BJSW Advance Access originally published online on February 9, 2007
British Journal of Social Work 2008 38(6):1132-1150; doi:10.1093/bjsw/bcl379
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‘There Are Wonderful Social Workers but it’s a Lottery’: Older People’s Views about Social Workers
Jill Manthorpe is Professor of Social Work at King’s College London and Director of the Social Care Workforce Research Unit. She has long-standing interests in work with older people and has published widely on the subject. Her current research includes workforce studies, adult safeguarding, mental capacity and dementia, service evaluations and social work education.
Jo Moriarty is Research Fellow at the Social Care Workforce Research Unit. She has particular interest in dementia support and service development. Current and previous research addresses ageing and ethnicity, social work education and user participation in social care.
Joan Rapaport is Research Fellow at the Social Care Workforce Research Unit. She has particular interest in mental health and is an active member of the British Association of Social Workers, and co-ordinates the Social Work History Network as part of her work at the Social Care Workforce Research Unit.
Roger Clough is Emeritus Professor of the University of Lancaster and is engaged in a variety of studies of social care for regulatory bodies and other funders. His most recent publication The Support Older People Want and the Services they Need (Clough Manthorpe and OPRSI, 2007) continues his joint work with older researchers.
Michelle Cornes is Research Fellow at the Social Care Workforce Research Unit. She has worked on research and community development with older people and is currently engaged in studies of hospital discharge and of service improvement in the UK.
Les Bright is an independent researcher and consultant.
Steve Iliffe is a practicing General Practitioner in inner London and is Reader in General Practice at University College London Medical School. He has particular interest in service design and development, and in dementia care.
OPRSI (Older People Researching Social Issues) are a research co-operative of older people who have particular interest in communicating the views of older people and carers to policy makers.
Correspondence to Professor 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
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Summary |
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This paper draws on the evaluation of the impact of the English National Service Framework for Older People (NSFOP) on the experiences and expectations of older people, four years into its ten-year programme. The NSFOP focuses on achieving cultural changes so that older people and their carers are treated with respect, dignity and fairness. The evaluation took a mixed methods consultation approach in ten localities. This paper focuses on what was said by older people, their carers and in voluntary sector groups about social workers’ roles and activities. The data suggest that they find social workers’ roles unclear and variable. They appreciate a person-centred approach, informed about older people’s needs in a confusing social care system. Their perceptions tally with those of social workers that the tasks of care management can be reductionist, but older people also desire specialist knowledge combined with a relationship that is ‘on their side’. Social workers’ roles in rationing support and means-testing did not seem to promote such models. At a time of rising expectations about the skills of social workers and of changes to social work roles in England and Scotland, this study provides one of the few examples of information directly gathered from older people themselves.
Keywords: social work, older people, satisfaction, quality assurance, professional role, user perspectives
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Introduction |
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There have been few opportunities to ask large numbers of older people what they think about the service they have received directly from their social workers. At first sight, this may seem surprising, since service evaluations and user experience surveys are commonplace, 1.2 million older people used social care services in 2004–05 and they account for almost half of all local authority expenditure on social services (NHS Health and Social Care Information Centre, 2006). However, there are a number of reasons why these opportunities have not been grasped. First, many older people do not encounter social workers until they are at a time of crisis (Godfrey et al., 2004), often with high levels of disability, especially cognitive impairment. Second, their encounter with social workers may be brief, although their relationship with the often separate provider of social care services may be more lasting. Third, there has not been a great tradition or interest among social workers about what older people think of them. Social workers have had much to say about empowering older people (e.g. Thompson and Thompson, 2001), but this is rarely informed by studies that draw on older people’s views about what they would want or receive from their social worker. In a study of public perceptions of social work and social care, for instance (Research Works Limited, 2001), for the Department of Health, no older people were included in the sample of members of the public consulted and in the report of focus group discussions with service users and carers to inform the new social work degree in England, the views of older people were not separated from those of other service users (Barnes, 2002). In this context, this paper provides one of the few examples based on empirical data gathered from older service users. It will suggest that some of the frustrations expressed by social workers about the tensions between managerialist agendas and the values of their profession are reflected in the experiences of service users. In addition, it shows that older people value encounters that go beyond the simple provision of information but are rooted in empathic and knowledgeable engagement with the concerns of individual older people and their carers.
