Select Committee on Health Minutes of Evidence

Memorandum by the British Association of Social Workers

RELATIONSHIP BETWEEN HEALTH AND SOCIAL SERVICES (HSS 50)

  BASW welcomes this Inquiry and fully supports its aims to investigate the interface between health and social services.

  The Association recognises that health and social services are interdependent and that current divisions and level of services are in many ways unsatisfactory in particular areas such as: the relationship between hospital and health services for elderly people with social services department eg in discharge arrangements and care management, and "community care" services for people suffering from severe mental illness.

  BASW recommends that the proposals for future developments of organisational structures, working arrangements and resourcing do not further inhibit effective and quality care where it does exist across the health and social services spectrum. The Association further recommends that the following key principles underpin any future proposals for changes:

1.  Users' and carers' views, involvement and choice play an integral role in any future policy changes.

2.  Appropriate resources and structures are provided to support people to live in their own communities.

3.  Ethnically sensitive services are developed.

4.  Structures, resources and procedures are developed to ensure the provision of seamless services.

5.  Users and carers have one point of reference as far as it is possible.

6.  Service provision and planning is publicly accountable, and equitable.

7.  Any future changes should ensure local control and input is retained over service provision and planning (within overall Government guidelines) to ensure a flexible response to local circumstances.

8.  Greater consistency of service provision so that it should not, within reason, matter where a client/patient lives in respect of the quality of service they can expect.

9.  Government grants/funding for local authorities and health agencies must reflect local needs as well as strategic priorities.

  Social workers play an integral role in the provision of health and welfare services to the most vulnerable members of our community, working within and across health and social services. Social workers bridge the gaps of understanding and of action that occur between health and social services ensuring:

(a)  the interface between health and social service allows a smooth transition from health to social care;

(b)  there is a clear responsibility for assessing need, and for planning and ensuring continuing care;

(c)  children's needs are appropriately met in health settings and local authorities offer appropriate services to disabled children and children looked after by local authorities; and

(d)  the priorities for care set up by local authorities are properly understood by health professions sharing the care of clients.

1.  AGENCY RESPONSIBILITIES

1a.   Children's Services

  The Association would like to stress that alongside the work of social services there are a large number of agencies which work together to achieve good services for children and their families. These include education, probation, courts, housing etc.

  In relation to "children in need" and duties under Part III of the Children Act 1989, personal social services relationships with education services in the broadest sense (including education welfare, youth and play services as well as schools) are at least as important as relationships with the NHS, and there are many other important relationships (with housing services, the Benefits Agency etc). A similarly wide range of agencies are involved with young offenders.

  In child protection work, all these relationships and co-ordination of these agencies continue to be crucial. It is, therefore, important that, in considering specifically the relationship between the NHS and the social services, the Inquiry should be aware of the importance of other inter-service relationships, and should beware of proposing changes in agency responsibilities or organisational structures which might aggravate the difficulties of collaboration between the personal social services other than those of the NHS.

1b.   The Relationship between Children's and Adult Services within Social Services Departments

  The aim of the Local Authority Social Services Act 1970, was to unify the various social work and social care services provided by local authorities, but in recent years services for children and their families and those for adults have been growing apart.

  The problem of balance between child protection work and family support in social services, has arisen, not as frequently as suggested, solely as a result of policy shifts but also because of the lack of resources. Too little is being provided to cover too much, and family work has been sidelined as a result. This skew has frequently been driven by public opinion, anxiety and is primarily senior manager led. The balance has therefore become skewed towards investigating/policing social work as opposed to its more traditional role of support and counselling.

1c.   Particular problems in Social Services and NHS collaboration in respect of Children's Services

  (a)  The provision of Child Psychiatric and related support to Local Authority Child Care Services

  Under the NHS internal market arrangements, the principles, under the NHS Reorganisation Act of 1973, for local authorities and NHS to provide services to each other free of charge, have virtually disappeared. This was a sensible arrangement under which agreements were drawn up locally covering such matters as, for instance, the provision of child psychiatry sessions to support the work of local authority children's homes. The great majority of children's homes can now access child psychiatry only in respect of individual children, and then only via referral from the child's GP, involving long delays and an uncertain outcome. However, the proposals contained in the NHS White Paper suggest that this will change, but clarification will be needed around who will commission and refer under these proposals. These services can be expensive and too readily the needs of vulnerable children can be ignored.

