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.     

Medicalization of Social Workers in Mental Health Services in Hong Kong

Correspondence to Dr Kam-shing Yip, Associate Professor, Department of Applied Social Studies, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong. E-mail: ssksyip{at}polyu.edu.hk Summary Medical dominance is a crucial problem in social work practicein mental health services. This paper is an examination of theresponse of social workers to medical dominance in mental healthservices in Hong Kong. To explore the process and the effectsof medicalization of social workers, sixty-three social workersin various areas of mental health service settings were interviewed.Their reaction and daily performance in facing medical dominancewere analysed and evaluated. The findings show that facing medicaldominance was a common occurrence for social workers in variousmental health services in Hong Kong. Conflict existed betweenthe rationalization of medical knowledge by medical professionals,and social work rationalization of social work knowledge bysocial workers. The process of medicalization consisted of fivestages: ignorance of medical dominance, confronting medicaldominance, compromise with medical dominance, acceptance ofmedical dominance and internalization of medical dominance.The findings also show that medicalization was influenced bythe organizational and team context.     

The Role of Assertiveness in Clarifying Roles and Strengthening Job Satisfaction of Social Workers in Multidisciplinary Mental Health Settings

Correspondence to Dr Claire Rabin, Tel Aviv University, Bob Shapell School of Social Work, Ramat Aviv, 69 978, Tel Aviv, POB 390470, Israel. Summary Eighty-seven social workers, working in nine different mentalhealth settings, were administered four questionnaires tappingthe following variables: assertiveness in daily life; assertivenessin the job setting; role clarity; and job satisfaction. Stepwiseregression analysis showed assertiveness in the job settingto be strongly correlated with role clarity. Assertiveness indaily life was also significantly correlated with role clarity.Assertiveness in the work setting was significantly correlatedwith job satisfaction, although it was riot as powerful a predictorof satisfaction as of role clarity. Number of years of job experiencewas the most powerful predictor of job satisfaction. The implications for social work training and supervision aredescribed in light of the importance of assertive communicationin maintaining job clarity and job satisfaction within multidisciplinarysettings.     

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.     

Occupational Stress in Social Services: a Comparison of Social Workers and Home Help Staff

Correspondence to Jennifer Bradley, School of Health Sciences, University College Salford, Frederick Road, Salford M6 6PU. Summary An investigation of occupational stress among professional andsupport staff within a social services department in north-westEngland was carried out, with the aim of optimizing the useof resources in the planning of stress management interventions.A two-phased research design was used to collect qualitative(by interview) and quantitative data (by questionnaire). Theresults reported here are based on data from 63 social workersand 74 home helps, who were involved in ‘front-line’work with clients. Sources of stress, measures of individualwell-being, job satisfaction, rganizational commitment and absenteeismdata are described. Comparisons with other occupational groupsare included.     

Local Authority Intake Teams

Summary Amongst the many developments in social services organisationin the decade since Seebohm, specialist Intake Teams responsiblefor all initial referrals and short term work received by anArea Team, remain a popular form of local organization. Thispaper describes a small national survey of English local authoritiesto collect information on both intake teams and their long termcounterparts, and briefly outlines some of the major findings.The survey produced a broad picture of both the present structureof local authority fieldwork departments, and the personal characteristicsof social workers and their team leaders. The paper goes onto examine the relationship between intake and long term teams,particularly in terms of referral rates, relative caseloadsand the case transfer process; and concludes with an outlineof teams satisfaction with the intake system, and some indicationsof desired future developments.     

Stress in Social Services: Mental Wellbeing, Constraints and Job Satisfaction

Correspondence to Margaret Coffey, Liverpool Hope University College, Room AEW 098, Hope Park, Liverpool L16 9JD, UK. E-mail: coffeym{at}hope.ac.uk Summary The public sector is facing an impending shortage of staff,because young people no longer want to work in it and nearlya third of its workforce is over 50 years of age. Staff workingwithin the public sector report that stress is the biggest singlefactor affecting their decision to leave. This research notereports the findings of a recent study carried out in two socialservice departments in the north-west of England. The primaryaim of the research was to explore work-related stress, usinga ‘problem diagnosis tool’ to understand the stressorsexperienced by social services staff, and to inform the developmentof interventions aimed at reducing and/or eliminating them.This study used in-depth interviewing to develop a questionnaireincorporating a variety of measures to assess potential stressorsand mental well-being. The questionnaire response rate was 33per cent (n = 1234) and the results demonstrated statisticallysignificant differences between staffing grades. Staff workingwith children and families reported the highest levels of absenteeism,poorest well-being, and highest level of organizational constraints.Job satisfaction was low compared with established norms forvarious occupational groups. This grounded research baselineis a crucial step to inform specifically designed and targetedinterventions, which can be effectively evaluated from thisbaseline position.     

