Building Care Management Competence in Services for People with Learning Disabilities

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

Foster and Residential Care Practices Compared

Correspondence to Dr Matthew Colton, Department of Social and Administrative Studies, Barnett House, Wellington Square, Oxford OX1 2ER Summary This paper reports what is, remarkably, the first systematic,in-depth, comparative study of foster and residential care practices.The overall research objectives were: (1) to delineate and comparecare practice in special foster homes (i.e., homes accommodatingchildren traditionally considered too old or disturbed for fosterplacement) and Children's Homes for older children in localauthority care; and (2) if possible, ascertain whether the responsesmanifested by children in such settings can be related to thecare practices they experience. The approach adopted was essentially sociological. A lengthyperiod of field-work in two local authorities featured the useof a range of research instruments and included the collectionof data on the following: the management of recurrent–mainlydaily–social events; children's community contacts; theprovision of physical amenities; the controls and sanctionsused by caretakers vis-à-vis children; the roles of caretakersand their behaviour and attitudes towards children; and thecharacteristics of children, their behaviour towards caretakers,perceptions of their social environments and progress duringplacement. Quantitative methods were used in data analysis becausethey provide a useful guide to the import of observed differencesbetween foster homes and Children's Homes. Care practice in the foster homes was, overall, significantlymore child-oriented than in the Children's Homes. Moreover,the responses of residential children appeared to fall shortof offering justification for the ways that the lives of suchchildren seemed to differ from those of foster children.     

The New American Social Work Gospel: Case Management of the Chronically Mentally III

Correspondence to Dr R. A. Cnaan, School of Social Work, University of Pennsylvania, 3701 Locust Walk, Philadelphia, PA 19104, USA. Summary Case management is currently the most popular mode of servicedelivery in the United States, especially in community programsfor chronically mentally ill people. Proponents of case managementclaim that it is cost-effective and that it assures provisionof necessary services to clients. In this paper I do not challengeits effectiveness but argue that case management neither empowersclients nor is it free of drawbacks. Given that many countriestend to model the United States, foreign social workers andother human service professionals should first examine the usefulnessof case management vis-à-vis their own cultural and economiccontexts, especially in the light of its many drawbacks.     

The Effectiveness of Attached Social Workers in the Management of Depressed Women in General Practice

Summary Following early reports of the feasibility and usefulness oflocating social workers in general practice (Collins, 1965;Forman and Fairbairn, 1968; Cooper, 1971) the number of attachmentsto general practice has increased markedly over the last decade(Gilchrest et al., 1978). Although there have been a numberof accounts of the increased co-operation between health carestaff (Clare and Corney, 1982) there has been a dearth of objectiveevaluations of the advantages these schemes bring to generalpractice patients. This paper describes the design, executionand outcome of a clinical trial of social work carried out ondepressed women in general practice aged 18–45. It focuseson the social workers' activities and the clients view of help:more detailed information is described elsewhere (Corney, 1981).     

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

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

Adolescents in Care and their Social Workers: A Research Note

Summary There has recently been an increasing concern that young people,and especially those in residential care, should be encouragedto express their views, and that the views expressed shouldbe used in improving the care which they receive. The publicationof the Who Cares? booklet (Page and Clarke¹), and the emergenceof ‘Who Cares’ groups and the ‘Voice of theChild in Care’ organisation, is evidence of this concern.In sympathy with these developments has been a study of adolescents'perceptions of social workers, and a part of this research hasincluded a pilot study of the views of adolescents living intwo family group homes.     

Determinants of Substitute Child Care Practice

Correspondence to Dr Matthew Colton, Department of Social and Administrative Studies, Barnett House, Wellington Square, Oxford CX1 2ER Summary The first part of this paper attempts to examine the factorswhich help to define foster and residential care practices.The discussion is informed by a comparative study of fosterhomes and Children's Homes, which was reported in the previousissue of this journal (BJSW 18:1). Overall, care practices inthe foster homes compared very favourably with those observedin the Children's Homes. It is argued that this finding owesmuch to the bureaucratization of Children's Homes. The secondsection considers the implications of my work for policy andpractice in the field of substitute child care. Use is madeof the insights provided by the preceding section to suggestways by which the major shortcomings identified by empiricalresearch might be ameliorated. This statement includes an argumentin favour of a significant expansion of family placement forolder children in public care, and a proposal for a child-orientedalternative to the sorts of Children's Homes visited.     