  (b)  The Provision of Child and Family Mental Health Services

  These services must be provided through inter-agency teamwork involving staff from the NHS, the personal social services and, preferably, the local education authority. Universal coverage by such joint services throughout the country has markedly deteriorated in the 1990s, with agencies withdrawing staff from such interdisciplinary teams in order to protect their own "core functions". Where child mental health services are provided by child psychiatrists working separately from social services, and not in joint teams, children's interests can be damaged.

  These areas are at present not well managed and it is important that any changes or new divisions do not pull them further apart. The proposal in the NHS White Paper place the co-ordination of mental health and learning disabilities in the remit of Mental Health NHS Trusts. Clarification around these proposals as to where social work will fit in with the new structures is needed. In particular the role of the Approved Social Worker must be protected and the legal independence guaranteed.

  (c)  Parental Mental Ill Health

  The mental ill health of parents, eg depressive illness in mothers of young children, is a frequent and major element in many child care problems. Much closer collaboration is needed between local authority children and family services and adult mental health services in both the NHS and local authorities. The joint working relationships between Health Visitors and local area social services teams is crucial.

  (d)  Children looked after by the Local Authority

  Local authorities and health authorities should be required in particular to set up and maintain joint arrangements for safeguarding and promoting the health of children looked after by the local authority.

  (e)  Court Reports

  There are often long delays in obtaining reports for the courts from child psychiatrists. The courts appear to tolerate much longer delays for these reports than they accept for social work reports. Planning for children is too often disrupted by a lack of urgency and appreciation from not only health professionals but others—particularly psychologists.

  (f)  The contribution of Health Visiting Services

  The contribution of health visitors to supporting and keeping an eye on families experiencing difficulties has been of great importance. Health visitors have in fact always concentrated to some extent on work with families in difficulties, but have been well aware of the importance of being able to present themselves as a universal service whose attentions are free from stigma. Recent developments, stimulated by the Audit Commission, to make more explicit the rationing of health visiting time risks undermining the value of the service as one which is acceptable to the great majority of households. Health visitors also monitor social health needs and alert support services of need as this is identified.

1d.   Particular problems in Social Services and NHS collaboration

  (a)  Mental Health

  Mental health is often seen primarily as a "health" issue. However, the needs of people with mental health problems encompass a spectrum of health and social care provision. Far from being primarily a health issue mental health is generally dominated by social need. With the introduction of community care legislation many people with mental health problems and long-term care needs have been resettled in the community. This has placed a considerable amount of responsibility on care provision for people with mental illness on social services departments. This may, however, change in light of the NHS White Paper. It must be recognised that the health element of mental illness may be crucial but is by no means the key to good care.

  Currently, there is no requirement for local authorities and the NHS to produce joint mental health plans. This should become a statutory requirement. It would also aid clarification, the co-ordination and provision of services.

  There are, however, a host of complex boundary issues to be addressed:

—  the dividing line between "severe" illness and other mental health problems;

—  co-operation with social services departments regarding social care and co-ordination;

—  access to care—the response to emergencies: the link between the new health authority's services and A&E Departments and SSD emergency duty teams;

—  access to general health service, eg for neurological screening, health promotion;

—  the high incidence of non-psychiatric health problems in the severely mentally ill and their need for holistic health care;

—  age-related divisions which cross the boundaries of social services such as: children; people of working age; older people;

—  liaison of psychiatry and care of physically ill people with mental health problems eg overdoses and self harm, people with health problems such as multiple sclerosis, renal failure etc;

—  responsibility for personality disorder; and

—  substance abuse services eg alcohol, drugs—where do they fit in?

  Failures in care provision can lead to expensive hospital admissions. Many people would not require re-admission to hospital if crisis care was available in the community. Patients find they get caught in the revolving door syndrome of discharge and re-admission.

  A holistic approach to the long term health care needs of people with mental health problems is essential, and must involve users and carers. There also needs to be effective co-ordination, co-operation and communication of care provision and planning on an inter-agency, multi-professional basis to enable continuity of care, ensure early identification of potentially harmful developments and assist with timely and appropriate support.

