Think Ahead – Why the Fast Track Mental Health Social Work Scheme is confused and poor

Last week, I read an article about the proposed government attempts to bolt a ‘Frontline’ scheme on to Mental Health Social Work. I was angry and I raged. Thanks to a comment (and I genuinely mean that) I wondered if I’d prejudged the process by some ill-considered quotes from the so-called ‘senior researcher’ and a government minister. Then I read the report itself and realised that while I hadn’t known all the detail, none of the concerns which I raised had been addressed.

People who have far more skill and knowledge than I do have written about this scheme – and people who actually know and understand the sector, unlike a think tank researcher who, on his own Twitter bio, claims to have expertise in education policy. I’d recommend the following pieces to learn more about the response to the scheme. This piece by Dr Martin Webber – a social work academic who has a particular interest in mental health social work (and more importantly, actually knows what it is) and this piece by Matt Graham, again, a social work academic who has worked in and knows mental health social work. Then there’s the sector commentary, from Community Care (an incredibly disingenuous interview with Norman Lamb which actually makes him into a bit of a laughing stock as he clearly demonstrates his lack of understanding of mental health social work – when he says, for example, that ‘only 8% of social work students choose a mental health placement’. Seriously – I feel a little sorry for him having been fed this by IPPR because anyone who knows social work and social work education will understand what that figure is really about and it isn’t about students not choosing mental health) and Mental Health Today.

 

I want to look at the report itself and while I don’t want to repeat some of the issues raised above, I am going to relate the cognitive dissonance between what the report says and my understanding and knowledge of mental health social work and why I think it’s based on flawed assumptions.

 

Starting with a solution and then ‘consulting’

This is something that is raised in the above pieces. It is blindingly obvious the government agenda was to take the ‘Teach First’ or ‘Frontline’ agenda and impose it on mental  health social work. Regardless of any consultation or discussion. This was a development that started with a solution and then went in search of a problem. Is the problem in mental health social work that there aren’t enough high calibre graduates coming into the profession? I’d say not but then, I’m biased and I know the excellence of my peers. I’m actually not opposed to new routes into social work for different groups of people. Our profession is strengthened by diversity. However, my worry is that this obsessive inferiority complex that social work, as a profession, has is going to stifle rather than extend diversity in social work. I see a professional voice that is growing and becoming more secure in itself and then we are told there’s a problem with image.

Having worked in and around mental health social work, I have never felt anything other than highly respected and valued as a member of a multidisciplinary team. Certainly, the consultant psychiatrists I’ve worked alongside have told me that they greatly value the social work profession and what it adds to multidisciplinary teams. So where is the problem? Not enough people who can’t get into clinical psychology considering social work as an option? Because that’s what seems to be presented in this document.  The document calls for an ‘improvement in the status of social work’ but certainly, within mental health (perhaps, unlike adult social work where professionals really have been deskilled and I’ll come back to that) I don’t see any concerns about the status within those who work in the profession. I was far more valued as a mental health social worker than as an adult social worker. But our job shouldn’t be about what status we have as professionals. It’s about doing a good job well, in a ethically sound context.

 

I’m going to look at the report in chunks – particularly where I feel the evidence is flawed and consider the report in detail.  I’m going to use the report headings themselves for ease of cross-referencing.

 

The challenges facing mental health social work

This is the place where we see how poor the research and consultation was, in the first chapter. We see evidence presented of the need for robust mental health services due to a rise in need. It’s hard to relate this to the destruction with which this government has unleashed on the health sector in general and mental health services in particular and not wonder what on earth the report is trying to prove. I hope the government didn’t pay a lot for this research as it’s pretty clear that the mental health sector is underfunded and working dangerously. However, the attempt to link this to a lack of the supply of good mental health social workers is flawed in the extreme as the problem isn’t a lack of supply or potential supply but a lack of actual posts available.  Here’s a nugget which evidences poor understanding

“Some local authorities have found it so difficult to implement integrated
working with the NHS that they are now choosing to bring their staff
and services back in house. It is important to find ways to deliver holistic
and integrated services in a more effective way”.

I’d say to the author that the reasons for pulling social workers out of mental health teams was related to Eric Pickles’ decimation of local government budgets rather than any decisions about ‘integration’ wasn’t working. Local authorities have different targets and sometimes social workers in mental health teams are pulled in different ways but I have spoken to many social workers who have been pulled out of mental health services and I’ve spoken with mental health teams who have had social workers pulled out.  The choices made were due to budgets not an ‘integration isn’t working’ agenda.

The integration agenda

The report then kindly explains to us what a ‘CMHT’ (Community Mental Health Team) is. I hope some of the directors of adult social services who are quoted in the article read this bit because my experience is that they rarely have a clue themselves.

The report says

Some {social workers] have reported benefitting from
greater levels of cooperation with other professionals, enabling them to
deliver a high-quality service to those with mental health needs. Those
that have reported negative experiences, however, have usually done so
due to a perception that they are unable to use their social work training
to deliver the social element of assessment and treatment. These mental
health social workers report either a situation in which their contributions
are undervalued and overridden by medical colleagues, or that their roles
as ‘care coordinators’ (see box 3.2) have caused the nature of their work
to become that of a generic health professional, requiring very little, if
any, social work expertise

So we can see what the researcher is doing by choosing the information that suits him. He discards the ‘some’ with positive experiences and picks up ‘those who have reported negative experiences’ and runs with it. He then goes on to pull apart ‘care coordination’ which he helpfully explains in a little box. This is my explanation of ‘care coordination’. Concerns about generic roles within CMHTs are not exclusive to social workers. I’ve heard nurses and CPNs describe the same. The issue isn’t solved by looking at social work in isolation. I have to say my experience was never one of disrespect or ‘being overridden’ by medical colleagues but maybe that says far more about a working culture and environment  and the leadership of the team than it does about social work specifically. If there is a problem, is it not one which is dependent on what profession you are but of general professional respect and hierarchies within teams. I would also absolutely refute that a generic role doesn’t require social work expertise. The point is that we, even when we work generically (and I did) contribute according to our professional backgrounds and work in multi-disciplinary teams to contribute our learning, values and positions.

