Risk Management Paradigms in Health and Social Services for Professional Decision Making on the Long-Term Care of Older People

Risk management systems and structures are developing rapidlywithin UK health and personal social services. However, therisk management strategies of organizations need to take intoaccount the conceptual frameworks used by professionals. Thisgrounded theory study used data from nineteen focus groups andnine semi-structured interviews (ninety-nine staff in total)to explore perspectives on risk and decision-making regardingthe long-term care of older people. Focus group participantsand interviewees comprised social workers, care managers, consultantgeriatricians, general medical practitioners, community nurses,occupational therapists, home care managers and hospital dischargesupport staff. Social work and health care professionals conceptualizedrisk and its management according to six paradigms that appearedto be in a state of reciprocal tension: (i) Identifying andMeeting Needs; (ii) Minimizing Situational Hazards; (iii) Protectingthis Individual and Others; (iv) Balancing Benefits and Harms;(v) Accounting for Resources and Priorities; and (vi) Warinessof Lurking Conflicts. The effective translation into practiceof risk management strategies needs to address the complex andoften contradictory issues facing health and social servicesprofessionals.     

Autonomy,Choice and Control for Older Users of Home Care Services: Current Developments in Swedish Eldercare

In Sweden, a policy shift towards more individualized eldercare, with an emphasis on consumer choice, has taken place. The aim of this study was to analyze the processes and practices of individualized eldercare, focusing on preconditions for older peoples’ choice and control. Data consist of qualitative interviews with users of home care services (n – 12) and staff (n – 12) and participant observations (n – 7) of meetings between staff and older people. The choice and control available to older users emerged as decisions about ‘what’ care and services, ‘who’ should provide the care and services, and ‘how’ the care and services should be performed. Three approaches to enable older people choice and control over their home care services were revealed: test and revise, services elaborated in close collaboration between users, care managers and home care staff; choices in the moment, users could choose services at each occasion; and quality improvement through competition, competing providers develop attractive services. The findings could guide policy makers in combining the strengths of these approaches to enable older people in need of support to become co-producers in designing, managing, as well as consuming, care and services. Future quantitative research is needed to achieve generalizable knowledge about the strengths and weaknesses of different ways to organize eldercare services.     

Working in the Social Services: Job Satisfaction, Stress and Violence

Correspondence to Professor Jan Pahl, Department of Social and Public Policy and Social Work, Darwin College, University of Kent at Canterbury, Canterbury CT2 7NY. Summary A major survey of the social services workforce (Balloch etal., forthcoming), carried out in the Research Unit at the NationalInstitute for Social Work, has produced new data about sourcesof job satisfaction and about the incidence of stress and violence.The survey took place in five different local authorities inEngland, and interviews were carried out with 1276 individuals,selected from four groups of staff: managers, social work staff,home care workers and residential staff. The results suggestedthat those who work in the statutory, social services do experiencemore stress and violence than workers in other parts of thehealth and welfare services. However, different jobs presenteddifferent hazards. In general, home care workers were the mostsatisfied with their jobs, and were also the group least likelyto be stressed or to experience violence in the course of theirwork. By contrast, residential workers, especially those withmanagement responsibilities, were most at risk of both violenceand stress. Men were more likely than women to experience violence,while other groups with a higher than average risk of stressincluded younger members of staff, and managers and social workstaff responsible for elderly people.     

Home Care Services for Indigenous Population in Taiwan: Cultural and Socio-Structural Implications for Long-Term Care Policy

Taiwan faces the world’s top aging rate over the next 8 years, making long-term care a priority for all populations, including the 16 indigenous groups who live primarily in the mountains and have different cultural practices than mainstream Taiwanese people. To examine how home care services are coordinated, managed, and delivered to the indigenous populations, we interviewed 10 public care managers and analyzed the interview content to assess their work experiences with home care workers and indigenous users in 2016. The research revealed four findings: (1) Home care utilization patterns and attitudes were different between the rural indigenous and non-indigenous populations; (2) home care utilization was limited by cultural, economic, and language challenges; (3) home care workers faced cultural and socio-structural challenges; and (4) policy and service provisions were rigid, without the socio-structural flexibility needed to accommodate the indigenous culture. A more efficient model will require the collaboration of public care managers, home care workers, and indigenous families to create a fair-coordinated plan. As Taiwan launches the Ten-year Long-Term Care Plan 2.0, a one-stop service delivery center to integrate care options and provide services for people of indigenous backgrounds is a must.     

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.     

