Examination of Witnesses (Questions 280
- 292)
19 March 1998
DR BILL
REITH, DR
SCOTT BROWN,
and PROFESSOR MIKE
PRINGLE,
Chairman
280. In respect of the Northern Ireland model,
one of the concerns that colleagues have looking at England in
particular, which is the experience of all of us around the table,
is the way in which there has been a quite clear shunting of health
provision on to local authorities. In a sense, to some extent
one could argue there has been a de-skilling of the kind of service
previously provided by nursing staff which is now provided by
home carers. I am not saying it is a worse service, but it has
changed. Do you see that this has happened also in Northern Ireland
with your structure, that over the last ten or 15 years provisions
that are now in the community are fundamentally changed from where
they were 15 years ago? That what was a health issue is now a
social care issue. Has that process changed in your area as well?
(Dr Brown) Yes , it has, and it has followed exactly
the model that you have set out. It has gone that way. It is causing
and continues to cause problems for my professional colleagues
in nursing services because the skills that they are using on
a day to day basis are changing. They are now not only into doing
what one would classify as classic nursing procedures in the community,
but looking at needs assessment, resource allocation, setting
up guidelines, and so on. I am sure that if and when you speak
to them you will get this sort of feedback from them. It has had
major problems but it makes the point again of how important it
is that we in primary care liaise closely together and I am sure
you will hear from them what you have just heard from us, and
that is that if the resources are there, there is a will to carry
out the delivery of the service.
Mr Lansley
281. I wonder if I could briefly revert back
to the role of social worker working alongside general practitioners
in the practice? How far do you see a difficulty in the situation
where the patient seeing these two professionals working together
is nonetheless very confused when on the one hand the general
practitioner is acting as advocate and on the other hand the social
worker is operating a statutory duty on behalf of an authority
in relation to the person, and those two roles might come into
conflict?
(Dr Brown) It has not been, in my professional life,
a major problem. The main areas of statutory obligation would
relate to child care and the Mental Health Act, possibly not necessarily
during the acute episode, but certainly at some stage. The point
that I would make is that there is a confidentiality and privacy
that the patient demands in his or her relationship with me. But
if my considered professional opinion is that the services that
they best need are provided by my colleague who is a social worker,
then I have to advise that that is where that service is delivered
from. With consent, information that can be passed across the
boundary that is done so, but there are certain matters I would
not pass on. I would make that perfectly clear to the patient
and in liaising with the social worker I would make clear that
there are certain issues I have not transmitted and it is up to
the social worker to take that up with the patient. That is the
only basis on which you can proceed. Where the difficulty arises
is in the emotional and contentional areas of statutory obligation
where one has formally to certify a patient under the Mental Health
Act and social services are involved or indeed in dealing with
a child at risk. I do not think there are any easy answers for
those cases, except to say, as I have done, that hopefully whenever
the dust settles one would have the opportunity to explain why
the various professions were involved and to reassure that the
confidentiality issue has been maintained as far as possible.
(Professor Pringle) Could I just address the issue
of confidentiality and shared records because I think it is an
important issue in this respect? One of the first requirements
of the record keeping and shared records is to know that someone
else is involved. At the moment we do not have that knowledge
and neither side knows who is actually involved. They have to
make enquiries and have to find out and the patient is usually
the person who tells you. You do not have to share full records,
and the fact that someone has seen them on a certain date may
be all that is required. The analogy that I draw to your attention
is with practice counsellors. Full psychological practice counsellors
would require that their full records are not accessible by other
members of the primary health care team. What they do is inform
us about whether they have seen a patient and then they will inform
us at the end of a treatment series of the sort of nature of the
problem and the implications for that patient's continuing care.
But they would not reveal all the material that has been contained
within those consultations. That is to do with the professionalism
and professional boundaries. That is perfectly acceptable. When
two professionals get together they share what they can, especially
when it is in the patient's interest for integrated care. So I
think what we are saying is not that by coming together you then
release everything so that you have a fully integrated record
with a fully integrated knowledge base about the patient. You
share what it is in the patient's interest to share and what is
ethical and moral to share and what you can share in order to
make sure you are maximising patient care.
282. In your evidence you have referred us to
some research and to some particular instances where a social
worker is placed in a primary health care team. In addition to
that research, or those particular instances of good practice,
have you, as a professional body for general practitioners, and,
say the British Association of Social Workers, come together in
order to try to arrive at a joint agreement for protocols for
how social workers and primary health care teams should work together?
(Dr Reith) Not that I am aware of, but it is a good
point and it is one that we will take on board.
283. Do you think in future that it is better
for you as a professional body to come together and agree between
yourselves what is best practice and then seek to have that disseminated
between your respective professions, or do you think it is better
to have institutional, organisational changes to lead to nationally
agreed protocols or performance indicators to which you then have
to respond?