I’ve found a bit I agree with

There are also significant concerns about the management of social
workers in integrated teams. Research suggests that social workers can
feel abandoned by the local authority

I certainly ‘felt abandoned by the local authority’ BUT why does the author then go on to completely confuse things by asking directors of adult social services for their input when they haven’t really proved that they know, understand or engage with mental health social work. I can live with feelings of abandonment from my employers to be honest, as long as I’m allowed to do the job I feel it is ethically right to pursue and a different training route does not solve this issue.  Then we get a really odd logical leap which evidences the need to find a solution and look for a problem. The author (I’m not going to call him a researcher anymore because he is using fiction), moves from a paper which talks about integration to a conclusion that we need

a cadre of highly trained social work
professionals with a commitment to integrated working will be required
to make multidisciplinary teams a success. A need therefore exists to
foster a new generation of mental health social workers, who have the
capabilities and confidence to work effectively with other professionals
in integrated teams.

So let’s get this unpicked a bit. He is blaming a lack of integrated working, entirely on the ‘cadre’ of social workers in integrated teams. Wow. We need a ‘new generation’ of mental health social workers. Need? Really? This is where we start seeing the arguments fall to pieces because what we actually need to make integration work are confident social workers who are able to challenge within teams. Sure, let’s bring some more in but this suggests we NEED new people in. Let’s have the new blood in because the current ones don’t have the skills. I see we move from fuzzy arguments to pre-defined solutions in a whirl. Funny that Lamb says this isn’t about denigrating current mental health social workers but it seems quite clear in that sentence.  You see, it’s OUR fault that integration isn’t and hasn’t worked. Our fault as mental health social workers. Not the local authorities who are desperate for money and need to bring their social workers back in house to pick up the local authority targets. No, it’s the fault of the social work profession.

And the conclusion

the first problem that a fast-track recruitment
programme in mental health social work will help to address – protecting
both the integration agenda in mental health and the role and status of
mental health social workers

And there we have it. This is going to ‘save’ the integration agenda. Unfortunately, the author has completely misunderstood (actually, I’ll give him some credit) or misinterpreted intentionally the reasons that integration has been struggling in mental health. Clue: It isn’t solely the fault of the social workers in the teams.

 

Recruitment

The next issue the ‘problem’ with recruitment. This is where the report gets very confused about the links and differences between adult social work and mental health social work. The author starts by saying

A situation has therefore arisen in which an increasing number of newly
qualified social workers are competing for a decreasing number of social
work positions. As a result, the vacancy rates in adult social work have
declined steadily from 9 per cent in 2011 to 6.7 per cent in 2013

Ok, what springs to mind immediately isn’t ‘What we need is a fast track scheme’. There are very different concerns and sensibilities than exist in childrens services. in fact the report talks about an ‘oversupply’ of newly qualified social workers.  There’s an odd little sentence about recruitment being a particular problem in adult mental health services. I travel around the country a fair bit in my current role and I speak to a lot of people in a lot of community mental health teams – both at work and outside of work – and problems recruiting to mental  health social work posts is never something I’ve come across. Of course, there may be parts of the country where that isn’t the case, but for London, where I am very well embedded, it’s not an issue I’ve ever heard raised. So where does the author go?

The most acute recruitment and retention problems concern
the role of approved mental health professionals (AMHPs). AMHPs
exercise functions provided for under the Mental Health Act 1983,
including making decisions about compulsory admissions to hospital.
Local authorities have a statutory duty to ensure that they have a
sufficient number of AMHPs to carry out the roles required of them
under the Act.

I sniggered at this. Yes, it is true there aren’t enough AMHPs but does he know the reason the change in the Mental Health Act 1983 – as amended 2007 – as made? It was to deal with this problem entirely. Now, it hasn’t been particularly successful but there are certainly a fair number of nurse AMHPs knocking around and the issue now isn’t so much the lack of availability of nurses (or social workers) to train as AMHPs so much as the lack of willingness for mental health trusts to pay for their training as the responsibility to provide AMHPs is the local authority’s. So having more social workers through a fast track route won’t ‘solve’ this problem. That’s the reason the number of social work AMHPs remains high – it’s due to the cost of training rather than the lack of supply of people who want to do the training. And then there’s a little box explaining why fast-track recruits can’t do AMHP training. Seriously what a clue has this author got about what the AMHP role is that he condescends to actually explain this. I would not want anyone without considerable work experience in a mental health setting (and 2 years training doesn’t come close) to take such a role and he insults our intelligence with  his little ‘explanation’ box. Mind, insulting the intelligence of social workers doesn’t seem to be a particular concern of his.

Then we have the little survey of directors of adult social services where no distinction is made in the questions between adult social work and mental health social work. So let’s look at some of the questions asked by the author and see if they are leading.

90 per cent of respondents either agreed or
strongly agreed with the statement that ‘more needs to be done to attract
the highest possible quality candidates in to the social work profession]

Firstly, this doesn’t specify adults, children or mental health social work and secondly, isn’t that about asking people if they like chocolate? Wouldn’t people say ‘yes’ to that question asked in relation to any profession? Should we do more to attract the highest possible quality candidates into teaching/nursing/law/journalism/banking – hard not to say ‘yes’ to any of this. And this is the ‘research evidence’ that this study is build on. A joke.

And he goes on

Our survey found that
47 per cent of respondents either agreed or strongly agreed with the
statement, ‘My local authority experiences a problem recruiting high
quality social workers in to adult settings’. While the response was
by no means unanimous, it does highlight ongoing concerns over the
quality of social workers.

47% is under half – there is no distinction between adult and mental health social work. This does not, to me, explain a specific concern about mental health social work and I’d ask the author why they put ‘adult social work’ in this question and not ‘mental health social work’. Remember, this is directors he is asking. Who probably haven’t got a clue about the quality of work done in the mental health trusts where they second their employees to. I’m not sure this is a fair reflection on the quality of social workers but what I’d say it is evidence of is asking questions and leading questions to evidence a solution which has already been proposed.

Let’s go on and please remember, these questions do not specify mental health social work.