Assessment processes in social work with children at risk in Sweden and Croatia

The aim of this article is to compare Swedish and Croatian social workers' assessments and protection of a 4-year-old child exposed to risk in its own family. The data were collected from 87 Croatian and 72 Swedish social workers by means of a questionnaire, which incorporated a vertical vignette. Effects of the participant's country of residence were investigated with respect to: (i) risk assessments; (ii) perception of the main problems; (iii) tolerance of corporal punishment; (iv) judgements about appropriateness of interventions. The results suggest that Croatian social workers have a more child-protective approach than their Swedish colleagues. Swedish social workers have a more supportive approach than Croatian social workers. Despite fundamental similarities in assessments between the countries, significant differences were found in preferred interventions. The Swedish social workers were more in favour of keeping the child at home with the support of social services. The Croatian social workers were more in favour of removing the child from home by means of a care order. This might primarily be attributed to the differences in availability of family support services and to different discourses in Sweden and Croatia.     

Navigations between regulations and gut instinct: the unveiling of collective memory in decision‐making processes where teenagers are placed in residential care

The decision to take a young person away from his or her family into out‐of‐home care and treatment is the most drastic intervention within the statutory powers bestowed upon social services. The results of reports on the quality of residential treatment reveal that state supervision has not proven to be a good substitute for parental care. In this paper we analyse the decision‐making process when young persons are placed in residential care. Focus groups and individual interviews with different stakeholders were conducted. The results show that the placements are a collective process involving negotiations between the different parties with a coordinating social worker in the middle, with the aim to bring something to build hope on in often desperate situations, regardless of the specific treatment method used. To inform the process, the social workers draw on a ‘collective memory’ shared among colleagues in the department. Important signs of quality of a residential unit were the relational and collaborative competence from the staff. The inclination to use soft, diffuse information in decision‐making shows a striking lack of evidence upon which social workers can build well‐informed and knowledge‐based decisions.     

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.     

Towards Integrated Community Care for the Frail Aged

The growing awareness of family support among the frail aged has yet to be incorporated into a clear strategy for developing comprehensive community care. A starting point is to identify the characteristics of target populations, the range of tasks associated with aged care, and the capabilities of various informal and formal providers. Fully appropriate services would take into account the availability of family support as well as the needs of older people themselves. It is suggested that services be designed to (1) supplement support from spouses; (2) periodically substitute for other co-resident carers; (3) complement assistance from nonresident family; and (4) substitute for the unavailability of family support. Community services currently provide modest supplements, principally to nonresident support, but do little to address the other contexts of care. Suggestions are made for program developments that would provide genuine alternatives to institutionalisation without devolving the social costs entirely onto families.     

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.     

Sheltered Housing and Community

This paper considers the role of sheltered housing following the introduction of new community care arrangements in 1993 and examines the continuing uncertainty about its exact role as community care continues to develop. It reports on a study conducted in Shropshire, using a postal survey and interviews with older people and service professionals. The study highlights the importance of sheltered housing for older people, particularly in relieving them of concerns about maintenance and repairs, social isolation and security. These factors were crucial for their overall peace of mind and quality of life. While only a small proportion of tenants received help under social services' community care arrangements, the additional support, monitoring and service coordination provided by wardens helped some of them to remain in sheltered housing when residential or nursing home care might otherwise have been necessary. Sheltered housing was overwhelmingly popular with older people — but their satisfaction was closely associated with the availability and quality of the warden service. Although sheltered housing is not currently in vogue in housing policy, the paper argues that it plays a vital role in local provision for older people and needs to be more closely integrated into community care policy, while at the same time preserving the characteristics that make it popular with its residents.     

Loss and grief: The experience of transition to residential aged care

There is growing recognition of the experience of non-death-related loss and grief. One unexplored area of non-death-related loss and grief is associated with older people’s transition from home to residential aged care (RAC). This paper reports findings from a qualitative study that explored the experiences of people living in RAC, carer-relatives of people living in RAC and RAC staff. Using theories of loss and grief, the paper identifies features of the transition to RAC that are associated with unresolved loss and maladaptation to changed circumstances, and the types of support that would mitigate these. Using a series of focus groups with both residents and carer-relatives, as well as staff, the study found that residents and their families need more support to negotiate the multiple, often necessarily hasty decisions and bureaucratic requirements associated with transitioning to RAC, while simultaneously experiencing loss and grief. The types of support that families would welcome from service providers include facilitating shared decision making, valuing family and community carer expertise and providing practical information and assistance to fulfil administrative obligations.     

Young people leaving care in Sweden

The transition from a placement in care to an independent life can be a problematic phase for young people. In Sweden, special care‐leaving services are almost non‐existent. What then happens to young people when they leave a placement in out‐of‐home care? This paper draws on the results of a study in which 16 young care leavers between the ages of 18 and 22 years were interviewed. Telephone interviews were also performed with the young care leavers' parents, social workers, foster carers and institutional staff. The aim of the study was to investigate how young care leavers perceive the transition from care to an independent life. The Swedish welfare model, the prolonged transition to adulthood and the family‐oriented welfare discourse have been used as analytical perspectives. The results show that young care leavers have a pronounced need for social, emotional, practical and financial support. Whilst such support is occasionally provided by foster carers and residential staff, it is seldom given by social services or biological parents. This group is at risk of facing severe problems in the transitional phase from care to independent life, a fact that is not acknowledged by the Swedish welfare system.     