Psychological Distress in Staff of a Social Services District Office: A Pilot Study

Correspondence to High Winnard, Church Road, Bishopsteignton, Devon TQ14 9QH, UK Summary This comparison study of fieldworkers and administrative workersin a social services district office addressed three researchquestions. Would fieldworkers show more internality and wouldthey perceive higher job demands than administrative workers,and would there be a positive relationship between perceivedstress and perceived job demands for all workers? The GeneralHealth Questionnaire 28 was administered, in addition to a jobdemand inventory. Self-reported absenteeism due to illness wasconsidered, and locus of control was considered as a moderatorof stress, as were years of service, age, and whether the employeeworked part- or full-time. Because fieldworkers might generallybe thought to be under more stress due to their work contentthan their support staff, data from fieldworkers were comparedwith those from administrators. Gender differences were alsosought. Statistical tests showed no significant differencesfor gender or between the administrative staff and fieldworkstaff for internality or job demand. A positive relationshipwas evident between perceived stress and perceived job demandwith a correlation of 0–40 (p <0·05). In addition,over 72 per cent of the sample scored above the cut-off pointon the GHQ 28 indicating psychiatric morbidity. The implicationsof the results are discussed.     

Job Satisfaction and Organizational Structure: A Comparative Study of Nine Social Service Departments

Summary The authors investigated the relationship between aspects oforganizational structure and job satisfaction as experiencedby personnel employed in nine social service departments. Aftera series of unstructured interviews from 28 respondents in oneauthority, interview schedules were used for three distinctgroups of 603 respondents in nine organizations: those makingexecutive decisions, those making supervisory assessments andthose primarily concerned with client interaction. The bestpredictors of organizational structure were dimensions of centralizationand formalization which related significantly but negativelyto job satisfaction. The relevance of these findings is discussedin relation to the rapid growth of social services and the effectit has had on social workers and other employees.     

Primary Health Care Workers' Views about Social Work

Summary SUMMARY A comparison of the views about social work held by 188 primaryhealth care workers—118 GPs, 31 health visitors and 39district nurses—working in the same teams is presentedhere.^* The study focussed particularly on their perceptionsof social workers, their role and performance. The data indicatea general acceptance of the social work role, but a lack ofknowledge of or extensive criticism about, social work performance.Significant differences of view emerged about social work training,role and clients, indicating occupation is a significant factorin perceptions held. In particular, the client group predominantlydealt with appears to have had an impact on perceptions. However,views about social work performance did not differ greatly,suggesting the influence of occupation on perceptions shouldnot be overstated.     

Team Building, Inter-agency Team Development and Social Work Practice

Correspondence to Paul Iles, Human Resources Strategy Lecturer, Open Business School, Open University School of Management, Walton Hall, Milton Keynes, MK 76A Y Summary The need to improve the effectiveness of working teams in socialwork practice has often been recognized, and a variety of teamdevelopment techniques exist which aim to develop teamwork skills.Some of the more important techniques are reviewed, along withthe evidence for the effectiveness of team development strategies.Such approaches have however primarily been employed with teamsin single autonomous organizations, and their transferabilityto multi-disciplinary or inter-agency teams remains problematic.Drawing on an intervention with a Community Drug Team involvingsocial work, health and other professionals, and an action researchproject designed to promote better collaboration between hospitalsocial workers and nursing staff in a hospital maternity unitante-natal clinic, a framework for inter-agency team developmentis described and its relevance for social work practice discussed.     

The Impacts of Acculturative Stress and Social Competence on the Mental Health of Mainland Chinese Immigrant Youth in Hong Kong

Correspondence to Dr Daniel Fu Keung Wong, Associate Professor in the Department of Social Work and Social Adminstration, 1317 K K Leung Building, The University of Hong Kong, Pokfulam Road, Hong Kong.E-mail: dfkwong{at}hkucc.hku.hk Summary Attempts were made to examine migration stressors, social competence,and mental health status of immigrant youth in Hong Kong andto examine the effects of social competence on stress and themental health of immigrant youth. Data on 106 immigrant youth,which were collected through a structured questionnaire, wereanalysed. It was discovered that immigrant youth found survivalissues and losses, rather than cultural differences and unfulfilledexpectations, to be stressful. Male immigrant youth exhibitedmore psychological distress symptoms than female immigrant youth.Hierarchical regression analyses revealed that social competenceexerted moderating effects on stress and the mental health ofimmigrant youth. Immigrant youth who had a higher level of socialcompetence, in terms of self-control, empathy, assertivenessand the ability to read social cues, had less stress and enjoyedbetter mental health. In conclusion, personal and socio-culturalreasons are put forward to explain the findings. Practice andpolicy implications are also discussed.     