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Background |
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Although social work with older people has been a neglected area of academic and professional interest, there are, of course, exceptions. Chesterman and colleagues (2001) found that older service users’ satisfaction overall was affected by the quality of their social care assessment and this is a key social work activity. Ware and colleagues (2003) examined the files of fifty-five older users of social care and interviewed the older people concerned, their carers and care managers, noting general satisfaction with assessment, albeit in the context of low expectations. Phillips and Waterson (2002) interviewed twelve older people being discharged from hospital to long-stay care, finding that the assessment process seemed largely irrelevant to them and they experienced variable levels of advice and information, and practical help.
There is also the question of whether older people would or do think differently about their social workers than any other group of people who use services. The British public appears to see social workers as largely concerned with children and ‘problem families’ (Research Works, 2001) and many of those in contact with social workers working in other contexts, such as child protection (Spratt and Callan, 2004), appear to regard the process of approaching social workers with apprehension, ambivalence or some confusion. And concerns have been expressed that the process of ever tightening eligibility criteria only serves to stigmatize older people using social services and to disempower them in terms of their relationships with social workers even further (Tanner, 2003). We cannot answer questions about possible comparisons between age groups and would point to the great heterogeneity among older people (Iliffe and Manthorpe, 2004) and to the difficulty for many researchers in focusing on individual professions such as social work whose functions are regarded as unclear. Finally, there is some evidence that older people may not find it easy or sensible to raise concerns about care services (Bauld et al., 2000) and thus comments about social workers may be affected by this reluctance to voice criticism.
While social work with older people has always been seen as being of lower status than work with other service users (Hugman, 2000; Richards, 2000), in recent years, British researchers have identified a new tension between what have been seen as managerialist concerns and those of professionals, such as social workers (Rummery and Glendinning, 1999; Parry Jones and Soulsby, 2001). While some managers have questioned the need for qualified social workers to work with older people (Lymbery, 2006), those with a background rooted in work with older people have argued that, on the contrary, older people faced with making difficult decisions about their future need the support of experienced and skilled practitioners (Richards, 2000; Dwyer, 2005). Many of these tensions are considered to have dated from the implementation of the 1990 NHS and Community Care Act. Here, despite the evidence focusing on the value of specific targeted approaches to implementing care management (Davies and Challis, 1986; Davies et al., 1990; Challis et al., 2002), a policy decision was taken to adopt more generalized and less intensive approaches (Edwards, 1996). This has resulted in as few as 5 per cent of older people receiving the sort of intensive care management designed to deal with complex needs, potentially compromising the success of policies aimed at supporting older people to live at home or improving integration between social and health care (Challis et al., 2001). It is also thought to have led to a perceived decrease in professional autonomy and to more anxieties about conflicts with social work values among many social workers (Postle, 2001, 2002; Gorman and Postle, 2003; Bradley, 2005).
Concerns that older people had poorer access to support than their younger counterparts and the desire to improve integration between health and social care services were among two of the underpinning objectives behind the National Service Framework for Older People (NSFOP) (Department of Health, 2001) (National Service Frameworks are long-term UK government strategies for improving specific areas of care and set out a series of goals to be achieved over a set time period). The NSFOP is a matrix approach to policy implementation in a multi-system environment. Based on wide consultation, and combining different strands of demand, it is a comprehensive, evidence-based strategy aimed at ensuring fair, high-quality, integrated health and social care services for older people, with a ten-year timetable for action. As a policy lever, it is unique in older people’s services, seeking to promote and sustain change across local government and health services. For social workers, working at every level and in all types of work with older people, its implications are potentially profound. It has the potential to raise the status of work with older people and to enhance whole systems approaches to long-standing boundary disputes between health and social care, where social workers have often occupied uncomfortable middle ground (Reed and Morgan, 1999; Glasby and Littlechild, 2004).