Our survey of local
authorities found that the five skills deemed to be most lacking among
job applicants were:
• analytical ability/critical-thinking skills/intellectual capacity (56 per cent)
• awareness of evidence and its impact on practice (44 per cent)
• practical experience of social work (39 per cent)
• leadership skills (35 per cent)
• knowledge of integration and partnership working (32 per cent).
It is therefore clear that more needs to be done to attract talented
individuals into the profession, particularly those that can bring these
particular skills with them.

So remember how these questions are asked – they are not asking if applicants lack these skills but rather, if they have to choose skills which applicants lack, which would be their top five – so we are starting from a point of identifying deficits which are assumed to exist – and remember only 47% of respondents said they ‘agreed’ or ‘strongly agreed’ with their LA having difficulties recruiting high quality social workers. Surely it would have made more sense to ask these questions within mental health trusts where social workers actually work and where their job and the quality of their performance is known rather than directors of adult services who base their experiences on the far higher numbers of adult social workers that they would have contact with. This is why I say this evidence is flawed.

So what makes a ‘good’ graduate entrant into social work. Let’s see

Despite recent recruitment initiatives, social work is still not seen as a
career of choice for many graduates from highly selective universities.
In 2011/12, 2,840 people started social work master’s degree courses,
but of these only 270 had completed their undergraduate degree
at a Russell Group university, and only 10 had attended Oxford or
Cambridge. This means that only 9.7 per cent of people who started
training to be a social worker through the master’s route in 2011/12
came from a selective university

Now, before I get told off for hypocrisy myself, I have no issue with more graduate recruitment into social work from ‘selective’ universities but I don’t see the lack of recruits from ‘selective’ universities as a problem with social work recruitment. People want to join the profession – great – but why is which university you go to seen as a determiner of the quality or attractiveness of the profession. Is it a problem for social work that the profession doesn’t ‘compete’ with law, medicine and finance? Maybe we should rather, compare to nursing. Or better not compare with any other profession because, you know, we aren’t any other profession. I was lucky enough to get a grant when I went to university. I didn’t pay for my university fees (yes, that ages me!). I could choose any university that would take me – I was lucky to be able to choose a university with a good reputation. However, were I going to university and needing to pay for it without a grant, I would choose the cheapest, nearest one. That doesn’t make me less able than someone who happens to live in a town with a ‘selective’ university.  There is a route into social work for all graduates – which is the masters route – and it’s the route I took. It still exists.  Then he comes on to his great ‘let’s attract people who can’t make it onto clinical psychology courses’ argument. Um. I’d rather have people who actively choose social work to be honest. This is the argument for a specialist ‘mental health’ route but I don’t see any comparison (which makes far more sense to m e) with mental health nursing which is a different route to a mental health specific profession. I’ve often written of the need for generic training in social work because it preserves the integrity of social work – separating the routes out weakens the profession at a whole. If we have one ‘fast track’ route for ‘high flying’ graduates into childrens social work (Frontline) and one for Mental Health (Think Ahead) – where does that leave adult social work – working with people with physical disabilities, learning disabilities, older adults (which is my particular area of interest) – are we saying that doesn’t need ‘high flying’ graduates. I think we need one coherent path which allows for higher level specialism after qualifying and a more coherent post qualifying framework at a higher level – rather than fragmenting entry routes but that doesn’t exclude ‘high flying’ graduates. I’m very happy for them to join us. Delighted.

 

Education and practice learning

The author moves on to a critique of current training. I was a practice educator in a mental health team so was particularly interested in this. The author picks up general criticisms of social work education however Croisdale-Appleby and Nearey reports are considering these issues and will, hopefully, look at the whole education setting. It isn’t an argument for a completely new route in. He conducted a ‘focus group’ with students

All of the students felt
that the practical element of the course was important, particularly
for those who had come straight out of an undergraduate degree
that contained few practical elements

Did that need a focus group? I guess it did if you  have no idea about the sector but maybe it would be useful to take more students who have practical experience in social care settings rather than relying on the degree to do it all. I am not saying everyone needs years of experience of work in social care to enter the course but it seems like the solution could be ‘get the experience yourself’ rather than rely on a course to turf out a perfectly functioning social worker. I worked in social care for years before I did my social work training and it embedded a culture and understanding of the sector that could not have been replicated in a two year Masters degree. That’s my experience. Maybe the answer is to demand experience before admission to training courses rather than trying to ‘do it all’. It would display a commitment to the sector too –and I include experience as a user or carer of someone who uses social work services – it doesn’t have to be paid employment but it seems like the obvious answer.

We have Lamb rabbiting on about social work students not ‘choosing’ mental health placements but here’s the evidence he uses

A particular problem appears to be that fewer social work students are
qualifying with experience of mental health work. Placements in mental
health and other NHS services account for between 0 and 8 per cent of
all social work placements

So do we see the problem here? I don’t see the word ‘choice’ anywhere. As someone who offered a mental health NHS placement to students, we were massively oversubscribed in terms of students wanting placements. Mental Health placements in statutory services were seen as ‘gold dust’ in my experience. This is absolutely not about choice. My concern is that we are seeking the wrong solution. Think Ahead will deprive all students who come into social work from other routes from mental health placements as there are so few around and they will be able to ‘cherry pick’ for their own students and offer money to organisations for their own students to have placements. This means there will be fewer opportunities for those who use other routes into social work to have mental health placements with the risk that the diversity of students coming into mental health social work will decrease.

The author then goes on to waffle about bureaucracy in social work and how social workers should be able to ‘deliver effective interventions’ in mental health social work. I’m not going to waste my time on this simply because his paper doesn’t address a solution which is exclusive to graduates of a Think First type scheme. I think the idea is that these ‘effective interventions’ will be somehow ‘taught’ on the course but that replicates my concern about the Frontline scheme. Social work qualification courses aren’t about ‘teaching’ interventions – that comes with the job and the specific role as mental health social work varies and the tools you learn to use in a specialist dementia setting would be significantly different to those used in CAMHS – not least, the interventions change. The requirement of the job is not to train social workers to deliver specific interventions but to have an understanding of a framework to fit different interventions into different settings. So he shows no understanding of the needs of community mental health teams. Again.

