Assessing the mental health needs of older people
Lymbery M (1998) Care management and professional autonomy: The impact of community care legislation on social work with older people British Journal of Social Work 28 pp.863-878
Social work and the professional project
The development of social work professionalism has been hampered by the following factors:
- The level of hierarchical accountability in bureaucratic local government structures has decreased the level of professional autonomy of social workers.
- Social work has had difficulty in maintaining its 'technicality/indeterminacy' ratio. This has resulted in a defensive tendency for social work to develop more technical approaches.
- As traditional social work knowledge has been contested, there has been a move away from 'deep' understandings towards a concern with competence. This has influenced the development of vocational qualifications.
Social work with older people
Before the establishment of unified SSDs in 1970, social services for older people were organised within welfare departments, often with fewer and less qualified staff than in children's services. Unqualified or inexperienced social workers and welfare assistants carried out much work with older people. Following the establishment of SSDs, social work with older people continued to be perceived as having lower status than that with children and families and has therefore been less developed in terms of a 'professional project'.
Community care and care management
The introduction of community care in 1990, saw 'managerialism' impacting on social work services, particularly through the role of 'case manager', later 'care manager'. Welfare reforms were influenced by the New Right political belief that private sector style management, consumerism and competition could achieve more efficient and economical social services.
It was assumed that community and home-based, day and respite care (provided by a mix of statutory, voluntary and private agencies) would be more cost-effective than residential and institutional care. It was thought that the process of 'care management' could achieve gains for the consumer at no extra cost and engineer a shift away from institutional to community care.
Care management and social work
There was no clear blueprint for the change to a care management system. Theories about its impact on the role of the professional social worker differed. For some care management appeared to offer a more professional and co-ordinated approach to meeting the needs of older people, while others warned that it would deskill social workers and demand greater emphasis on managerialist and technical responses dominated by resource priorities. Generally it is thought that care management has moved social work towards an administrative model.
SSDs had to cope with the increased burden of assessment for older people who would previously have gone into residential or nursing home care. The administrative systems for assessing need, complex eligibility criteria and forms have made it difficult for social workers to retain a sense of the professional nature of their role. Budgetary constraints and rationing resulted in increased monitoring of social worker decision-making.
Some SSDs thought it inappropriate to use care managers' time to monitor and review care packages, a task which was passed on either to unqualified and lower paid 'reviewing officers', or left to the service providers. In some cases a separation of assessment and care management has occurred. The centrality of eligibility criteria for rationing services has led to concerns about excessive bureaucracy. Often the social worker is unlikely to maintain an active involvement in individual care management, with routine monitoring and review carried out by the service provider.
The introduction of care management has led to a shift in the balance between 'counselling' and 'social care planning' in social work, with the elements of social care planning taking precedence. Time and resources limit the tasks of the social worker within the care management model, sometimes leading to practice dominated by routinised and administrative approaches. The efficient allocation of resources remains a priority.
The balance of power in social work with older people has shifted in favour of increased managerial dominance over practice. This may lead to a re-evaluation of social work skills that favours a competence-based model, and a possible shift away from 'professionally' qualified staffing.
However, UK care management is now the subject of critical research and scrutiny. Some social work professionals are trying to reclaim social work as a central element of care management. The potential difficulties of the 'top-down' implementation of community care need to be recognised.
The nature of some work with older people demands the involvement of a professional social worker. The simplistic character of much care management practice is not sufficient to respond to the complexity of human experience. As well as 'social care planning' skills, the care manager will also need to enable a service user to understand and come to terms with their difficulties and circumstances.