Matching interventions and people

COVID-19 and the subsequent Public Health England guidelines on social distancing changed social work practice. Many previously face-to-face interactions have been carried out or are being carried out either over the phone or through video calling.

Some benefits of face-to-face interactions are undeniable in terms of the increased ability to gather non-verbal communication, direct observation of the person in their own environment, and of the environment itself. There are instances, however, where this way of interaction is not necessary, does not add value, or could be too intrusive for the individual.

This decision-making tool supports social care practitioners to decide the best method, or combination of methods, for a given interaction.

It can be used for any social care interaction and/or intervention including provision of information and advice, assessment, Mental Capacity Assessment, care and support planning, or simply a regular catch-up to see how a person is doing

The options explored for interaction in the decision-making tool are:

• face to face
• email
• phone
• video calling
• social media – e.g. WhatsApp
• specific care planning apps (i.e. Leaving well: Improving support for young people leaving care.

What to consider

When deciding what is the best way to carry out an interaction or intervention (which normally comprises a series of interactions) the key elements to consider are:

1. Legislative requirements.
2. Type of intervention (including the purpose).
3. The individual and their circumstances.
4. The professional and their circumstances (including the organisation).
5. Social Care Practice principles.

Once the above elements are considered using helpful prompts below, you can find some pros and cons for each mean of intervention in a later section.

1. Legislative requirements

Your starting point should be to consider whether what is proposed is lawful.

Care Act 2014

The Care Act 2014 is clear in the legal duty to be proportionate and appropriate in the performance of an assessment, and the duty to be flexible in other interventions such as support planning, financial assessment or support plan reviews (Care Act Statutory Guidance, 6.3, 6.28, 8.16, 10.50, 10.58, 13.16, 13.17).

The Care Act emphasises the importance of ensuring that any interaction with the adult or carer is carried out in a manner that is appropriate and proportionate to the individual’s circumstances. To follow are extracts from the Statutory Guidance which highlights that not every interaction needs to be face-to-face; all or part of it may be done by phone, in writing, via an app, or by video calling.

• 6.3 Open

  An ‘assessment’ must always be appropriate and proportionate. It may come in different formats and can be carried out in various ways, including but not limited to:

  • a face-to-face assessment
  • an online or phone assessment.

• 6.28 Open

  Where appropriate, an assessment may be carried out over the phone or online. In adopting such approaches, local authorities should consider whether the proposed means of carrying out the assessment poses any challenges or risks for certain groups, particularly when assuring itself that it has fulfilled its duties around safeguarding, independent advocacy, and assessing mental capacity.

  Local authorities have a duty of care to carry out an assessment in a way that enables them to recognise the needs of those who may not be able to put these into words.

• 10.50 Open

  The level of involvement should be agreed with the individual. There may be instances where remote involvement is just as effective, such as over the telephone, through video conferencing, or other means.

• 13.16 Open

  Local authorities should have regard to ensuring the planned review is proportionate to the circumstances, the value of the personal budget and any risks identified. There should be a range of review options available, which may include self-review, peer-led review, reviews conducted remotely, or face-to-face reviews with a social worker or other relevant professional.

2. Type of intervention (including the purpose)

To help you consider the best approach for each intervention, consider the following questions:

• What type of intervention are you considering/undertaking?
  • Different types of meetings – e.g. formal case conferences – may be better suited to a video conference call.
• What is the main purpose of the specific interaction?
  • gather or confirm objective information like demographics
  • facilitate engagement
  • identify potential risks
  • make a decision
  • identify the individual needs
  • introduce yourself, etc.
• Do others need to join, or would it be beneficial if others join all or part of the intervention?
  • If so, what are the possibilities or abilities for those to join using the different ways?
• What does the intervention entail?
  • Is it necessary to complete in one conversation, or
  • can it be split in different parts and carried out using different methods for each interaction?

Once you have defined the above, you would be able to ascertain the pros and cons of each of the options.

3. The individual and their circumstances

To determine the best method for an interaction the Care Act guides us to support the individual to take a lead. As such it is key to ask the individual what their preferences are, taking into account all their circumstances and considering things such as:

• The person’s cognitive and communication abilities. As the Care Act Statutory Guidance explains, people with significant cognitive or verbal impairments may be less well able to engage with remote forms of interaction. That will not always be the case – video can be useful in the assessment of people with profound and multiple learning disabilities, for example, but should be borne in mind.
• The person’s willingness to engage in different options. All social care interventions should consider the needs and wishes of the individual person. If someone is set against the idea of certain means of intervention, this should be respected. Alternatively, people might have specific preferences for methods of working that aren’t face-to-face. For example, some autistic people like the opportunity to engage over technology.
• Technology. Many people lack the confidence, skills, or equipment to work with some forms of technology, such as planning apps or video conferencing.
• Breaks. Video conferencing is tiring. Bear in mind people’s need for a rest.
• Support networks. Video conferencing may be an ideal way of bringing physically remote members of a person’s network – be they family, friends, or other professionals – together in an efficient and effective way. The right of carers to a wholly separate assessment needs to be considered, however, as do any potential conflicts of interest or problems arising from group meetings.
• The known nature of the person’s needs/request for assistance. If the issue at hand is a safeguarding one, for example, being able to see the person may be important. Less complex matters may be more proportionately managed by other methods of intervention.