 

Design Debates

Now the paper looks at how a course might actually look – The paper looks at Frontline as an exemplar – of course, because Frontline was developed by IPPR and has a similar type agenda as Think Ahead  which is quite open. And what of Frontline – remember, this is what Think Ahead is striving towards.

Frontline has completed recruitment for its first cohort of
participants, who will start the programme in the autumn of
2014. It received 2,684 applications, representing a ratio of 25
applicants for every one available place on the programme. Of
these, 1,272 applicants had completed an undergraduate degree
at a Russell Group university, and 184 were Oxbridge graduates.
This compares to the 270 Russell Group graduates who started
a master’s degree in social work in 2011/12, only 10 of whom
graduated from Oxbridge. Frontline has also attracted a larger
share of men than other to social work training routes

Russell Group/Oxbridge as determiners of quality, oh and more men. That’s good then. That’s always a plus. Seriously though, I don’t have any issue with Oxbridge/Russell group grads (or even men (!!)) choosing social work  but lets have some honesty with this debate. Yes, they had more applicants  but nowhere do they mention the £20,000 pay for people to take this qualification route. Now, who WOULDN’T choose to apply via that route rather than a Masters. Doesn’t matter if you want to work with children or not. If you have the option of choosing to apply for a bursary which is significantly lower or a course which pays decently and where you’ll be guaranteed placements – even if you weren’t bowled away with the programme, of course you’d choose the option with more money attached. So I think we have to take those figures with  pinch of salt. What I don’t understand and what’s written nowhere is how the outcomes of these students will be measured. There is no thought of seeing how Frontline cohorts perform BEFORE rolling out to other sectors or seeing if there is an evidence base to prove they are improving social work practice. No, that would take too long because the government has an agenda.

 

The little box about Frontline also doesn’t mention that the Frontline programme fell pretty steeply at the HCPC hurdle which monitored and regulated the quality of social work education. Oops.

 

The paper mentions recruiting for values but every single social work programme in the country should be doing this. This is not specific to a fast track scheme but they we get on to the real nub

The graduate recruitment market is extremely competitive, with many
corporations offering handsome rewards and training packages to
attract the most talented individuals. The programme must therefore be
designed to be attractive to graduates

AKA let’s pay people more to do social work courses. Actually, if they just stuck to that bit and threw away all the rest of the document, we’d probably recruit people into the profession but something that they should be aware of is that in some parts of the country, social workers won’t be early much more than the training salary when they qualify. This is not the equivalent of a medical degree where you train but in return get a higher salary on qualification. Or lawyers. It is much more akin to  nursing in terms of salary levels – except in nursing there are far more routes to management and leadership than there are in social work.  Funnily, this is their evidence that retention would not be an issue

Two-thirds of Teach First participants remain employed in teaching for
at least one year beyond their completion of the two-year programme

Er, guys, you know measuring retention after a two year programme and one year employment isn’t really much of an indication of long term retention rates.. guys.. guys. Seriously, one year out they have measured retention rates – oh and a 33% dropping off is seen as ‘good’. That’s even worse than social work. How about a comparison with regular retention rates in social work rather than pulling teaching in because you know, they are actually different professions. Oh, then the figures might not prove what the author wants them to prove (remember, starting from the solution and working backwards way of working). The paper then wiggles a bit and says, well, it doesn’t matter anyway because the programme actually isn’t about providing ‘frontline’ mental health social workers anyway, see –

What’s more, even if the proposed fast-track programme did have
a lower retention rate than existing, traditional training routes, there
is in any case considerable value in having a set of ‘high-calibre’
professionals who are trained in social work but who go on to forge
careers elsewhere in society

Which is completely counter to their argument about needing these high calibre graduates to embed and lead integration within social work settings and as social workers within mental health teams. And oh, the knowledge of interventions they will waste. No, this is about giving graduates a two year course in ‘leadership’ (what on earth.. ) and ‘mental health interventions’ (which they might need in some board rooms but probably not the way the programme was planned) as they flit through actually speaking to people with mental health needs really quickly on their route ‘to the top’.

If I were advising someone who wanted a leadership role in mental health, I would advise them to take mental health  nursing as a route to leadership and management as there are far more opportunities there. Every board of every trust is required to have a lead nurse. So where will these ‘leaders’ go? Oh, I shouldn’t say that, I’ll probably have one managing me in about five years time! So Lamb’s bleating about this programme improving the status of mental health social work is actually about this

Participants on the programme will develop an insight
into the problems that mental health social workers help to address,
and take that knowledge with them if they move into other leadership
positions in fields such as law, government and business

It’s a little game for a leadership class to play at mental health social work for a couple of years before passing on to private sector positions or better paying jobs. It isn’t even about leadership within the mental health sector. Is that what the government really wants to create a leadership ‘class’ and it is using social work as a tool. It has no interest in the profession itself. But we knew that, didn’t we?  There is a feel of ‘go, my bright young stars, try to see what ‘common people’ do for two years and then we’ll take you back into our law/govt/business embrace”.  This programme,in the words of the author “

it could help elite groups in society to gain a better understanding of the society that they serve

even if they don’t stick around for more than two years. I wonder if the author (I know nothing about him – wonder if he’s an elite) realises how incredibly insulting and patronising that sounds. It feels a bit like a person who is privileged staring into the lives of ‘poor people’ as if it’s some kind of sociological experiment without an understanding of the deep affect that relationships have in mental health social work. This is not an area to experiment. These are people’s lives and realities and it is not a testing ground for elite groups in society to play around with other people’s lives. I feel very strongly about that and was actually both shocked and sickened by these phrases. There is someone who doesn’t understand social work at all. I did ask the author if any service user groups had been consulted about this programme. I haven’t had a response. I hope he drops these phrases into the service user consultations – because there will be service user consultations, right? I mean I hope there already have been because as far as I’m concerned, that’s where I’d start.