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Methods |
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The NSFOP declared that ‘For social care services, Social Services Inspectorate inspections of services for older people regularly show user satisfaction rates of around 80%’ (Department of Health, 2001, p. 2). However, satisfaction surveys may generate poor-quality or puzzling data (Qureshi, 2002; Qureshi and Rowlands, 2004), and, in interview, many older people appear to be cautious of appearing critical of services or the staff who provide them (Chesterman et al., 2001; Ware et al., 2003). To counter some of these problems, we adopted a rapid appraisal approach (Ryan et al., 2001) to provide a means of involving communities in identifying their own needs—important both intrinsically for the democratic process and for enhancing trust in the researchers’ independence from service providers. This approach can provide timely, relevant information, contextualizing such needs within the social relationships, economy and service cultures of local communities (Jee et al., 1999). A portfolio of methods (public listening events, nominal groups and individual interviews) was used to allow for the possibility of conflicting or differing opinions (Jee et al., 1999). On its own, each method is limited, but, together, their combined strengths, and the scale of the consultation process, allowed us to draw generalizable conclusions to reflect the perspectives of older people across a range of localities. Importantly, this meant we were able to hear from older people who were currently service users, those who may have been in the past, and those who may have applied unsuccessfully for support or who may have ruled themselves out as ineligible. This method of consultation formed part of a statutory inspection of older people’s services and equipped the inspectors with an independent source of data about the experiences of older people.
Through the involvement of Older People Researching Social Issues (OPRSI)—a research co-operative (Clough et al., 2006)—older people were involved in the design of the evaluation, in its implementation and in the analysis of findings, following the research and development methodology advocated by Scott and colleagues (2004). The multidisciplinary nature of the research team overall helped contain and reduce professional biases.
A purposively selected sample of localities had been identified by the joint inspection bodies (Healthcare Commission, 2006). These included urban and rural areas with diverse populations, covering ten local authority areas (see Box 1) (Healthcare Commission, 2006). Population profiles were reflected in the respondents’ socio-demographic characteristics (ranging, for example, from 55.3 per cent of respondents in the City of Leicester being from Asian or Black groups, to 0.8 per cent in the County of Wiltshire (specific details of ethnicity were collected but these were grouped into categories as in some area numbers were so low as to compromise confidentiality)). A total of 1,839 older people and carers, whose ages ranged from people in their fifties to those in their nineties, participated in public listening events. Of these, 1,639 took part in nominal groups and 120 were interviewed individually, across 2005.
Box 1. Localities in the study
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Listening events, nominal groups and interviews were conducted using a semi-structured enquiry schedule. Researchers were asked to request, as far as practicable, that all experiences recounted were explicitly recent (defined as in the last year) and personal, or reported the accounts of an older family member or close friend, to minimize the risk of hearsay and generalization, say around media reports.
As the consultations were part of a statutory inspection, approval was not required from ethics committees. However, the research team sought informed consent from all participants and gave assurances of anonymity (numbers used for quotations indicate the local authority area and the initials whether the data were gathered in interview or group discussion). Transport was arranged, if wanted, expenses and carer costs were met and refreshments were provided. Assistance with communication for people who did not speak English or for those who had a hearing impairment was provided.
In each of the ten local authority areas, the team used an explicit analytic induction technique (Znaniecki, 1934; Ragin, 1994) to review data from the groups and interviews to assess commonalities across the different areas. At the end of the study, when reports had been produced covering all ten localities, the research team met in a consensus conference. Through a process of progressive focusing (Bartunek and Murningham, 1984), the team scrutinized the data and those discussions relevant to social work have been extracted and analysed (by social workers and non social workers); the themes are presented and discussed in this paper. All qualitative analysis is a process of reduction and this can compromise the totality of qualitative data. However, iterative processes described above offset the risk of oversimplifying rich data.