  (b)  Health Related Social Work

  The transfer of social workers, such as those working in mental health, learning difficulties and primary care, to local authorities from the NHS in 1974 resulted in many specialised hospital social workers joining generic departments but retaining a separate identity and management. This had a direct impact on social services and social work departments and the way that they allocated resources. What has been at issue is not the quality but the quantity of social work services provided, responsibility for the employment of social workers in health settings, their role in care management, their accountability and conditions of service, together with a structure which maintains their professional identity. The result has been, in many cases, for social work in health care to be seen as peripheral in local authorities.

  Clarification is needed about the role of social work, especially in light of the NHS White Paper, in relation to Primary Care Trusts/Groups and Mental Health Trusts. The Association would stress the importance of local authorities retaining statutory responsibilities for social work provision in health settings. This would ensure social workers retain their professional identity, and receive appropriate training, support and professional supervision. The establishment of a General Social Care Council would also go some way to clarifying the employment and training issues, and ensuring that appropriate standards and regulations are set and social work staff are registered and employed according to these standards.

  (c)  Primary Health Care

  There are many good examples of social workers in primary health care settings liaising and co-ordinating care for children and adults. However, there are many questions which need consideration. While the White Paper goes some way to setting out proposals for developing primary care, BASW would urge further consideration is given to the following:

—  The way in which assessment of social needs and provision of social care fits into a primary care led NHS (this is crucial).

—  A means of enabling the achievement of a seamless and inclusive service across the health and social care "divide" needs to be developed.

—  Schemes that have been developed across the country with social workers based in GP practices and Health Centres. The results of such schemes have generated encouraging results in some areas. These have ranged from a more holistic appreciation of social and health needs; more attention to the social exclusion of patients—especially older people—in given localities; a less stigmatised and more accessible local service; cost benefits in more collaborative working with less meetings and more continuous arrangements in hospital discharge and general relationships between primary and secondary care; higher quality services and better understandings of cross agency policies.

—  The issues raised by continuing health care needs, and in particular, provision for these in the community, needs more attention and emphasis.

—  Where social workers are not working directly in primary health care there is often confusion about the social work role, liaison and accessing social care by the primary health care team, and vice versa in respect of health care.

  In addition consideration needs to be given to the following areas:

—  co-ordinating multi-agency provision;

—  the promotion of multi-disciplinary perspectives, flexibility and diversity of service provision and including local perspectives;

—  primary care links with social care led initiatives;

—  the development and clarification of community mental health care teams and specialist mental health services;

—  social work links with GPs in the development of Care Programme Approach in mental health;

—  child psychiatry and psychotherapy;

—  the views of users and carers;

—  the role of social work in the training of health professionals, joint commissioning, joint planning, direct service provision eg assessment, advocacy, etc; and

—  the role of Counsellors.

1e.   Future Requirements

  (i)  Child and family social work has a significant contribution to make towards combating social exclusion, particularly when it is practised in an authority which is sympathetic to community social work. This contribution needs to be brought together with similar commitments in the NHS to tackle inequalities, not merely in health service provision but in health outcomes, and with commitment in schools to provide a better service to socially and educationally disadvantaged pupils. Collaborative machinery for this purpose should be established at a fairly local level. It should be concerned with primary and community health care and health promotion, with the contribution of mainstream schools and with social service family support services. Planning should be undertaken in partnership with local community representatives. The NHS White Paper addresses such collaborations with the proposals for Health Action Zones.

  (ii)  At the authority wide level, joint planning for more specialised services, such as child protection, should continue and be developed. Both these more specialised bodies and the local collaborative machinery should be sub-groupings of a main authority-wide joint body charged with children's services planning.

2.  ORGANISATIONAL STRUCTURES

2a.   General Organisational Issues

  Many organisational changes in the last decade have created fragmentation of services and of responsibility, and have placed obstacles in the path of joint planning, joint organisation and joint delivery of service. Among changes which created such difficulties were purchaser/provider separation, GP fundholding, and in the education sector, local management of schools and the option of grant-maintained status. All these changes have impaired the ability of the responsible authority—Health, Education and Social Services—to deliver on their joint agreements.

  Joint working is essential in children's services, and requires powerful co-ordinating bodies. It cannot be satisfactorily built on the basis of negotiation between large numbers of small and relatively autonomous service providers.

  Local government reorganisation has created a number of local authorities which are too small to plan and deliver a number of the essential elements in children's services, such as residential care.