So the course is a proposed two year programme but you know, the responsibility needs to come early because

In a national High Fliers survey, graduates ranked ‘having
responsibility from day one’ as one of the most important motivations
for applying for a job

I’m  confused as to whether this is a job or a training opportunity. Starting a masters course doesn’t sound like a ‘job’ to me but then, I stuck around for too long to fast track into govt, law or business so clearly I’m not as clear minded as the group that will be attracted by this route.  So what about a fast track then – well, let’s look at the evidence, says the author

While social work lecturers expressed concern about compressing
course length, those behind Step Up to Social Work and Frontline
believed that a carefully designed programme targeted at exceptional
candidates could be delivered in a shorter space of time

And let’s discard what the lecturers say and use the words of those who have no vested interest and are running condensed programmes say. Oh. Now, there’s choosing your evidence to suit your outcomes. We don’t have any clear outcome measures over the long term of the effectiveness of fast track routes. Frontline hasn’t even started running yet but the author thinks it is appropriate to take ‘what they say’ as evidence to show that fast tracking can work. That’s is the candidates are exceptional. Ah, maybe that’s the difference. It would be nice to have evidence though but that’s never troubled any politician or think tank. The programme will be located where the recruitment difficulties are. Ha ha. Good luck with developing that, Think Ahead. They say

The proposed programme must
be designed to address this issue by targeting areas and individual
NHS mental health trusts that have particular recruitment difficulties.

Do they know that few mental health trusts recruit social workers directly and those that do recruit them as ‘mental health professionals’ rather than as social workers? Why would a Trust choose to train a social worker rather than a nurse? Possibly because Think Ahead will pay them to take people on but this won’t develop models for sustained retention over the years – but then, that isn’t really Think Ahead’s purpose either. It’s about fast tracking people into professions that pay more and using this merely as a developmental tool along their journey – the cost being, people’s lives who are affected by short term relationships and people who have little interest in developing in practice. Again, we see evidence of a lack of understanding of the sector.  Their muddled thinking is evidenced by putting in the same sentence

Even so, the
programme should still aim to work with local authorities that are facing
particular problems in recruitment and retention as much as possible.

So wait, are they going to be working with mental health trusts or local authorities because they seem to be confused themselves. And I may not know everything (quite!) but I do know the mental health sector in London pretty well and wonder where they are going to find these vacancies. My suspicion is that the programme will bribe LAs and NHS trusts to provide placements so the scheme can get up and running – because honestly, the posts don’t exist anymore. The flit across the need for generic training but what hasn’t come across to me at all, is that there is any understanding that ‘mental health’ is not one speciality. Let me give my own experience. I worked in adult services in an older adults team and then moved into older adults mental health. My understanding from working in a social work team and doing care planning and care management was a key skill to take with me into older adults mental health services. If I’d done a generic ‘mental health’ social work course, I would have learnt different skills. I think we need a longer rather than a shorter course. My own solution would be to pick up on the AYSE and post-qualifying routes and firming up the routes into specialisms at that point – not at the entry level to the profession. That doesn’t exclude anyone and any ‘elites’ who want to join are more than welcome but it doesn’t create a separate route for ‘elites’.

And they argue that this training needs to be delivered by a social enterprise. And there’s the rub. This is a push to privatise social work recruitment and education. Remember, Frontline haven’t made it through the HCPC accreditation process yet but this is an attempt to split the profession and turn the training into a profit-making ‘social enterprise’ that will be a platform for division rather than unity. What will make social work stronger is unity rather than division. Fine, lets have new routes in but isn’t that what Narey and Croisdale-Appleby were looking at anyway. How about we stop, and assess the research and evidence before charging down a new path, especially when the evidence is based on so many fallacies.

 

How the programme will operate

If we need more evidence of the lack of understanding that this report is based on we need look no further than this section which explains in more detail how they propose to run the programme.

Let’s look at the avowed aims of the programme

The programme will be designed to attract high-calibre individuals
into employment as mental health social workers within integrated
community mental health teams. It will develop participants’ practice
capabilities and leadership skills, emphasising the inherent role of
leadership within social work practice (bringing together a range of
actors to solve complex problems). It will be designed to develop a
cadre of social workers who are able to lead the integration agenda,
as well as address issues concerning recruitment and progression of
social workers in the area of mental health.

FACT – integrated community mental health teams are rapidly disappearing because the government has driven enormous cuts to LA budgets.

FACT – if there’s one thing which is no missing in mental health social work it is professional leadership. In fact, mental health social workers are highly respected in the field and as AMHPs are often asked to contribute advise to the teams.

FACT – it isn’t a lack of the ability of social workers which is not pushing the integration agenda. To suggest this is frankly, laughable, and makes the whole document a joke.

FACT – there aren’t any issues around recruitment of mental health social workers. The document muddles adult and mental health social work in its survey and admits that there is an oversupply of social workers

FACT – The lack of progression of social workers in mental health is related to the way that NHS trusts operate and this is not going to reconfigure the entire NHS

So there we have it. The whole project is based on poor assumptions.

It’s even worse when it goes on to explain the problems it will solve, including the  lack of supply of AMHPs. Seriously, they just don’t get it. Especially if these elites are off being lawyers, politicians and businessmen because the one saving grace of being an AMHP is, you need actual, real experience. The issue about the lack of practice placements is not due to lack of choice but lack of supply. I suspect this programme will buy placements but that will affect supply of placements to those taking other routes which is a problem for the profession as a whole although it won’t be a problem for Think First ‘graduates’.

Ah ha, I see the first use of the word, service user to indicate involvement

As with all social
work courses, it is also important that service users and employers are
engaged in the design of the programme and in recruiting participants

I wonder how many service users were involved in the development of this paper. I asked that question.  It hasn’t been answered. And where will the placements be?

Community mental health teams are therefore strong contenders
to become the teams in which the Think Ahead programme is primarily
based. They are the ‘hub’ for the majority of mental health work carried
out in the community, and have strong links to other parts of the system
such as inpatient hospitals and children and adolescent mental health
services.

Oh, and they’ll dabble a bit in forensic mental health. I don’t see any attention paid to older adults services or dementia. Maybe they forgot that that falls into mental health services too. Oh, maybe they’ll be a problem with access to CMHTs which don’t have social workers in them anymore. But Think Ahead have a solution – they are going to be responsible for re-integrating mental health services personally – cos the programme is THAT attractive.