(Dr Reith) I do not think they are necessarily mutually
exclusive. I think that there is a considerable merit in organisations
like ours and the British Association of Social Workers to come
together to meet at, as it were, senior officer level to begin
to thrash out the issues and so come to some agreement at that
level, and also to carry that through to joint working between
general practitioners and social workers, nurses and so on. If
we were thinking of developing guidelines, previous experience
in this field makes it quite clear that it is important to involve
people at grass roots level in terms of getting ownership and
so on. There would be a bit of top down and a bit of bottom up
perhaps in what you are suggesting. I think that that sort of
initiative could quite easily go hand in hand with other organisational
changes and of course any sort of working between the two organisations,
to take the example you have given, could of course influence
or seek to influence what organisational change was going on as
well.
284. Audrey Wise previously referred to indeed
your own recommendation about agreed codes of conduct within localities.
To what extent do you think that those should be the product,
for example, of national guidance, how far should localities derive
them for themselves, and to what extent should agreements between
health authorities and local authorities guide that as distinct
from primary care teams arriving at their own solutions for their
own particular localities?
(Dr Reith) Well, I think that the sort of role that
I would envisage for national organisations like our own would
be to set a broad general framework and say what seems acceptable
at a professional level and to try and identify and disseminate
best practice, as we have said. It seems that one of the ways
that people can learn very helpfully is to learn what is going
on in other areas which is good, so that is certainly one thing
at the national level. I think it is always very important, though,
to relate that to local circumstances and up and down the country
of course local circumstances vary enormously, and I guess that
what would happen would be that in some localities you would very
quickly get effective working between primary care teams and social
work departments and perhaps at the forefront of developing good
practice in other parts of the country for all sorts of reasons,
not just professional reasons, but resourcing issues and so on,
it might be a little bit slower, but I think that both have a
role to play.
285. For accountability reasons, would you agree
that joint performance indicators agreed between social services
departments and primary healthcare groups should be answerable
through the health authority and the local authority and they
should have in effect a policing role to see that these meet presumably
the standards that are set in health improvement programmes?
(Dr Reith) I think that certainly they have a role,
but I think again it is interesting that if the health authority
or indeed the local authority is the funding body and is then
also policing, there may actually be a conflict there because
it may well be that the professionals have decided that they would
like to do things which are appropriate, but actually are being
prevented from doing so by the funding body, so I think there
could be a conflict there. I think what we would see is that an
organisation like our own, and presumably BASW, would actually
be helping to set those standards and providing, if you like,
safeguards for the professional person in terms of saying, "Well,
these are the standards to which we expect you to work as a GP",
or as a social worker or whatever, "and you must always be
mindful of these". I think there are issues around about
that and of course again the White Paper on healthcare looks at
that whole issue and has raised the whole issue of clinical governance
within general practice, looking obviously to maintain and improve
standards, but actually it looks at that whole sort of regulation,
if you like, which I think again is an anxiety at times for professionals,
particularly if resourcing is tight, and I think a number of various
inquiries have shown that, that, for example, social workers may
have wanted to do more, but there have been issues about resourcing
and so on, and also in the medical sphere as well.
286. Can I just conclude with one question about
the education and training of general practitioners themselves?
In your evidence you give some ideas in relation to that. To what
extent do you think or is it your intention that those who are
training for general practice in future, where they are placed
in a training practice, that that training practice itself should
have a specific responsibility to undertake this kind of joint
working with social workers as part of the primary healthcare
team so that those who are coming into the profession are trained
in that context?
(Dr Reith) I think again obviously one of the issues
that we have within general practice is that general practice
is the only medical specialty where we currently only have twelve
months in which to train someone in our discipline and that is
an enormous handicap for us, so there is a limit to what we can
do in the time available, but I have no particular problem with
the suggestion that you are making. Because of the fact that before
a practice can be approved for training purposes, it has to be
properly assessed and so on, our training practices are amongst
the best practices in the country where we would expect just these
sort of good practices to be going on.
(Dr Brown) Within Northern Ireland, some of the criteria
used for approving training practices cover this very area and
in my own practice, which is a training practice, we take both
undergraduate students and postgraduate GP registrars and built
into each of those attachments and at the start of the registrars'
placing with our practice is an orientation period where they
specifically go and are attached to social workers, so it does
exist and actually the model you have alluded to is being used
in Northern Ireland at the moment and it is extremely helpful.