Early Recognition of and Responses to Dementia: Health Professionals' Views of Social Services' Role and Performance

Correspondence to Jill Manthorpe, Social Care Workforce Research Unit, King’s College London, 150 Stamford Street, London SE1 9NN, UK. E-mail: jill.manthorpe{at}kcl.ac.uk. Summary Increasing calls for early diagnosis of dementia look set toimpact on social services. This article explores some of theissues, drawing on a series of multi-professional dementia workshopsheld in the UK. The workshops identified a series of questionsthat need to be addressed by social services in the areas ofthe drivers for early assessment, ensuing expectations, problemsand advantages in involving social services, and the benefitsof early diagnosis for individuals and their families. The articlediscusses the implications for social services in light of thedata and notes a possible move to specialist services, withinor without the social services sector. Tensions between currentresource shortages and anticipated demands for services areidentified. The difficulty of meeting low level needs whileservices are targeted on those with high levels of need presentsa further challenge to service delivery.     

Social Service Teams and their Managers

Summary A study is reported of the perceived effectiveness of teamsof social workers and their managers. Prior studies are reviewedand shown to give disproportionate emphasis to the supervisionelement in the manager's task. It is shown that in the sampleof teams studied the correlates of perceived team effectivenesswere quite different in area teams from those found in socialwork teams. Social work teams required a manager who was primarilysupportive, whereas in area teams the manager's role was foundto be less important than were group process variables.     

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.     

Community Based Care for People with a Mental Handicap: A Family Placement Scheme in County Durham

Correspondence to Dr R. F. Drewett, Department of Psychology, University of Durham, South Road, Durham DH1 3LE Summary In 1984 a family placement scheme for people with a mental handicapwas started by Durham County Council Social Services Department.Thirteen were placed in ten families by the summer of 1988,when we interviewed all clients and carers in the scheme. Responses to the scheme were generally positive, both from thecarers and from the clients. All but two of the carers, however,had considerable previous professional experience with peoplewith a mental handicap, and generalizations from the experienceof this initial group of carers therefore need to be made withsome caution.     

Worker Participation and the Social Service Agency

Summary Is there real sharing of decision-making responsibility withinsocial service agencies? What hope is there for participationby the consumer of services if the agency worker nearest andmost relevant to him has little voice or leverage within theorganization? This paper examines the notion of worker participationwithin the context of the social services department and theprobation service, noting the imperfections of the ‘publicmandate’ behind the authority structure of these organizations.Above all it looks for continuity between the values socialservice agencies publicly represent and the values in theirday-to-day dealings with their own staff and clients. Currenttrade union proposals for worker representation at committeelevel are considered, and Dutch experience in extending theworkers' council from the industrial to the social welfare sphereis presented as one alternative model.     

Mental Health and the Asian Communities: A Local Survey

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

Specialism, Genericism and Others: Does it Make a Difference? A Study of Social Work Services to Elderly People

Correspondence should be addressed to Roger Fuller, Social Work Research Centre, University of Stirling, Stirling, FK9 4LA Summary A previous paper published in this journal (Fuller and Petch,1991) described a preliminary feasibility study designed toinvestigate the effects of organizing social work teams alongspecialist or generic lines. The main study which developedfrom this work is here reported. The study, using modified casereview forms, compares the way samples of referrals of elderlypeople (n=1232) were dealt with at initial assessment and forup to a year subsequently by 15 social work teams of contrastingorganizational approach. The latter include specialist and genericteams, and comparisons are also drawn with teams adopting aself-styled community social work approach. Although the organizationalagenda has moved on since the study began, the issues are ofcontinuing relevance for the implementation of community care,particularly in view of its growing focus on specialist services.While not arguing that there is any one optimal model of teamorganization, the paper sets out some of the measurable consequencesof opting for the various models; in particular, it emergesthat the strengths of specialization are more clearly apparentin certain aspects of their engage ment with clients than inothers and at certain stages of that engagement than at others.     

Treating Older Persons with Severe Mental Illness in the Community: Impact of an Interdisciplinary Geriatric Mental Health Team

Little information is available concerning community-based interventions to treat the growing number older persons with severe mental illness. This study examined treatment efficacy of a specialized interdisciplinary geriatric mental health team (mental health geriatric interdisciplinary teams or MHGITs) for 69 older clients with severe mental disorders. Depression, life satisfaction, health, and psychiatric and medical hospitalization data were gathered. A decrease in depressive symptoms and in psychiatric hospitalizations, and an increase in life satisfaction at 6 months were found. No change in health nor medical hospitalizations were reported. This study provides preliminary support for the feasibility and efficacy of a MGHIT approach in treating older community-dwelling adults with severe mental illnesses. Implications for social workers are discussed.