The NHS
mental health trusts that are selected to partner the programme and
provide the practice settings for participants will therefore need to be
committed to making integration work and promoting the role of social
workers within integrated mental health teams. In some cases, the
programme will have to actively rectify the structural and organisational
weaknesses that in the past have created difficulties for social workers
in integrated teams. This means that, in return for taking part in the
programme, trusts may have to improve their structures and systems
for supporting social worker

Er, I see a bit of delusional thinking here. Firstly, it wasn’t the Trusts that chose to remove social workers but the LAs who removed them due to financial costs so this just shows pure ignorance. And they really think that as a training programme they can demand integration of social workers into CMHTs? That’ll be interesting. I’m sure they’ll have money to do that but wow, the incredible lack of insight and arrogance is phenomenal. Do they think their programme will be so attractive that trusts will reconfigure to suit them? My experience of mental health trusts is they won’t deal with the hassle and will just employ more nurses instead. THis is just an incredible claim. Think Ahead is going to be able to demand integrated services.

As for the details, the graduates will have a DipSW after year one, and year two will see them employed in CMHTs on a year’s training contract to develop skills in the field. Seriously so despite them waffling about generic qualifications, they are condensing a two year social work programme into one. I have an idea. Why not extend the training to two years and call it a postgraduate programme – then, choose the very best social work graduates, from whatever route they choose and give them an extensive placement and support within a mental health setting. Oh, because that doesn’t ensure that only the elite can access this route. And it doesn’t allow a social enterprise to profit. Silly me.

After this two year programme

Given the amount that the NHS mental health trust and local authority
will have invested in the programme up to this point, it is likely that they
would offer participants a permanent job at the end of the programme
(although they would be under no obligation to do so). The programme
should therefore provide a more direct link between the supply and
demand for newly qualified social workers.

 

Invest? Do they understand the financial situation at the moment? Do they actually know what the demand is for mental health social workers at the moment? I can’t really see a geniune cohort existing. They are looking in the wrong places, at the wrong issues.

 

Conclusion

Well, I took the challenge and read the document. Much of it made me laugh but it also made me sad that this has been presented as an answer when the problems have not been clearly defined or identified. We, as a profession, have to consider what this will  mean as a whole if we allow these schemes to develop in the way that they have been presented. This isn’t about broadening entry. This is about removing social work education from the public sector. This shows incredible lack of insight and understanding into mental health social work.  As for the people who were consulted – they were as follows:-

 

Baroness Claire Tyler, chair, CAFCASS (chair)
Joan Beck, chair, Association of Directors of Adult
Social Services
Steve Bridge, social care workforce strategy manager,
Department of Health
Karen Dolton, head of care, Manchester City Council
Annie Hudson, chief executive, the College of Social Work
Dee Kemp, director, Topaz
Professor Julian Le Grand, professor of social policy, LSE
Doctor Glen Mason, director of communities and local
government, Department of Health
Josh MacAlister, chief executive, Frontline
Bridget Robb, chief executive, British Association of
Social Workers
Lyn Romeo, Chief Social Worker for Adults
Professor Hilary Tompsett, chair, Joint University Council
Social Work Education Committee
Frances Turner, social worker, Central and North West
London Mental Health Trust, Milton Keynes
Professor Aidan Worsley, chair, Association of Professors
of Social Work

I see one currently practising mental health social worker. I see no mental health trust management representation. Most tellingly, I see no service user representation at all. Is this the way we are allowing our profession to be defined. Read the report and weep. It is based on fallacy and factoids. It is based on leading questions and little knowledge.

We should look at where demand actually is, if there is demand and focus on that. We should develop stronger post-qualification frameworks and ensure that the social workers we have, stay and lead. We should fight for our profession as one and not look at mental health, adult and childrens and family social work as separate strands. Otherwise we don’t know what we’ve lost until it’s gone.

 

And I am waiting for the response about which service user groups were involved in this consultation still. Waiting.

Fast tracking Mental Health Social Work

First they came for the children and families social workers..

Last year, the government announced the shiny ‘Frontline’ scheme which was designed to fast-track ‘elite’ graduates into child protection jobs in ‘tough’ areas and push these sparkly bright graduates into ‘leadership’ roles. At the time, I moved this blog out of retirement specifically to challenge the processes, thinking and mostly the lack of consultation and involvement of children and families social workers – or indeed any social workers – when this scheme was developed. I’ve written about it here.

I spoke out and spoke up as best I could because I think these ‘fast track’ schemes are a folly and are attempts at solving the wrong problems. I lost that battle because it was the government doing what the government wanted to do. Yes, those in favour say, this is just about another route in to social work – perhaps I’m simple-minded, not being an Oxbridge graduate and all, but I thought we already  had the post-graduate route in to social work training (Masters qualification route). We even had a specialist child-focused route in to social work (Step Up to Social Work – which I’m also not a massive fan of, incidentally) but no, this would be different because this would fast-track even more and focus even more. So it would take all the worst parts and combine them.

This morning, the Independent reports that the IPPR (the same think tank of policy bods who haven’t got a clue about what social work actually looks like) are presenting a lovely report to Norman Lamb about encouraging graduates to move into mental health social work and this week ‘Think Ahead’ will be launched. Actually just typing that causes a deep nausea in my stomach and makes me shake with rage. ‘Think Ahead’ – that’s nice.

This is what the Independent says

Just 10 Oxbridge graduates studied for a social work master’s degree in 2011-12, compared with 10 per cent of the entire cohort applying for Teach First, the successful graduate teacher training programme. Despite the high skills required and difficulty of adult social work, very few top-flight students regard it as a prestigious job, the IPPR report says.

So that’s it, guys. Quality is judged by whether you are an Oxbridge graduate or not. Apart from the nausea, I have to say the tears are coming now. There are fantastic mental health social workers out there. There are fantastic mental health social workers coming through. This is a kick in the teeth of the highest degree. If we didn’t go to Oxbridge, clearly we aren’t good enough. Is there so little understanding that the issue is not about new entrants into mental health social work but the pulling apart of mental health social work so that there aren’t any jobs anymore. Surely we should be focussing on THAT. There is no shortage of newly qualified social workers who are very skilled who want to work in mental health. Maybe pushing some of the money and support into building strong post qualification frameworks to support them might be a better idea than pulling in people who don’t really have a clue what social work actually is.