Good Practice in the Education of Children in Residential Care

Correspondence to The Directors, New Horizons (Child Care) Ltd., Unit B, Silkmoor, New Street, Frankwell, Shrewsbury, Shropshire SY3 8LN, UK. E-mail info{at}new-horizonschildcare.co.uk Summary Research shows that the education of children in residentialcare is generally poor, in terms of both process and outcome.This has highlighted the uncertainty over how best to educatethese children and a pessimism over what they can achieve. Drawingupon the findings of an evaluation of a children’s home,this paper argues that children in residential care can havegood educational outcomes. It also shows that it is possibleto identify the processes by which these outcomes can be broughtabout. However, this largely positive assessment is predicatedupon education being defined broadly in respect of ‘process’and ‘outcome’. Moreover, it is important not tounderestimate the formidable challenges inherent in this work.While the multi-agency nature of this work gives rise to oneof the most significant, it has to be recognized that responsibilityfor the education of children in residential care falls primarilyto children’s homes. If children’s homes are tomeet the increasing expectations that are being made of them,national and local government will have to undertake a radicaltransformation of residential childcare, especially in termsof attitudes towards, and resources invested in, this sector.Central to this is the establishment of a qualified and properlysupported workforce.     

Contract Management and Community Care: A Negotiated Process

Correspondence to Jackie Powell, Department of Social Work Studies, University of Southampton, Highfield, Southampton, SO17 1BJ, UK. Summary Drawing on a wider study of community care arrangements forvisually impaired people in England and Wales, this paper exploresthe implementation of contractual arrangements as part of thedeveloping formalization of partnerships between local authoritysocial services departments and voluntary organizations. Itargues the importance of conceiving contract management as acomplex set of social processes involving a diversity of interestsand inequalities of power, where skills in negotiation are centralto promoting greater participation in community care policyand practice. It concludes with a brief discussion of the relevanceof social work to the implementation of this key area of contemporarycommunity care arrangements.     

Integration and Targeting of Community Care for People with Severe and Enduring Mental Health Problems: Users' Experiences of the Care Programme Approach and Care Management

Correspondence to Professor John Carpenter, Director, Centre for Applied Social Studies, University of Durham, Elvet Riverside II, Durham DH1 3JT, UK. E-mail: J.S.W.Carpenter{at}dur.ac.ukJ.S.W.Carpenter@dur.ac.uk Summary We report the experiences of different models of community careof random samples of 262 people with severe and enduring mentalhealth problems living in four districts in the north of England.The districts were characterized in terms of the extent of (1)integration between the health service-led Care Programme Approach(CPA) and social services Care Management, and (2) targetingof services on people with severe mental health problems. Themajority of service users felt involved in planning their owncare and considered that they had choice in their care and treatmentwhen in the community, but not in hospital. Although all theseusers were formally subject to the CPA, the proportions of usersin the districts believing they had a written care programmeranged between 37 per cent and 60 per cent. Of these, the greatmajority were very positive about their care programmes andfelt that they were being helped to become independent. Theseresults were replicated when 87 per cent of the original samplewas re-interviewed six months later. There were significantdifferences between the four districts and evidence that userspreferred an integrated health and social care service. In addition,a higher proportion of users in inclusive districts were satisfiedcompared to those in targeted districts. Notwithstanding thesepositive findings, there is still considerable room for improvementin relation to the involvement of family carers and the provisionof adequate information about prescribed medication and makingformal complaints.     

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.     

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’.     

Regulation in Child Protection--Policy Failure?

Correspondence to Mai Walton, Department of Applied Social Studies and Social Work, University of Keele, Keele, Staffs. ST5 5BG Summary This paper examines child protection policy formulation andimplementation. It suggests that policy has been incrementallyformed in an expedient fashion to suit the political and organizationalstatus quo. It draws upon models of issue ascendancy, policyanalysis and inspection, and argues that child protection policyis regulatory in nature yet lacks the prerequisites normallyfound in regulation. It examines perceived policy failure anddemonstrates that this results from partial policy formulationand lack of clarity in objectives.     

Is Gender Inequality in Social Work Management Relevant to Social Work Students?