One key issue was to decide upon the parameters of social work and this was resolved by taking the activity of social workers to be social work, even though some of these activities might be described as care management. Thus, when individuals spoke about services (such as home care) arranged by social workers, or arising from a social work assessment (such as a place in a care home), these services and their personnel have not been included as social work. The reason for demarcation is that opportunities to focus on social work are rarely available from the perspective of older people and their carers. To obtain a broader view, we have included some contextual points made by voluntary and community group members, when these seemed to consolidate the points made by individuals. We have framed the data into five main themes: a focus on social work, roles and responsibilities, perceptions of social workers, skills and knowledge, and the adequacy of competence. When possible, we have noted where the experiences we use to illustrate the themes are dominant, from multiple sources, or are outliers, running counter to the majority of views that we encountered.
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Results |
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A focus on social work
Although the title ‘social worker’ has been protected (2000 Care Standards Act) by all four UK Care Councils, it remains often applied to unqualified staff who undertake a range of social services tasks (British Association of Social Workers, 2005). Alternatively, people using services may employ the term ‘social care’ as an umbrella term to include social workers, for example, as in the experiences of service users reported by Beresford and colleagues (2005). From the interviews and discussions in this study, it was clear that participants were sometimes referring to social care workers, occupational therapists, physiotherapists or, on occasion, district nurses when they mentioned ‘the social worker’. The term ‘social services’ was also used interchangeably with that of ‘social workers’. An example of this lack of clarity is captured below:
Interviewer: Let’s pick up on social services.Service user A: They’re excellent. I’ve had a wheelchair, a special chair, a bed.
Interviewer: This is the occupational therapist, isn’t it?
Service user B: Yes (IS5int2).
It is doubtful that a social worker would have seen it as his or her role to accompany a person with dementia to a football match, or have had the time to do so. In the example below, the ‘social worker’ was probably a community support worker or social care assistant:
I had help with social services and I was lucky with the particular social worker I was allocated . . . there was some rapport between himself and D . . . took him to football matches . . . I think that was over and above (IS9LE).
Moreover, the growing role of the voluntary sector in carrying out formal social support tasks contributes to the broad and fluid interpretations of the term ‘social work’. Several of the groups attended by voluntary sector representatives made reference to commissioning arrangements by social services departments with voluntary agencies to provide services. The extent and scope of contractual arrangements were highlighted in one group interview:
We provide a social work department on behalf of social services. We have to meet all of the requirements of social services (IS3VCS).
This made the task of analysis difficult and meant that data had to be interpreted in light of an individual’s broader responses and the context. This paper should therefore be read with these confusing and overlapping interpretations of the term ‘social worker’ in mind.
Roles and responsibilities
Problems of terminology were reflected in older people’s understanding of the roles and functions of social workers. One participant asked:
Social services—a big umbrella term—what do they do? (IS8LE)
However, participants’ views about the core functions of social workers, care managers or social services did emerge from the research. These related primarily to assessment for services, arranging services, providing information about services and occasionally arranging Direct Payments (cash to purchase care or support). Assessments focused on the possible need for residential care, respite care, home care services, mobility aids and equipment, and transport and day-care facilities. Social workers were seen to ration services and follow ‘rules’ closely in the assessment process:
I’m terrified of social services—they want to know too much—I struggle on—it’s just the fear of not being well—I carry on as long as I can—he (my husband) won’t be here that long (IS4Int2).Once you get social services in they go into your business. You have to go through that channel even if you’re paying yourself. Old people are reluctant to ask for help (IS4LE).
You’ve got to moan, moan, moan (IS5LE).
You have to demand services and be brutal and say, "What the hell’s going on?" (IS5LE).
Social Services need to be more understanding; they keep saying, "You don’t meet the criteria". What criteria? They need to give a little bit more help (IS8LE translation from Gujarati).