Challenging Professional Roles: Lay Carers' Involvement in Health Care in the Community

The bulk of care in the community is carried out by lay carers. Recent policy initiatives to support them in the United Kingdom are outlined. There remains evidence of significant gaps in support from professional health and social‐care workers including community nurses. This paper reports three studies of lay carers: those caring for older people, carers of technology‐dependent children, and home‐care workers involved in the “direct payments” scheme. Findings are reported in the areas of decisions about appropriate caring roles, the lay–professional boundary, training and respite opportunities and the expertise of lay carers. Recommendations for policy and practices are made.     

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.     

Long-term Care in China: Issues and Prospects

One of the major socioeconomic challenges China faces is the rapid aging of its population. China is now an aging society, even though it is still regarded as a middle-income economy. Coupled with the market-driven reform of social services and rapid erosion of family support, the provision of affordable and accessible social care services to older people has already become an urgent issue for the government to address. Looking into the future, the formulation of a sustainable position on long-term care (LTC) will increasingly become the major focus of social policy. This article sets out the background to the demographic shifts resulting in the emerging need for LTC in China. It analyzes the issues facing LTC services and reviews their prospects, including the structure, operation, financing, and interfacing of residential and community-based home care services.     

Migration, ageing and mental health: an ethnographic study on perceptions of life satisfaction, anxiety and depression in older Somali men in east London

This ethnographic study was carried out in the aftermath of an epidemiological investigation, the first of its kind, on the health and social status of Somalis aged 60 years and over living in Tower Hamlets, east London. The main aims of the study are to explore views on mental health and well-being and identify sources of stress and support so as to gain greater understanding of background factors of life satisfaction and depression in 'first-generation' older Somali migrants in Tower Hamlets (males). Face-to-face interviews were conducted among 28 males in Somali with the help of a bilingual interpreter from the same age, sex and cultural background of participants. Several factors were perceived to decrease life satisfaction and increase vulnerability to depression in male Somalis, in particular low family support in the face of increasing physical disability, loneliness, inadequate access to community services and inability to return home. Social isolation, low level of control over one's life, helplessness and social degradation – ageism, perceived racial/religious discrimination and, to a lesser extent, racial harassment – were common themes identified in people who said to be depressed. Family support was the main buffer against depression; other coping resources were represented by religious practices and reliance on Somali peers. Avoidance coping seemed to encompass denial of depression in participants who had low mood. The study revealed multiple reasons for ill-being, in particular in people who had high expectations about medical and social care. Low levels of distress were found in Somalis who felt supported by their families. There is a need for social workers and other health professionals to advance discussions of mental-health issues in the community and for service providers to promote greater access to culturally relevant medical and social services for Somali elders in Tower Hamlets and strengthen their informal support networks.     

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.     

Using Private Social Care Services in Finland: Free or Forced Choices for Older People?

ABSTRACT

Use of private social care services among older people is increasing in Finland. This study aims to understand why older people choose private care in a comprehensive tax-subsidized social care system and examines whether people choose private service as a free choice or a forced choice as well as what factors contribute toward making these choices. Data for this study (N = 1,436) were gathered in 2010 from people aged 75 and above living independently at home in two Finnish cities: Tampere and Jyväskylä. Data were analyzed with several quantitative tests: chi-squared tests, multinomial regression analysis, and qualitative content analysis (for the open-ended responses from the survey questionnaire). Findings reveal that people chose private services mostly because of the effortlessness involved in its use and of the need for additional services that are unavailable through municipality; for example, cleaning. Majority of the respondents performed a free choice to use private services. People who lived in a city center with a higher level of income and who needed more services were more likely to be constrained toward using private support. Major concern, due to diminishing public service provision, is about service accessibility of economically disadvantaged groups; therefore, more research is required to understand the effects of the growing care market in Finland.     

Lay Assessors and Care Home Inspections: Is There a Future?

This paper reports on research funded by the Nuffield Foundationexploring the role of lay assessors in the care home inspectionprocess in England and Wales. Lay people have been includedin many care home inspections for the past decade. Similar layinvolvement is included in other public service inspectionssuch as the Office for Standards in Education (OFSTED) inspectionsof schools. The Board of the short-lived National Care StandardsCommission (NCSC) controversially decided to dispense with suchlay involvement in the inspection process. The replacement body,the Commission for Social Care Inspection (CSCI), intends toinclude lay people in the inspections of support services inthe community but is hesitating about reintroducing them intocare home inspections. This research project was able to explorethe role taken by lay assessors in thirteen inspections of carehomes for older people and for adults with learning disabilities.The research concluded that lay assessors had a significantrole in communicating with residents and staff and observingcare home life. Their role was particularly important, as inspectorswere often so involved in paperwork and checking policy compliancewith the national minimum standards that they were often ableto spend little, if any, time talking to residents or staff.It is argued that there is considerable potential for a strengthenedrole of lay people in the care home inspection process.