Correspondence to Ms C. Taylor, Research Fellow, Social Work Research Centre, University of Stirling, Stirling FK9 4LA. Summary This paper reports on a study carried out in 1991 based on questionnaireswhich asked 169 female and male social work students about theiraspirations and expectations in respect of promotion in theirfuture career. Underlying the study is a concern about the unequalrepresentation of male and female workers at management levelsin social services in the UK, there being at present a predominanceof male managers. The phenomenon is not regarded as unique tosocial services, but as part of the pattern of gender inequalityin the workforce as a whole. The view that women contribute to the phenomenon by a fundamentallack of interest in, or unwillingness to apply for, promotionwill be challenged. It will be argued that the differences inthe aspirations and expectations of male and female employees,which previous research studies have reported, may be an effectof the experience of the organization rather than a cause ofthe scarcity of female employees in promoted posts. The paper will focus on some of the findings, including students'aspirations and expectations, their opinions about the unequalrepresentation of men and women in social work management, theimplications of this for their own career and whether they considerthis issue is, or should be, a significant component of socialwork training.     

Care Programming in Mental Health: assimilation and adaptation

Correspondence to Justine Schneider. PSSRU. University of Kent, Canterbury CT2 7NF. Summary Two years after the care programme approach in mental healthwas introduced there is still widespread confusion about itsmeaning and its relation to other changes in the arena of communitycare. This paper looks at how care programmes are being implementedand at whom they are being targeted. It also examines the relationbetween care management and care programming and raises somequestions about future developments in the light of communitycare reforms. It draws on data collected during 1992 from threecontrasting health districts, all of which had made considerableprogress in care programming. Sixty practitioners were interviewedabout the theory and practice of care programming. Their experienceis presented here in the context of a review of community careplans for 1992/93 which characterizes the responses of differentlocal authorities to the approach.     

Research Note: Developing Outcome Measures in Child Care

Correpondence to Dr Harriet Ward. Research Associate, University of Bristol, Social Policy and Social Planning. The Alfred Marshall Building, 40 Berkeley Square, Bristol BS8 1HY. Summary The complexity of the concept of outcome has discouraged researchinto the impact of the care experience on the child. This Notesummarizes the conceptual thinking behind a comprehensive systemof assessment which is being piloted in four local authorities,and reports on the preliminary results.     

Questions Raised for Local Authorities when Old People are Evicted from their Care Homes

Correspondence to Peter Scourfield, School of Community, Health and Social Studies, Anglia Polytechnic University, Cambridge CB1 1PT, UK. E-mail: p.scourfield{at}apu.ac.uk Summary Successive government policies have created a situation wheremost residential and nursing care is provided by the independentsector. It is in the nature of a marketized and privatized caresystem that homes will periodically close or change ownership.The physical and mental well-being of elderly residents experiencingeviction and relocation can be seriously damaged by the experience.No policy and practice guidelines have been issued from centralgovernment to cover how care home closures should be managed.Local authorities are therefore dealing with such events onan ad hoc basis. Understandably, the main emphasis is oftenput on actually finding appropriate alternative placements.Practices vary across different local authorities. This articleasks whether the necessary work required to minimize the harmfuleffects caused by the stress of relocation is actually beingcarried out properly. It also raises the questions of what exactlyshould be offered to older people when they are given noticeto quit, who is best qualified to do the work and whether caremanagement as it has developed within the ‘purchaser/providerframework’, is adequate to the task. In short, where cansocial work for older people be found when it is needed?     

Social Work, Social Science and Practice Wisdom

Correspondence to Michael Sheppard, Department of Applied Social Science, University of Plymouth, Drake Circus, Plymouth PL4 8AA. Summary Social work has for some time had an ambiguous and ambivalentrelationship with its social science knowledge base. However,this has arisen, at least in part, because of the emphasis onthe outcome or product of social science rather than the processby which research is conducted. This paper, focusing on assessment,argues that an emphasis on process goes some way to closingthe gap between social science and social work, that the methodsused by social researchers are, in many respects, simply refinementsof the methodology of everyday life, and that social workers,when conducting assessments operate rather like practical qualitativeresearchers. Using Analytical Induction as an heuristic device,it proceeds to explore critical characteristics of good practicein social work assessments. It concludes that practice shouldbe characterized by critical awareness, involving imaginativedevelopment of alternative hypotheses, a sceptical attitudetowards case assessments and a principle of adopting hypothesesleast likely to be in error.     

Community Care for the Elderly -- Rhetoric and Reality

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