The social work role in respect of financial assessment was generally seen as intrusive and at one event was described by an older person as ‘like being interrogated in the war’. Knowledge of resources could be helpful, especially where funding was found to support a residential placement or welfare benefits were secured. However, social workers did not universally undertake an assessment of benefit entitlements, as might have been done in the past, apparently because of resource constraints, rather than it being an inappropriate use of their time:
It’s no one’s job—social work staff don’t have the time (IS1VCS).
Social workers were also characterized as providers of advice and information, particularly about residential care, home care and about the costs of services. Respondents’ views about social workers’ efficiency in this regard were mixed. They were seen to be helpful where they gave a prompt response and provided information about what was available and more in-depth knowledge about a service meeting particular circumstances. Complaints on social workers’ competence ranged from not having proper information or knowledge about services and simply being ‘not good on advice’. Reports about inconsistencies in this regard emerged within the different areas and people described mixed experiences. For example, a carer in her late eighties had been told about a day centre for people with dementia for her husband by one social worker, but not by another, and perceived this as a poor variation in support for herself and her husband:
My first social worker did not tell me anything about the local EMI day centre [day centre for older people with mental health problems] run by [the] Council but another one did. It is better for him [husband] than other facilities as it is smaller (IS4NG).
Perceptions of social workers
Negative statements about social workers included references to unhelpful attitudes, guarding the council’s money and rationing services, and being too slow to respond to requests for help or to undertake social care assessments, or, in some cases, not responding at all. A body of complaint concerned refusal of services even where the general practitioner or community nurse had made the original referral requesting help for the individual. In some instances, either the carer or service user was challenging the decision and was awaiting reassessment. For example, in one area, a black woman of eighty-eight years of age had been told that she was not entitled to services, despite the apparent support of her case by her family doctor. She did not believe that the local social services department would ‘do anything’ for her and the discussion group agreed with her on the basis of resource constraints:
You keep getting told (local) social services has no money (IS2NG).
Another person recounted her experience:
My doctor told me that I needed a surgical stocking and that if I phoned social services someone would come and put it on for me. But they wouldn’t send anyone as they said I didn’t need personal care so didn’t qualify (IS8LE).
Lack of publicity and little tradition of reaching out to older people were also perceived as reducing opportunities for the social work role to make a positive contribution to helping people receive timely help:
The people who don’t go to social services seem to get left out—we’ve got very independent people—people who don’t need care but who need things—but it takes a lot of time because they’re not in the system—and of course they’ve got to go—and they don’t and they [social services] won’t come out if they don’t want a service (IS7VCS).
In some areas, depictions of social workers discriminating against service users who were living with their families emerged. One person said that social workers did not bother to assess when two older people lived together and one of them required help, with the result that both parties suffered in the interim:
Social services expect a lot from carers—if there is an able-bodied person in the house social services don’t consider you need help (IS1LE).
People from two groups of South Asian older people expressed similar concerns, although social workers’ expectations that families would provide care also emerged in other groups:
They think you are OK if living with family. We want our independence. When living in joint family, don’t always get listened to and family are busy with own lives (IS3NG).
There were also complaints about the quality of some social work staff, such as those who were described as carrying out poor assessments, offering inappropriate advice and services, and making false promises. Lack of concern, limited empathy and little understanding about the effects of disability were also reported. The daughter of an eighty-five-year-old woman who was about to enter residential care said she had attended her mother’s case meeting. The social worker was described as merely the note-taker who apparently registered that she had no further interest. This was because the department’s involvement was going to be minimal, as her mother was self-funding (paying for her own care, as the means test was applicable). Her daughter viewed this stance to be unacceptable and continued:
I don’t see why they should not be concerned (IS4Int).
Others from different areas also regretted that social work involvement seemed impossible if their income and savings were above the current limits.