 

Government endorsed ageism

I worked in an older adults mental health team. It is vital that I had a good understanding of adult social work as well as mental health social work. Lamb’s comment sticks in my stomach.

Mr Lamb said last night he was “very enthusiastic” about Think Ahead. “We are looking for people who can commit to do something to make a difference to young people with mental health problems, particularly people in their late teens and early twenties,” he said.

See, as far as Lamb is concerned, his focus is on making a different to YOUNG PEOPLE. Does he even know what mental health social work is or is he trying to develop a programme which is a mix between Frontline and Think First because, you know, Frontline blatantly isn’t focusing on anything other than child protection social work. This is evidence of the clear folly of building social work into specialist silos. This pot is where Mental Health goes. This pot is where Child Protection goes. We’ll train you as a ‘specialist’ social worker – whoops, what do we do if a child has mental health needs? Heaven forbid someone has dementia and that needs specialist social work input. Has there been ANY thought about it because it doesn’t look like it. I’d like to know from Lamb how many practising social workers they spoke to and where those people work – as well as their names – as they clearly don’t have a clue what happens in mental health social work nor what is happening now as local authorities pull their social workers out of mental health trusts. And that is happening all over the country.

What is social work?

According to the Independent article

The IPPR research shows that nearly 50 per cent of local authorities have problems recruiting high-quality adult social workers.

Well, I, for one, can’t wait to see the figures behind that research and there seems to be some confusion between adult social work and mental health social work which are not actually the same thing but I doubt the IPPR Oxbridge PPE graduates realise that. We are increasingly seeing a fragmentation of social work into discrete areas – you are a child protection social work or a mental health social worker etc. This is not helpful as the thing that makes the profession cohesive is our broad generic base. If we look at what social work is, it’s about a value base, an emphasis on reflection and social justice, a key understanding of how pieces fit together which are beyond labelling definitions and a focus on strengths-based models of working with people using specific approaches. This is beyond child protection processes or care management processes and it is what makes the profession one. I was disappointed to see one of the Chief Social Workers (for children and families) ask why genericism was important on twitter this morning when nurses had specialist training. What an utter heart-sink moment that was. If we have to explain why genericism is important to the fundamental definitions of social work to someone who defines themselves as a government appointment social work ‘leader’, I’m afraid we, as social workers are losing the battle. It is important that as social workers – social work practitioners, students, academics and social workers internationally, pull these definitions back from our government which is trying to define us by the processes that they ask us to do. We are far, far more than our tasks and that is why generic qualification is necessary and important. We need the space to understand beyond our specialisms and to grow and explore our values – because it is social work values that make social workers, not knowledge of specific child protection processes.

 

Choosing your team

Then the Independent goes on to say

The Think Ahead scheme will run as a social enterprise and operate rigorous two-year courses, starting in September 2015, for the “best and brightest” who could bring leadership to the profession. The board of the social enterprise will include Paul Farmer, the chief executive of Mind, and Dame Carol Black, the chairman of the Nuffield Trust and an adviser to the Government on health and social work. Mr Lamb also consulted Alastair Campbell, who has written extensively about his personal struggle with depression, on creating the programme.

And we get to the point. These are going to be the leaders and not the practitioners. They are not remotely interested in promoting good practice in mental health social work but producing a fast track leadership programme for privileged people who wouldn’t want to dirty their hands with actual social work. None of those people mentioned, the so-called ‘great and the good’ who are going to be on the board of this social enterprise are social workers. NONE OF THEM. Can we stop and think about that. Can we think about another profession that the government would treat with so little respect? We saw Ed Balls consult an agony aunt from the Sun to decide where social work should go after Peter Connolly’s tragic death. Now Lamb is no better in asking Campbell. This is a mess and it’s a government promoted mess. But he doesn’t need to bring social workers along with him because he is going to grow his own social work leaders who look like him, went to Oxbridge and don’t need to have any understanding of mental health social work. It makes me sick to my stomach and it’s difficult for me to even read but I’ll go on.

 

Kicking the profession while you’re at it

Now this bit made me laugh.

The new IPPR report says that “more than 90 per cent of directors of adult social services believe more needs to be done to attract the highest possible quality candidates into the social work profession”. Directors believe many job applicants lack analytical ability and intellectual capacity, awareness of evidence, practical experience of social work, and leadership skills.

The Director of Adult Services in the local authority I worked in didn’t actually realise that we, the mental health social workers which he had seconded into our mental health trust, were employed by him. He certainly wouldn’t have a clue what we did on a day to day basis or how skilled we were. And if he had said we lacked analytical ability and intellectual capacity, well, I’d have asked him (but he wasn’t remotely interested in what we did) to come out on a Mental Health Act Assessment with me. Does the government realise how insulting all this is? I think it does. They want to divide and rule and tell us how rubbish we are so we need to fling some Oxbridge graduates into the mix. Does Lamb or the IPPR even KNOW the difference between adult social work and mental health social work? Do they know that most Directors of Adult Social Services don’t know who their mental health social workers are because they are mostly seconded out? It sounds like pure ignorance of the sector to me. It seems like the government have built a solution without actually knowing or analysing the problem and certainly without an understanding of mental health social work.

And then the article says

Demand for adult social workers is high: a third of all families includes someone who is mentally ill, while one in four people will experience a mental health problem during their lifetime. In 2010, more than 1.25 million people used specialist NHS mental health services.

Ha ha. Ha ha. Seriously. Does the writer of this article actually know that these services have been slashed to pieces. Yes, more people need mental health social work  but there is less money and far, far fewer social workers delivering social work in Mental Health Trusts than there was in 2010. This makes a mockery of those of us who know how hard the cuts have hit.

 

Then we have the final kick in the teeth

Jonathan Clifton, senior research fellow at IPPR, said: “As the number of people diagnosed with mental ill-health increases, there is a moral imperative to develop effective services that can support each of them.

“Too many people can be let down when things go wrong, causing distress and putting vulnerable people at risk. A fast-track programme like Think Ahead could be one step on the journey towards changing this.”