You may utilise one or more methods during an intervention. For example, you may:

• Complete the basic details such as date of birth, address, etc. using a phone call or by email.
• Send the questions or context for the intervention in advance by email and provide an initial explanation by phone or video call.
• Visit face-to-face to confirm understanding of the individual’s circumstances and needs and have the opportunity to observe them in their own environment.

4. The social care practitioner and their circumstances

While the Care Act informs us that any interaction with the adult or carer should be carried out in a manner that is appropriate and proportionate to the individual’s circumstances, the circumstances of the professional(s), and those of the organisation they work for, need to be factored into the decision about managing an interaction in the best way. Some considerations are:

• The professional’s IT equipment. If a staff member has unreliable broadband, for example, this may rule out certain activities, such as group video conferencing.
• Organisational policies regarding online platforms or approaches. Using Zoom, for example, is barred in some authorities because of concerns about its security.
• The involved social care practitioner’s personal circumstances – especially when working from home. They will have to consider whether they can be overheard, by children or other family members, or whether confidentiality can be safely maintained.
• However, now that hybrid working has become practice normality it is important to minimise distractions given that we will be talking with people during very difficult circumstances. Consider the impact that a barking dog; a supermarket delivery; being passed a cup of tea, etc. can have during the interaction.
• Competence with technology should not be an issue. Unless there are specific reasons why a social care practitioner would struggle with, for example, video conferencing – such as having sensory impairments – then the employer should ensure staff receive appropriate training to enable competency.
• The social care practitioner may wish to consider how much of themselves they reveal in backgrounds etc. during a video call. Consider avoiding having family photographs in the background, for example.

5. Social Care Practice principles

On 19 March 2020, the Department of Health and Social Care (DHSC) published the Responding to COVID-19: ethical framework for adult social care, and its easy read version. Skills for Care have also developed a one-page version.

Although the ethical framework was developed in light of the pandemic, it embodies the key practice principles and ethical values that adult social care is built upon. Therefore, it is a useful framework for social workers and social care practitioners at all times.

The below section details how the different values can relate to making decisions about how to determine the most appropriate method of working with people. The principles and values are linked together.

• Respect Open

  This principle is defined as recognising that every person and their human rights, personal choices, safety and dignity matters.

  Have an open and honest conversation with the adult and/or carer about all the options available for the specific interaction and the pros and cons of any of them. Ensure that the individual knows that they have choices and that they can change their minds and select different means for different purposes or parts of the intervention.

• Reasonableness Open

  This principle is defined as ensuring that decisions are rational, fair, practical, and grounded in appropriate processes, available evidence and a clear justification.

  Any decision should be practical and feasible, not only for the professional, but mostly for the individual and their circumstances.

  All options should be considered, and the decision-making process should be clear and transparent.

• Minimising harm Open

  This principle is defined as striving to reduce the amount of physical, psychological, social and economic harm that our intervention, interaction, decisions or behaviours can cause to individuals and communities.

  Options and decisions should consider the aim of minimising harm for all parties. All participants should take responsibility for themselves and others, and honesty and transparency should be paramount.

  Acknowledge that in order to minimise harm a ‘less preferred’ option may need to be chosen. All circumstances should be considered, the limitations of the chosen option acknowledged and recorded alongside with the reasons why the choice has been made.

• Inclusiveness Open

  This principle is defined as ensuring that people are given a fair opportunity to understand situations, be included in decisions that affect them, and offer their views and challenge. In turn, decisions and actions should aim to minimise inequalities as much as possible.

  Individuals and/or their carers and all of their circumstances, not only their problems, should be included in the decision-making process about the best way or ways for an intervention.

  A strengths-based approach is key to these values and principles as we focus on the individual and all the circumstances of their life and not only on the presenting issue or problem ‘to solve’.

• Accountability Open

  This principle is defined as holding people, and ourselves, to account for how and which decisions are made. In turn, this requires being transparent about why decisions are made and who is responsible for making and communicating them.

  The social worker or social care practitioner should be able to professionally explain the decision and the decision-making process in relation to the evidence, the circumstances of the individual and the legislative context.

• Flexibility Open

  This principle is defined as being responsive, able, and willing to adapt when faced with changed or new circumstances. It is vital that this principle is applied to the health and care workforce and wider sector, to facilitate agile and collaborative working.