  The Association is encouraged by the NHS White Paper proposals for the integration of community and primary health care services with local authorities having a more strategic input into health authority service delivery and planning. This will go some way to ensuring that children and families will have access to various community services and not just services purchased by individual GP fundholders.

2b.   Mental Health Services

  Social Services Departments often find it easier to co-operate with NHS services than with Education and Housing services provided by their own authority. This arises from the fact that Education and Social Services are in competition for the local authority's budget. Inter-departmental co-operation within local authorities requires elected members' commitment; co-operation with the NHS requires only their acquiescence.

  BASW would further suggest the concerns and issues raised about the weakness of primary care services in mental health services are considered. These concerns centre on the lack of managerial accountability and organisational infrastructure to discharge the lead roles, skills and training issues.

2c.   Health Related Social Work

  While the majority of health related social workers are employed by social services departments in local authorities, they often work in multi-disciplinary settings managed by any branch of the health service. In many social services/social work departments this has generated debate about the most appropriate management of social work in health settings. Often the levels of service and staffing along with organisational management structures of social workers in health care have been unclear. However, where social work management has been based in the health service a strong and effective interface between local authorities and health authorities has existed, with the managers of hospital based social workers undertaking a policy/planning/liaising role with the two authorities.

  The following organisational and structural issues also need clarification:

1.  Social work must be recognised as an integral part of the health care process, concerned with the physical and mental well-being of individuals, families, groups and communities.

2.  Social work in health care is a very significant part of the work and responsibilities of Social Services Departments and must not be marginalised.

3.  Minimum staffing levels should be established, using an agreed formula, for the provision of social work support to health settings especially hospitals and specialist health care units, and primary health care services.

4.  There should be effective and efficient management structures for promotion and maintenance of social work in health care, both within Social Services Departments and the National Health Service. Social Services Departments should have identified posts at appropriate levels to negotiate and liaise with health colleagues.

5.  The funding of regional specialist units.

6.  Social workers located in health settings must be enabled to play an equal part in departmental activities, including planning and policy consultations.

7.  Social Services Departments and Health Authorities should examine together models and options for primary health care and care in the community in an integrated and co-ordinated way, to ensure a cohesive and communicating service.

8.  Health care systems must be re-orientated to ensure that they not only respond to medical needs of patients but they are sensitive to social and psychological needs, and also take the necessary initiatives to provide services in ways most likely to encourage their acceptance by those who need them most, including ethnic minorities.

2d.   Future Requirements

  BASW would also suggest consideration is given to:

(a)  the work currently being carried out on the preparation for Health Action Zones. When introduced these should be used as an opportunity to try new ideas out and not to reinforce old practices.

(b)  joint management structures (or merged management structures) to promote health and social care services especially for adults. The experience of Northern Ireland points up a number of major difficulties from which lessons can be usefully learnt.

3.  INCENTIVES FOR JOINT WORKING

  The Association supports the continuation of incentives for joint funding but:

(a)  priority should be given to innovative or pilot schemes; and

(b)  short-term funding can cause problems and this should always be acknowledged.

4.  ORGANISATIONAL AND FUNDING SYSTEMS AND PROCESS FOR PLANNING, COMMISSIONING AND SERVICE DELIVERY

  Social work support and funding to specialist settings such as forensic Secure Units, Special Hospitals, the State Hospital in Scotland and Rehabilitation Services needs urgent clarification. Health authorities have an obligation/limited responsibility to provide patients from outside of their geographical boundaries with a social work service. This has proved problematic and raised issues around the funding of social work services to people from outside local and health authorities boundaries receiving treatment in NHS hospitals, in, for example, regional specialist units, such as renal units, oncology and radiotherapy units. Some local authorities have pushed for funding of this service to be met elsewhere, for example, cross boundary charging, rate support grant or by the health authorities themselves.

  The issue of funding also relates to National Units and Special Health Authorities where many social work posts have been funded by charities or voluntary organisations on a short-term basis. Often the need for social work support to such units is long-term, but the posts do not necessarily become established. This presents uncertainty for the service users, the social workers in such posts and the multi-disciplinary team, and discourages the establishment and maintenance of necessary specialist skills.

  The Association would also urge:

1.  Commissioning must be related to balancing local needs against strategic direction. Clear government guidelines are essential.

2.  Building on and emphasising existing and long-standing multi-disciplinary working involving social workers in a number of areas eg mental health teams servicing all age groups, community teams for learning disabilities, renal and forensic care, hospital based staff, youth justice.

