in welfare administration since the publication of his work. She highlights the potential relevance of these insights for investigating the next planned transformation of adult social care, personalization, as well as for the implementation literature more widely.     

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.     

Balancing Research and Action: Reflections on an Action Research Project in a Social Services Department

The relationships between social research, policy development and implementation are complex. External researchers are frequently employed by agencies to research their activities, with the expectation that the results will lead to organizational development. In some research traditions this takes place after the presentation of a final report. In the action research approach the two are integrated and action is a part of the inquiry process. Frequently, however, despite the best intentions of the commissioners and researchers, little action ensues. Influential factors, including issues arising from changes of key research personnel, shifts in organizational staff and roles, multiple agendas, and issues in presenting findings, dissemination and feedback dilemmas, are explored, using a case study of the introduction of care management in one local authority social services department. Finally, the usefulness of this type of research by an outsider in a context of very rapid change is assessed.     

Moral Positioning: Service User Experiences of Challenging Behaviour in Learning Disability Services

Several studies have indicated the importance of challengingbehaviour as a limiting factor on quality of life (Murphy et al., 1996;Brown and Thompson, 1997; Schwartz, 2003). This article presentsthe findings of research that aimed to investigate adults withlearning disabilities’ understanding and experiences ofwhat is perceived by staff and services to be challenging behaviour.This study was the final phase of research reported previouslyin this Journal (Hayden and Stevens, 2004). Interviews, groupdiscussions and observations were carried out with twenty-sixpeople with learning disabilities using social services’residential and day services. Participants were able to articulatecomplex responses about challenging behaviour, which is characterizedas a ‘moral web’: a complex network of antecedents,behaviours and consequences. Social care staff were seen byparticipants to play a key role: protecting people and ensuringthat appropriate (negative) consequences were suffered by instigatorsof challenging behaviour. These findings are interpreted withina positioning theory perspective, suggesting the importanceof understanding the ways that challenging behaviour is constructedthrough social interaction. Implications in the following areasare discussed: developing practice; the role of social carestaff; and the study of challenging behaviour as a social phenomenon.     

Researching Risk in the Probation Service

This paper will draw upon research and consultancy experience across a number of projects on risk assessment and management in the Probation Service between 1993 and 1999. The projects reflect a range of sponsors and funders, from central government bodies such as the Home Office and the Scottish Office, to professional, managerial and employment bodies such as the Association of Chief Officers of Probation and the Central Council of Probation Committees, to individual Probation Service areas. The projects have required engagement with different levels of staff and different vested interests, including the professional/union bodies representing the management and officer grades respectively, in addition to central government policy makers. All the projects have had an applied policy and practice focus. The paper begins with a review of current ethical and political dilemmas in research on offender risk assessment, and then contemporary responses to ethical dilemmas are critically reviewed, followed by an outline of 'practice guidance' for researchers. The paper concludes by arguing that researchers in the social arena should be subject to the same standards of defensible decision making as their counterparts in social care practice, and that essential to such defensibility is the transparent demonstration of the 'grounds' upon which ethical decisions are made.     

Patterns of practice: An exploratory factor analysis of child and family social worker skills

There is relatively little research on the communication skills that social workers use in direct practice with families. This study explores patterns of practice skill found in child and family social work home visits. The study analysed 127 practice interactions in family homes, coding for seven dimensions of worker skill using a coding framework drawn from motivational interviewing. Exploratory factor analysis was employed to establish patterns of skill within the data and to group key dimensions of skill. The findings make two contributions. First, three fundamental dimensions of good practice emerged, which we characterize as care and engagement, good authority, and support for behaviour change. Second, in exploring the relationship between “care” and “control” elements of social work, skilled social workers were able to combine good authority and empathic engagement, whereas those who were less skilled in use of authority were also less good at engagement. This contributes to debates about care and control in social work. The usefulness of these dimensions for conceptualizing practice in child and family social work is discussed and directions for further research are suggested.     

Parental substance misuse and child care social work: findings from the first stage of a study of 100 families

Parental misuse of drugs or alcohol is known to be a common issue for child care social workers, yet there has been surprisingly little British research on the topic. The study reported here attempts to address this gap. All files going for long‐term allocation in four London boroughs over on average 1 year were examined (290 files). Parental substance misuse (PSM) emerged as a major feature of social work caseloads. Of the 290 cases, 100 (34%) involved concerns about parental substance misuse. The families involving substance misuse were more vulnerable on a variety of measures: the children were younger, the parents had more individual problems and the families lived in more difficult social situations. PSM cases tended to be ‘heavy end’ at the point of allocation: they accounted for 62% of all children subject to care proceedings and 40% of those placed on the child protection register. There was a fairly even spread between alcohol and drug misuse, and a number of cases involved both. Substance misuse specialists were rarely involved in working with families, primarily because parents said that they did not think that they had a problem. Suggestions for ways in which policy and practice with PSM might be improved are made in light of these findings.     