Examples were given of poor joint working with health and the voluntary sector, visits that were supposed to take place but not happening and visits that petered out without explanation. Many of these problems were attributed by older people to shortages of social workers. In one area, older people observed that many social work staff carried the title of ‘acting’. Some of the consequent problems were captured first by a voluntary sector day centre manager:
Domiciliary, social services and health care staff shortage is a serious issue. Carers are told this as an excuse for non-delivery of services. I don’t think they should have to put up with that. Staff shortages create problems for the services, but this is as nothing compared with the difficulties carers have to surmount. I don’t think carers should be given that excuse (IS4VCS).
Social workers were thus not able to offer a continuous service, there was insufficient forward planning and sometimes delayed responses to crises. One individual was very concerned about his wife’s future, given his frail health:
I have a wife—she can’t look after herself. If I’m ill . . . or have a heart attack, what happens? I’ve tried to get social services to come in but social services don’t want to know until something happens. The social services will not do an assessment in advance. I’ve already had two heart attacks (IS6LE).
However, there were also examples of positive experiences of social workers who had been found to be helpful, caring, trustworthy and responsive. These examples arose in the same areas as those which also contained accounts of negative experiences, suggesting that the attitudes of individual workers contribute significantly to people’s experiences of services. One participant observed:
There are wonderful social workers, but it’s a lottery . . . (IS5LE).
There were several stories of social work staff being ‘very good’. At different events held in the same area, a retired nurse and a day centre manager said that social services were ‘doing their best’ within financial constraints to provide appropriate care. In another area, a carer commented on the good service that she and her husband were receiving from a local service for people with dementia. This example conveyed the existence of a good working relationship between the psychiatrist and social worker:
I get first class treatment from the psychiatrist and the mental health social worker. If I leave a message I always get a reply (IS9LE).
Several service users and carers and a few voluntary agency staff praised the thoroughness of the assessment process and the appropriateness of services provided. For example, a carer praised the support of a social worker who had helped her to move her mother from a care home that was not suiting her needs to another that was entirely suitable. Her social worker had understood the difficulties and had facilitated a move that had completely transformed the situation surrounding her mother’s care (IS7Int).
Skills and knowledge
Participants liked social workers who were able to work collaboratively with other organizations and families, were reliable and knowledgeable about services and took account of their wishes. A husband whose wife had dementia described his experience of collaborative working between front line professionals and simultaneously illustrated the importance of his attitude and involvement in the process:
Liaison with social services and CPN (Community Psychiatric Nurses) are very good. When my wife went into the day hospital the CPN gave feedback to me once a month and it worked. Then she went into residential care, they were also good. My approach to the services was to try to have partnership for her benefit. It seemed to come together (IS4NG).
Older people and their carers prized the skills and qualities of social workers whom they considered were knowledgeable about specialist services, persistent, committed, reliable and accessible, supportive, sympathetic and prepared to listen. Thus, a professional and humanitarian approach was a vital element underpinning a social worker’s skills and knowledge base. One carer of her ninety-year-old mother-in-law expressed her gratitude regarding the social worker’s understanding of dementia and its effects on her and her family:
She had a fall. We hadn’t realized before that her memory was going. We looked after her for three years. We had a good social worker who was very supportive and she went into a day centre twice a week . . . he persuaded us to consider a care home. It was getting too much, especially at night (IS5Int).
Social workers were also valued where they had been able to act as ‘trouble-shooters’ to sort out difficult situations and for their practical approach:
They couldn’t get us a social worker for a very long time. But anyway, they’ve got us one now and she’s fantastic. She works with Dr Y’s team [Community Mental Health Team]. She’s really good; she knows what’s what and comes straight to the point. She’s sorted things out like incontinence pads (IS8NG).My husband became very aggressive because of his illness. He has been moved from three care homes and is now in a private nursing care home. The social care manager has been wonderful (IS4Int).