  Decision-making processes, forms, procedures, etc. should be flexible to enable its adaptation to the individual circumstances and wishes and to current circumstances.

  Social workers and social care practitioners should use procedures, forms, etc. flexibly to ensure they are adapted to the current circumstances and primarily to the individual and or carer circumstances and priorities.

• Proportionality Open

  This principle is defined as providing support that is proportional to needs and the abilities of people, communities and staff, and the benefits and risks that are identified through decision-making processes.

  When making the decision it is important to ensure that the most appropriate and proportionate way(s) of contact are chosen in relation to ALL the individual circumstances.

General pros and cons of each way of intervention

Please note that there is no need to choose one method for the entirety of the intervention, and that a combination of the below may be the most appropriate and proportionate approach.

• Face-to-face Open

  Pros

  • Facilitates non-verbal communication.
  • Facilitates understanding of the individual in their own setting.
  • Allows observation of people’s home environment.
  • Enables some individuals to feel more comfortable.
  • Facilitates safeguarding concerns to be detected earlier.

  Cons

  • Non-verbal communication could be hindered/misleading by nervousness or intimidation about the face-to-face experience.
  • Can be perceived as intrusive by the individual.
  • Travel time has to be considered.
  • Greater difficulty for breaks.
  • Greater difficulty for shorter sessions or a number of sessions.
  • Could make participation more difficult for other parties and professionals.

• Email/messaging apps Open

  Pros

  • Enables preparation of message to be written.
  • Enables ability to re-read the information, and gives people time to think through and prepare their answers (often popular with autistic people).
  • Provides objective and consistent understanding of the message.
  • Information can be shared with other parties not present.

  Cons

  • Does not enable for explanation or gathering of feedback easily.
  • Could be difficult to get the right tone if there isn’t already an established relationship.
  • Difficult to provide context.
  • Delays response to queries.
  • Requires certain level of technical knowledge and equipment.
  • Loss of ability to understand the person’s home environment.
  • Some safeguarding alerts will be harder to spot.

• Phone Open

  Pros

  • Enables practitioners to pick up on verbal clues.
  • Efficient in terms of time.
  • A well-established technology that most people are familiar with.
  • Allows in-depth exploration of issues.
  • Some people find it easier discussing difficult topics when they cannot be seen.
  • Useful for short, regular check-ins.
  • Lowers risks from COVID-19.

  Cons

  • Loss of visual cues to person’s mood, environment etc.
  • Some safeguarding alerts will be harder to spot.
  • Some people will be uncomfortable not seeing the practitioner.
  • Individuals with hearing impairment could miss essential information/not understand what is being discussed.

• Video calling Open

  Pros

  • Easy to bring in other parties – e.g. relatives, other professionals – into a group discussion.
  • Video facility allows for easier connections to be made than with email, messaging or phone.
  • Less intrusive and intimidating for some individuals.
  • Seeing the person may alert people to safeguarding concerns, etc. more easily than by phone or messaging.
  • Useful for short, regular check-ins.

  Cons

  • Many people lack the broadband, equipment, or skills to make this work reliably.
  • Some people find it intimidating, and/or have concerns about privacy and security.
  • Group conversations can be hard to manage, and people can find it difficult to have their say.

• Support planning apps Open

  Pros

  • Evidence that they can be popular, especially with younger service users.
  • Specifically designed with social care assessment and planning in mind, and can be linked to databases.
  • Sense of control for people who use services.

  Cons

  • Not widely used.
  • May not suit all client groups.
  • Harder to input professional judgement at early stages.

Key social care practitioner’s competences for telephone or video call interactions

The below is not meant to be comprehensive but an indication of the key competences a social care practitioner should have to enable successful rapport and building meaningful relationships through technology.

People may behave differently online

When establishing online interactions social workers and social care practitioners should be able to:

• Draw on knowledge that people may behave differently online from how they would do in a face-to-face interaction.
• Recognise the implications of the above differences in the process.
• Be aware that the sense of anonymity can play a role in the behaviour the adult and/or carer may display in an online interaction, as well as the practitioner’s behaviour.
• Take into account that, without face-to-face checking, developing inaccurate assumptions may be more likely. They should therefore ‘reality check’ any assumptions, gaining clarification, evidence, corroboration, etc. and proactively identifying when assumptions could have been made.

Potential differences in impact of written word

Social workers and social care practitioners must be fully aware of the impact of the written word as opposed to a verbal message - ‘it can acquire a sense of permanence, it can appear more authoritative than the spoken word its meaning cannot be moderated by contextual features’ (BACP).

Potential blurring of boundaries

Social workers and social care practitioners should be able to establish appropriate professional boundaries using technology in their interactions.

Appropriateness of online interaction

Social workers and social care practitioners should determine the best way to interact with a given adult and/or carer.