3.  Interpretation of service criteria eg continuing health care/social care must be flexible and act in the interests of users/carers not hinder them.

5.  TRAINING AND PROFESSIONAL BOUNDARIES
  (a)  An emphasis should be put on multi-disciplinary professional training especially at post qualifying level.

  (b)  Related to this and other themes, experience has shown that where staff from different disciplines work from the same site/offices/clinics, the chances of them communicating effectively significantly increase and traditional professional boundaries/barriers are more likely to break down or reduce. The emphasis on joint assessment, treatment/support, review processes all enhance this, together with involvement in service planning/monitoring/review arrangements.

  (c)  Within health authorities the professional role of the social worker working in a health setting is often undermined by the employment of unqualified people into social workers and social work posts. These posts range from discharge co-ordination to counselling. The lack of an ethical, professional and statutory base for such posts is a matter of grave concern. The role of health related and hospital based social work as a major source of knowledge, practice experience and skills learning for social work and other professions must be safeguarded. This can be achieved by the establishment of appropriate social work and post qualifying training courses which incorporate health related social work training as compulsory knowledge and skills base for social workers.

  (d)  It is essential that elements of health care training are integrated into social work training and elements of social work training are integrated into health care training for GP's, nurses etc.

6.  RELATIVE COST-EFFECTIVENESS OF SERVICES AND THE MOVEMENT OF MONEY BETWEEN SECTORS
  (a)  The issue of free/charged for service is fundamental to how services are perceived and used.

  (b)  If health/social care services are merged, money should be ring-fenced for core activities specifically for mental health and community care eg to avoid acute hospital care overwhelming services in the communities because it has powerful voices behind it.

  (c)  Value for money must always be at least in part balanced against ensuring services are both flexible, accessible and of high quality. Some community based services may not always be cheaper but they are more accessible for local people.

7.  RECRUITMENT/RETENTION OF STAFF

  The use of supervision, training, Investors for People, team meetings, supportive communication, good working environments, and health and safety support must all be in place to support staff. Personnel procedures should support and encourage women, people with a disability, and people from ethnic minorities, and part-time staff. The dedication and commitment of social care staff in often complex, volatile and/or distressing situations needs to be recognised and assisted.

8.  BARRIERS AND INCENTIVES TO ENCOURAGE OR DISCOURAGE THE USE OF PARTICULAR SERVICES
  (a)  Information on services should be readable and accessible. Radio/TV and other media should be used together with large print, Braille, tapes, etc.

  (b)  One-stop approaches should be considered.

  (c)  Joint management/planning processes should support joint professional working.

  (d)  Clearer links should be made explicit and expectations made clearer of how different commissioners will work together eg social services, GPs, health authorities.

  (e)  We should build on and emphasise locality planning on a joint basis.

  (f)  Social services and other local authority Directorates now work very closely with both the voluntary and private sectors to a greater or lesser extent and many positive partnerships have been forged. A community development approach to health with the emphasis on local communities articulating their needs and taking some action themselves and/or lobbying for change must be encouraged, and financial incentives made available for that purpose. Local authorities could play a lead role in such initiatives in line with their role around local governance and developing services that are responsive and accountable.

  (g)  The use of advocates for users who have no other voice or where there are conflicts of interest should be encouraged and financed.

9.  CONCLUSION

  Local authorities should have a major role in any future developments. They cover a wide range of other statutory duties which draw upon both social work and health care services. Social work as a profession cuts across both local authority and health care services, often working with the most vulnerable members of our communities.

  They have knowledge on how to obtain appropriate services for clients, working jointly with other agencies, and working with individuals and their families etc.

  The fundamental weakness of health taking any strategic leadership role is the lack of democratic accountability. Coupled with the inevitably narrow focus that health professionals will bring to local planning plus the different funding arrangements for health from that of social care, will ensure continuing problems and tensions at the interface between health and social care.

  The sensible and long-term way forward must be through local authority structures. Provided that local government is strengthened once again, following the years of neglect under the Conservative administration, it makes sense to pass responsibility for health, along with all local public services to local authorities. As the devolution of powers evolves the future must rest with local communities, through local elected representatives taking responsibility for all local provision, health, social care, education, environmental health etc. BASW would support detailed work exploring such a proposal.

January 1998

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Prepared 21 May 1998