Commitment to enabling people to remain in their own homes and to keep their independence was also valued. This required detailed assessments and supportive care plans, and could also involve considerable risk taking. One participant had been so impressed with the care provided to allow a ninety-five-year-old neighbour to return home after having broken her leg that he made a point of praising social services when he subsequently wrote her obituary for the local newspaper.
The adequacy of competence
Participants wanted social workers to be more professional, have specialist knowledge about disability and relevant services, and enable older people and their carers to lead more fulfilled lives:
Need good old-fashioned social workers, but more professional than previously—more enabling . . . (IS7VCS).It may be a nurse or they need a social worker, but certainly a qualified person to actually go and assess them rather than a run of the mill care assistants who agencies often employ with very little or no qualifications and expect them to go in and assess a patient. I think that is wrong (IS10Int).
A group of older people with multiple sclerosis (MS) (IS7NG) were very critical about staff and their lack of knowledge about MS and how to operate equipment for people with disabilities. They drew up a list of desired social work competences and qualities. They wanted staff, including social workers, to be:
- knowledgeable about the condition and its effects;
- able to listen and respond appropriately;
- skilled in enabling a person to speak out without taking umbrage;
- sympathetic and not intimidating; and
- able to make a thorough and informed assessment.
The need for specialist expertise was reflected in views about other roles, although one participant also suggested that some flexibility between roles that did not breach core professional boundaries could also help the service user:
I’ll be eternally grateful to T, she actually listened—understood the problems and recognized that K was in need of help (IS7NG).Fuzziness between social work and nursing—not always a bad thing—flexible roles can be helpful to the patient (IS7NG).
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Discussion |
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There is always a contingency about what social work is and what it should be (Cree, 2003, p. 168). This paper highlights some of the uncertainties that exist in terms of how social work with older people is defined and in the priorities that are placed on different social work tasks. For example, the Performance Assessment Framework places high priority on the numbers of assessments taking place and the speedy provision of both assessments and services that are arranged as a result of these assessments as an indicator of how well local authorities are performing (Commission for Social Care Inspection, 2005). The views of older people in this study confirm that assessment and care planning seem to be given priority but, even so, these processes are not experienced as always timely. Waits and delays were reported, but what seemed to be the cause of most concern was that there was unevenness of experience and that expectations of a personal relationship, with the social worker being ‘on the side’ of the older person, were unmet. This applied to those who had been refused support for apparent lack of need and to those whose finances were such that they would not qualify for social services funding. Much depended on the personal qualities of the social worker, for those who had one, but there was also disappointment that this service was restricted. It emphasized a seemingly more impersonal approach to the social and health care of older people more generally.
This raises important questions about how social workers can manage the tensions between societal demands for efficiency and utility and the recognition that resources are limited, shown by the organizational requirements to undertake assessments quickly and to target resources on those most in need, with their other obligations to advocate on behalf of service users or to promote empowerment (International Federation of Social Workers and International Association of Schools of Social Work, 2004). This question is particularly apposite in the UK context, where most social workers are employed by local government. Phillips and Waterson (2002) found that older people and carers valued social workers who operated as effective ‘go betweens’ but also wanted social workers to recognize their feelings and worries. The authors commented that under current practice, ‘this traditional social focus on social work activity may not be there at all’ (p. 182). Gorman (2005, p. 164) has also observed that building a relationship is often sacrificed under the pressure to undertake assessment and care planning more speedily. This is despite the evidence that the time and sensitivity required to build a relationship building are almost always a prerequisite to undertaking effective assessments with all but the most well informed and ‘decided’ older people (Richards, 2000). This has led to a concern that managerial and procedural concerns have outweighed the value of professional autonomy (Lymbery, 1998; Postle, 2001).