“A game of two halves?” Understanding the process and outcomes of English care home closures: Qualitative and quantitative perspectives

With care services increasingly delivered via a market there is always a risk that care homes could fail financially or struggle in terms of quality, ultimately having to close. When this happens, the received wisdom is that subsequent relocation can be detrimental to the health and well‐being of older residents (possibly even culminating in increased mortality). However, there is very little formal evidence in the United Kingdom (UK) or beyond to guide policymakers and local leaders when undertaking such sensitive work. Against this background, this article reports findings from an independent evaluation of what is believed to be the largest care home closure program in the UK (and possibly beyond). This consisted of qualitative interviews with older people, families, care staff, and social work assessors during the closure process in one case study care home and one linked day center, as well as self‐reported health and quality of life data for older people from 13 homes/linked day centers at initial assessment, 28 days after moving and at 12‐month follow up. The study is significant in presenting public data about such a contested topic from such a large‐scale closure process, in its focus on both process and outcomes, in its mixed‐methods approach, and in its engagement with older people, families, and care staff alongside the use of more formal outcome measures. Despite significant distress part‐way through the process, the article suggests that outcomes either stayed the same or improved for most of our sample up to a year after moving to new services. Care homes closures may thus be a “tale of two halves”, with inevitable distress during the closure but, if done well, with scope for improved outcomes for some people in the longer term. These findings are crucial for current policy and practice given that the risk of major closures seems to be growing and given that there is virtually no prior research on which to base local or national closure processes. While some of this research is specific to England, the underlying issue of care home closures and lessons learned around good practice will also apply to other countries.     

Childcare with gloves on: protecting children and young people in residential care

Summary Abuse of young people in out-of-home care has caused internationalpublic and professional concern over the last fifteen years.Although research has been undertaken to identify factors thatare likely to contribute to a safer environment for young people,little consideration has been given to the impact of abuse scandalson workers' perceptions of what constitutes abusive behaviour.This paper presents the findings of a study undertaken in threeresidential children's units in one local authority which soughtto explore this area and considers two key findings which raiseissues for the social work profession. These are, first, thatthe perception of abusive behaviour was in the main determinedin terms of the workforce's own vulnerability to allegations.Secondly, staff found it difficult to conceive of a colleagueas a potential perpetrator of abuse. The paper concludes byevaluating recent government policy documents in the light ofthe study findings.     

Advance Care Planning Throughout the End-of-Life

Abstract

Advance care planning throughout the end-of-life is an increasingly important aspect of professional practice with older adults and their families. As the nation's population continues to live longer, more and more people will experience years of functional and cognitive decline prior to death. This article discusses the growing importance of advance care planning using a long-range, holistic perspective of examining care needs throughout the end of life. End-of-life care is conceptualized by three trajectories of decline leading to death, with about two-thirds of all older adults succumbing to four key conditions: congestive heart failure, emphysema, frailty, and dementia. Research regarding the advance care planning needs of older adults with the key conditions is presented. Further research is needed to enhance social work practice in this area.     

Social Work Teachers and Social Work Practice

Summary A survey was undertaken to discover the extent to which thosesocial work teachers who teach social work methods, continueto practise after they become educators. The results suggestthat not more than 25% do so, and many of these on only a tokenbasis. Most respondents however regarded such practice as animportant aide to the teaching of social work methods, althoughsome consider consultancy roles to be equally relevant. In nocases was such practice linked with research, and only exceptionallydid employers allow time explicitly for it. We outline fourdifferent bases on which teachers might practise, all of whichwere suggested by respondents, many of whom added personal notesto the questionnaire, indicating the extent to which this subjectis a matter of wide interest and concern     

Child protection social work and men's abuse of women: an Irish study

This paper reports the findings of an exploratory study of the response of social workers within a community care setting, in a large Dublin suburb, to cases involving men's abuse of women. This research aims to focus on what child protection workers do regarding this abuse, and what they say about what they do, thereby giving readers a sense of the action taking place in this social work team. The data, generated from both qualitative and quantitative methodological research, reflects this aim, as it taps into the working model of responses to men's abuse of women held by social workers, and identifies what influences that, thereby reflecting the realities and constraints of everyday work. At the time the research was carried out (2000), the results confirm that the prevalence of cases involving men's abuse of women on this team was in line with international findings. This research revealed an absence of a team policy, an agreed definition of intimate violence in this context and agency practice guidelines, and illuminated how these gaps act as a deterrent to effective intervention. This paper explores some of the ethical and practical dilemmas that may arise for child protection social workers intervening in cases where the abuse of women by men is present. Recommendations arising from this research identify a need for a clear policy and best practice guidelines for social work staff in relation to this abuse.     

What do social workers and children do when they are together? A typology of direct work

There is renewed interest in the place of direct work and relationship‐based practice in social work. This paper explores the day‐to‐day direct work that happens where children and young people are ‘looked after’ at home, from the perspectives of children, social workers and those supervising practice. It is based on interviews with eight children and 25 professionals about their experiences. In this paper, I highlight that despite barriers, direct work, which is characterized as meaningful by children and professionals, happens and that the relationships formed between children and social workers are an important precursor to and an outcome of direct work. The research was undertaken in Scotland, and although the legislation, policy and guidance differ from other jurisdictions, the messages about direct work are relevant for practice in other countries.     

Critical understandings of child development: the development of a module for a post-qualifying certificate course in child protection studies

This paper explores the dilemmas involved in selecting appropriate theoretical and research material to help social workers in practice. Concentrating on the needs of those working in child care and protection, the paper uses the example of the area of child development knowledge to illustrate a process of presenting theory for practice. Specifically, the focus is on the redevelopment of a child development module for a post-qualifying certificate course in child care and protection that aims to encourage students to make critical use of current research and theory. The paper explains the reasoning behind the choice of attachment theory as the underpinning theoretical framework. It also addresses possible pitfalls in an uncritical use of such theory. The paper finally sets out how the module addresses the need social workers have for a framework to guide intervention in individual cases. The dimensions described are those of individual vulnerability or resilience and factors in the environment that are adverse or protective.