The decision-making tool aims to support you to determine which is the best method(s) for an intervention and assess suitability for phone or video calling. This decision should be made jointly with the adult and/or carer.

Some things to consider are: the adult’s preference regarding the type of technology to be used, their competence in using different technologies, and whether the adult would feel comfortable communicating and/or expressing their feelings using particular technologies.

In some cases, supplementary ways of communication or additional questions may be needed to get a full picture of the adult and/or carer and their circumstances and needs.

Identify and manage risk

Identification, assessment and risk management is core in social work and social care interventions. Using phone or online communication could prevent professionals from identifying risks that could have been easily observed in a face-to-face interaction. Having said this, the professionals should carry out interventions in a way that allows the identification of risks in a different way.

Social workers and social care practitioners should understand that it can be difficult to identify risks in phone and online interactions without input from non-verbal communication and observing the context. They should therefore use verbal communication to gather information otherwise gathered by observation.

They should also be able to manage their own anxieties in relation to the change in practice and potential limitations in identifying, assessing or managing risk.

Professional skills

Social workers and social work practitioners should have the necessary abilities to behave in a professional manner using phone and online communication. This includes:

• ability to open the conversation in a professional and approachable manner
• conveying empathy and ensuring the adult feels listened to
• being able to infer the adult’s and/or carer’s emotional state without non-verbal communication
• being able to gather evidence and information through questions and nuances
• ability to end the phone or online communication appropriately.

Dos and Don'ts

Case study: About Lucy

Lucy is 35. She has a sister that lives local to her and two brothers who live some distance away, but they stay in contact via WhatsApp.

Lucy lives in a small residential home for young people with learning disabilities. She is very close to the other people who live in the home and gets on well with most of the people who support her. Lucy has some communication barriers, but is known to be thoughtful, caring and funny. She loves to be part of the action of the home, and if there is laughter, Lucy is most likely the one to be laughing or causing others to laugh.

Lucy has a very strong character, with a positive outlook on life and she often brightens the day of those she meets.

Alun recently came to live in the same house as Lucy, but she has struggled to adjust to his character. She is withdrawing from the activity of the home and asking her brothers to come and take her to their houses.

Lucy’s sister has made contact with Adult Social Care as she is concerned about this change in Lucy, but Lucy does not wish to talk to her about how she is feeling or why she now wants to live with her brothers.

Using the practice principles

If a social care practitioner wants to engage with Lucy, they may wish to consider the ethical principles in their decision on the best methods for interacting with Lucy. Professional skills are fundamental in all interactions, including when someone does not necessarily want to be contacted.

The social care practitioner may consider the following when using the practice principles.

• Respect Open

  • Lucy’s right to self-determination alongside their duty of care and their duty to promote her wellbeing.
  • How to contact Lucy with respect to her and her circumstances, bearing in mind that she has the ability to make choices based on her own values.

• Reasonableness Open

  • Work with Lucy through reasonableness to determine what and how many types of communication(s) would be necessary and/or preferred before and for the intervention. It may be that more than one interaction is needed for the intervention, and that more than one method is necessary too.

• Minimising harm Open

  • Aim to engage with Lucy in a way that can establish a meaningful relationship that supports her to be aware of her current circumstances and enables identifying together what would help her to feel better.
  • Balance this principle with others, as face-to-face interactions may need to be limited to reduce harm coming to Lucy. Because of this, video calls may be the preferred way of contact, or a combination of phone calls, video calls and emails.

• Inclusiveness Open

  • Consider how to be inclusive and ensure that her brothers and sister, Lucy’s friends and support staff are included in the interactions, provided this is what she wants.
  • Consider planning a second interaction by phone or video call. Lucy should be informed of her right to have someone present during the meeting.
  • Prepare Lucy for any interactions by sending her a copy of what will be discussed by email or letter or having an initial conversation with her about it. And explaining what the intervention is (i.e., review) and ensuring each interaction is inclusive.
  • Explain to Lucy the content of the intervention in advance, so that she can discuss this with her friends or family in preparation for the call. This would enable Lucy the best opportunity to participate fully.

• Accountability Open

  • Be accountable and make decisions based on evidence, as much as possible.
  • Communicate any outcomes or decisions to Lucy and the people she would like present explaining the decision-making process and the rationale for the decision made.

• Flexibility Open

  • Discuss with Lucy the options for communication and methods for interactions ensuring there is clear flexibility. The tone and content may suggest an initial phone call to ask her when and how she would like to interact with adult social care.
  • Perhaps ask her by letter whether she prefers a phone call, a video call or a home visit as an initial contact.
  • One or more phone or video calls may be needed before the preferred way of carrying out the review meeting is established.

• Proportionality Open

  • Be proportionate to Lucy’s circumstances in their approach.
  • Based on Lucy’s capacity and her ability to make decisions on the preferred method for each interaction, proactively involve her when and if necessary.