(Professor Pringle) Chairman, can I just address that
because I would not want you to understand from our answers that
yes, training practices should tomorrow be required to have this
sort of collaborative working because that should be good practice
in training practices. I think before that we have to understand
that the reason why this has not occurred is not because in good
practices they would not wish it to, but because the structures
and the imperatives in the system have been a positive disincentive
and so what we need is the permissive culture and the encouragement
from both statutes and organisations that mean that that coming
together would actually work. We have heard, and I can echo it
from my own practice, where collaboration with social work departments
was withdrawn because that was the organisational imperative at
the time, so we have got to put in place the permissive structures
and culture to allow it to happen, but that is not all we have
to do; we then have to develop the culture in which that coming
together is valued. Now, we can do that in training practices,
but first we have to have a situation in which that is possible
and it is positively encouraged throughout the whole service on
both sides.
Chairman
287. I am very interested in this point on the
training of GPs in particular and the next witnesses may well
refer to this. My experience in undertaking statutory work in
social services was one of concern that many GPs I dealt with
had little idea of their key statutory functions, especially in
the mental health field, and it was a grievance to me because
I used to end up making decisions on behalf of the doctor and
the doctor got a fee for the decision, which seemed rather unfair.
Therefore, I was very interested in the Northern Ireland model
and hopefully that will be something which we can look at. Before
I bring in Robert Walter, can I just press you further on the
issue of the statutory function and the issue of confidentiality
because clearly the confidentiality issue has always been a barrier
to collaboration between social services and general practice,
and having seen it from one side of the fence, so to speak, I
have some sympathy with social services where clearly decisions
in respect of, for example, the removal of a child from its home
through the courts, but these decisions have to be made in collaboration
with senior managers and indeed in some instances with social
services committees. How can we achieve a balance in developing
an understanding between GPs and social services when these requirements
are in place and, in a sense, required by law?
(Professor Pringle) Again I have alluded to the counsellors
and the confidentiality issues, but in fact we have health visitors
with our primary care teams who have statutory responsibilities.
Now, I am not minimising in any way the clash of imperatives that
occurs when you have got statutory responsibilities and also responsibilities
to the team, but I think that part of being a mature professional
is to recognise that those occur and to be helped through education
to understand how you deal with those. Now, I think that if we
had an integration and a coming together, one of the educational
functions is for both sides to educate each other, firstly, about
GPs' statutory responsibilities and those areas, and I welcome
much more contact with social workers to understand the dimensions
of those far better, but equally we need to be educated on the
general practice side about what the implications are for those
statutory functions in terms of the confidentiality and the imperative
functions of a social worker which are not visited on general
practitioners. Now, I do not think that that is outside our capacity
to handle if you take the example of health visitors and that
is handled there, I think, very effectively within a primary care
team.
Mr Walter
288. I wanted to come back on a slightly different
approach, or perhaps not really a different approach because all
these approaches are related, but there is a section in your evidence
about the relative cost-effectiveness of services and moving money
between sectors and you come with a thought that it would be helpful
if health could more easily purchase and commission social care
in certain circumstances. I wonder if you could perhaps elaborate
on that in terms of what social care you think should come within
that framework and perhaps then explain how you think that a seamless
service would come from that angle of approach?
(Dr Reith) I think again the whole notion of working
together and the general practitioner and social worker and indeed
nursing colleagues as well discussing what seems best for a patient
and then deciding which will have the responsibility for providing
that particular bit of the service or the whole service would
seem to be the way forward at a sort of immediate patient level.
I think one of the—I am not sure if it is a difficulty,
but certainly one of the issues at the moment in terms of commissioning
is the tremendous organisational change that we are about to go
under and I think what we will have, it seems, is the opportunity
of working in primary care groups, at least in England, to work
much more effectively with the economies of scale and so on, we
assume, that will allow greater contact with social work departments
and social services. Now, that is partly primary care groups,
we would anticipate, which will have some function in better determining
the needs of the population than perhaps has been the pattern
up to now with general practices, and actually begin to do it
on a sort of locality basis, working with social services. It
seems that there is much more opportunity for partnership in the
organisational changes that are about to happen.
289. Would you see primary care groups or perhaps
more particularly primary care trusts actually taking on social
services' functions and actually buying those services in for
your locality?
(Dr Reith) I think that could well happen. Again I
think the important thing is to allow that flexibility, allow
that permissiveness to move down that route if it seems to be
the appropriate way to go in a particular locality, but then actually
to evaluate it as well rather than a sort of wholesale change.