The emphasis on assessment may also mean that other aspects of the process of arranging and monitoring packages of care have remained neglected. Confirming the points made by Barnes (2002), while carers and service users clearly appreciated the benefits of ‘good’ social work assessment, support and networking with other agencies in care planning arrangements and providing equipment were also thought to be important. Concerns have been expressed about the lack of differentiated approaches to care management and the failure to adapt this process to the needs of different service users (Weiner et al., 2002). This was reflected in this study where, for example, complaints about the quality of the home care provision were evident (see Healthcare Commission, 2006) but few people mentioned that their social workers had helped resolve these or took responsibility for monitoring the care package. Such dislocations in relationships between care managers and service users have been observed elsewhere (Ware et al., 2003).
Situations such as these highlight the uncertainty about social workers’ roles with older people, especially at the interface of health and social care (Lymbery, 1998, 2001). The Social Services Inspectorate (now Commission for Social Care Inspection) considered that in many areas, there is over-use of qualified professionals such as social workers, and declared this to be unnecessary and expensive (Bainbridge and Ricketts, 2003). However, we found that participants desired greater expertise among those helping to meet their often complex and sometimes distressing needs. While few would argue with the value of specialist approaches, such as community mental health teams (CMHTs) (Audit Commission, 2000, 2002) or specialist practitioners in secondary care (Challis et al., 2004), the reality is that many ‘ordinary’ social work teams receive a considerable number of referrals of older people requiring complex levels of support for themselves and their families (Moriarty and Webb, 2000) where there is no expectation that there will be resources to provide them with specialist levels of support (Challis et al., 2002).
Participants were not oblivious of some of the constraints in which social workers were operating. Older people, it would appear, do understand some of the demands on social workers as portrayed by Gorman (2005), Postle (2002) and Tanner (2001) and do not inevitably cast them as individually culpable for system failings. Social workers were often seen to be working within tight financial constraints and affected by staff shortages, with inevitable negative consequences on their ability to provide continuity of care, services and choices, and planning for contingencies. The contribution of the social worker is bound up with organizational systems, and these inevitably affect how social workers fulfil their role. Thus, some older people considered themselves underserved where information about services seemed poor and agencies were not working together well, or a service was not forthcoming after an assessment—just under a third of those assessed do not meet criteria for service provision (Department of Health, 2003). Where there were criticisms specifically about social work, these were embedded in the accounts in which participants reported that social workers were discriminating against older people on account of their age to restrict access to services, and that money was being spent on younger people. As noted above, some older people and carers held that they were being denied services where they lived with their families or a carer was in the picture. Phillips and her colleagues (2006) have argued that deeper gerontological knowledge is highly desirable among social workers supporting older people. This raises questions not only about the extent to which generic social work training programmes are able to equip social workers with the skills to practice in this arena, but also how far a commitment to anti-discriminatory practice is seen as encompassing the issue of ageism.
It is also important to consider the extent to which the role of social work with older people will develop in the future. The proposals for new forms of workers to undertake tasks of navigation between services, passing on information, promoting choices and informing care purchasing (Department of Health, 2005) with emphasis on greater user control and self-assessment, suggest that there may not be significantly more investment in social workers, or even care managers. However, others argue that social work should continue to play an important part in helping older people to make decisions about their lives (Lymbery, 2006; Phillips et al., 2006). What may happen in the future remains uncertain. What is clear from this study is that social work needs to continue to address how it can support older people and to find more effective ways of incorporating their views into debates about the profession.
This study was limited in that the sample of older people consulted was self-selected and that not all those interviewed or participating were able to distinguish the social work contribution to their current circumstances. It is, however, a study that was independent of services and the localities and this may have resulted in greater frankness, and the mixed methodology allowed for the views of a wide range of older people and their carers to be heard. Those who had not been considered as eligible for social care services and who had ruled themselves out in the face of means testing and other thresholds were also involved. This broad spectrum of experience, beyond that of a snapshot of the experiences of current service users, provides a mirror to the profession of what a wide range of older people think to be the purpose of social work.
Accepted: December 1, 2006
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We are grateful to the Healthcare Commission for funding this work and to all those who offered their views and experiences, who helped with practical arrangements and who undertook interviews and data processing. The views expressed here are not necessarily shared by the Healthcare Commission.
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