(Dr Brown) I think where the potential strength of
primary care groups is lies in the area of needs assessment and
strategic planning. My colleague mentioned that there may well
be efficiencies, probably not cost savings, but efficiencies,
more value, better quality services produced for the same amount
of funding and where you have two professions coming together
to both not just react in an acute way, but to try and plan strategically
and you are then down to looking at the area of need and what
is required within the patch and that is an area where we obviously
look to our public health colleagues as well to help us to drive
that forward. The other point that you mention, I think quite
correctly, is quality and quality issues. Where the College is
a little concerned, and again we accept that the structures are
still a bit embryonic, but where there is an area of potential
conflict is in the role for us as general practitioners and patients'
advocates in thinking strategically, putting in place a model,
assessing it, piloting it and then looking at the outcome measures
and whether it has produced high quality clinical and social care
and continuing to act in an advocacy role for our patients given
that there are problems with resource allocation and we are having
then to make decisions about what actually we can fund within
the trust or the PCG and that is an area which gives us concern.
Chairman
290. Could I pursue that particular point? It
struck me, talking about the statutory function side, that I can
recall an experience where I was in a conflict with a particular
GP over a particular case where we had evidence in relation to
alleged sexual abuse of children and where I took them to a place
of safety, two girls, as a consequence of the evidence we had.
The GP held that we acted wrongly and a conflict occurred to the
extent that he gave evidence in court against the social services
as to the action which was taken. In such circumstances, how do
you square up that kind of conflict within the Northern Ireland
model, and particularly how would you square up that conflict
within a social worker attached arrangement within a general practice
where the social worker has clear statutory obligations and they
take those in the way that I did in this particular case and there
is a conflict with the GP? How would you resolve that kind of
issue?
(Dr Brown) I have no personal experience of this type
of conflict having occurred and certainly at the conference that
we ran, as one might expect, they were looking at the positive
end of things, so I cannot specifically respond to your question,
but obviously you will want to take that up whenever you visit
Northern Ireland. My suspicion is that the management structure
that they have in place in the models we looked at, being slightly
removed from primary care, is sufficient to allow these matters
to be dealt with and for a more impartial decision to be taken.
The decision that you describe is hopefully relatively uncommon,
but I know that it can occur and I think that there has to be
a recognition of the buck stopping with our social work colleagues
if a decision is incorrect and making one's evidence and leaving
it at that and allowing one's social work colleagues to make the
decision. If you like, if that sort of decision-making process
is also going to be incorporated within primary care groups, it
increases our unease about the role of members of the PCGs who
are GPs as well. I see that being an area of potential conflict,
but it is a difficult issue and one actually which I will take
up with my colleagues when I return to the Province.
(Professor Pringle) I think that problem is much more
likely to occur where you have this cultural chasm. Where in fact
people are working together and educating together, share value
systems and understand where their value systems clash, they are
much less likely to end up in that sort of adversarial situation.
I cannot say it will not happen, but it is much less likely. I
do need to remind you that GPs have statutory responsibilities
too and that in fact in any team you have a number of people who
have external accountabilities that are not shared and that is
part of team work. I think at the primary care group level, there
is going to be a regulator, or a moderator, if you like, which
is a much better word, in that sort of tension because there are
actually going to be peer groups too who can reflect on the different
cultures and help to try to minimise those sorts of conflicts
too.
Mr Gunnell
291. If I can just return briefly to Dr Brown's
comments throughout the session really about the Northern Ireland
experience which have generally been very positive, but the very
first time you mentioned it, you did say that things worked well
in your part of Northern Ireland, but did suggest that it was
not a uniform experience. I just wonder, compared with the structures
that you have got in Northern Ireland and the structures that
most of us have in our own localities in the UK, whether you consider
that we are paying a very high price in terms of the lack of integration
for having a system of locally-elected representatives to hold
accountable?
(Dr Brown) If I understand your question correctly,
I think that whilst the system that we have in Northern Ireland
is not 100 per cent effective, it is well worth the investment
in it at the moment and the impression I got following the conference
and discussion with colleagues and, in particular, colleagues
from the non-medical professions who were involved in these initiatives
is that more and more health boards and the locality areas within
the health boards are actually looking towards these models for
improving patient care. They are seen as being the way ahead simply
because of what is likely to ensue within Northern Ireland. Now,
as you are aware obviously, we are still not completely sure what
sort of structure will evolve over the next 12 to 24 months, but
looking at the models within England, Wales and Scotland, the
view taken is that we are going to have to change and what we
are looking at as examples of good activity and good models will
in fact be the sort of structures we are going to have to look
at, but, as I have said and as you have alluded to, it is not
100 per cent effective in all areas, but compared to the way things
were even five to ten years ago, there has been a major change
and quite a cultural change as well. It has taken a long time,
but it is beginning to occur and the feeling of being threatened
or being subservient by various professionals and concerns about
budgets being taken away from professionals, those fears, I think,
are beginning to disappear.
Chairman
292. Do any of my colleagues wish to ask any
further questions? No. Gentlemen, could I thank you for your very
helpful evidence this morning.
(Dr Reith) Thank you very much for inviting us.
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