Oh, dear, Jonathan Clifton, you really are a bit thick and haven’t done your research very well if you are the best they can do with a ‘senior research fellow’. The issue isn’t the quality of support and the fast track programmes. The issue is mental health services have been utterly decimated by this government and there isn’t money left to pay those who did the job well. I know because I left when we went through cuts which actively harmed people who used the service. Yes, vulnerable people are at risk but they are at risk because of people like Lamb cutting mental health services and support  – not because there aren’t people coming into the profession.

 

Rage, rage against the dying of the light

This scheme is ill-thought out, ignorant and insulting. It shows no understanding or insight into mental health services or social work services. The quotations are muddled, the thinking is illogical. As social workers who are committed to driving the profession and most importantly supporting and advocating for people who use social work services, we need to shout out and long about these destructive programmes and the lack of input that social workers have had into them.

If we want to look at what will ‘save’ mental health social work – I’ll  happily tell Lamb but then, as a social worker, I’m not the kind of person he’d want to consult with – especially as I guess he’d say I lack intellectual and critical rigour and analysis (although I’d like to see him say that to my face). You see, Lamb needs cleverer people than social workers to decide where social work needs to go – clearly. We are too thick and too many of us are plebs for us to be properly informed and consulted. No, it needs a think tank and other professionals to tell us. But if he were to ask me, this is what I’d tell him.

1. Fast track isn’t the answer. Longer, slower track is.

Keep the generic qualifying routes we have. We have postgraduate qualifying routes. What’s wrong with them? THEN, then, we have a robust, compulsory one year additional course supported by employers to get the specialist skills embedded but where this ‘let’s focus on young people’ thing comes from I don’t know. If we are going to build specialisms, please lets have an older adults one too which combines specialist mental health (particularly around dementia and late onset functional mental health needs) and physical disability which often affects older people.

We need more time not less time.

 

2. Consult social workers who are actually doing social work

I know, this is blue sky thinking. Who would think they could change the profession and actually ask the professionals working in the field. What would we know? But it would be nice, wouldn’t it.

3. Listen to people who rely on social work services.

Quick, let’s find ‘one of us’ who has had a mental health difficulty and shove them in the consultation. Ergo Alistair Campbell. No, Mr Lamb. Find someone who is currently using a mental health social workers’ services. Someone who has been detained by one of us. Find someone who is living in poverty and is being supported by a social worker because they don’t have any other support. Of course, have Mr Campbell as well but he may not be representative of all people who use social work services. Show a bit of respect to those who are reliant on these social workers coming through.

4. Drop the leadership strand.

You can’t train new graduates to be leaders without actually doing the job. We would be creating the wrong leaders. Look what the NHS graduate leadership programme does when leaders grow who haven’t had any clinical experience. The focus is on providing good quality social workers so why push them into leadership roles immediately. Leadership has to be earnt.

5. Genericism is important.

I won’t repeat myself but it is what makes social work, social work. We can’t allow others to define it for us. Let’s focus on post qualification training and make that more robust. Let’s push the focus into retaining and supporting good social workers. Let’s emphasis time to reflect and grow rather than jump on fast track scheme. That will improve mental health social work.

Care plans – Now and Future Me.

This morning I read a post by Mark Neary (whose blog I highly recommend) which highlights the hypocrisy and inaccessibility of the language of social care. I am used to jargon. I have been working in health and social care since 1993 so a lot of the language comes easy to me and I can almost forget what is jargon and what is usable by ‘normal’ people. It is posts like Marks that remind me of where our sector has lost its humanity. When we talk about ‘accessing the community’ rather than being a part of it as a part of a personal budget, we seem to have lost the idea of what community actually is.

 

Mark’s post got me thinking about how my life would be in the care and support plans I used to write so I’m going to imagine and put myself in that situation and see what my care plan would say. It’s not quite going to be ‘me me’. It’s going to be the me who, in 30/40 years time is living with a dementia which has affected my cognition. I’m in my 80s. I’m living alone and have no children. I’m a bit of a loner because I always have been and don’t have many friends living nearby.

Because someone in an office decides I may not be able to make decisions about what care I need, those decisions are made for me. I have a personal budget, of course, because everyone does. It isn’t a snazzy flexible one because I get confused by money and finances and am not sure I’d be able to make decisions about money management. I get my £5 and my £50 mixed up and that’s got me into all sorts of trouble at the local supermarkets. Sometimes some of the local lads offer to clear my garden. I give them £100 for an hour’s work because it seems fair to me and they are such nice lads. They always smile and they come every week. So my ‘personal budget’ is managed by the local authority.

 

Between 7.30am – 8am I have a carer to come and give me a shower or strip wash. The carer often doesn’t turn up until past 8.30am. I’ve always been an early riser so sometimes I try and get up and dressed within her help. I don’t like waiting till 8.30am when I’ve been up since 5am. I can’t manage the shower though and she thinks it’s a shame to change me after I’m already dressed.  “Carer to help with shower or strip wash”. Sometimes I’d like a bath. There isn’t enough money for that. That’s a shame. I last had a bath four years ago. I remember it sometimes.

 

I sit in the lounge. The carer sometimes puts the television on before she leaves. I don’t pay much attention to it. Because I’m over 65 now, I don’t get any ‘day opportunities’. The day centres have closed and I don’t have any family to visit. I sit and watch TV. It’s ok. I don’t want enforced company so I’m not so lonely. I miss going out to the shops though. Accessing the community? That would take too long and cost too much so I just have a carer come once every fortnight to do my shopping. I write out my shopping list in advance. Mostly it’s the same from week to week. I don’t do spontaneity anymore.

The carer comes at 12pm to make my lunch. Lunch is a tuna sandwich. Lunch is always a sandwich because there isn’t time to cook. It’s always tuna because I once mentioned I liked tuna 2 years ago. Now I have tuna sandwiches every day.

“carer to prepare light lunch and cup of tea. Clean up afterwards”. Sometimes I miss coffee.

 

It’s Thursday which is shopping day. Shopping day is only once a fortnight. So shopping is lots of instant meals which don’t need to be prepared. I wish I could go out sometimes and potter around in the supermarket. But that would take too long. You see, my allocated hour wouldn’t be enough because I’m a bit slower on my feet. It’s tins of spaghetti hoops. Bread for the freezer. Milk for the freezer. Chocolate hobnobs. Some cheese. Lots of tuna. I like all these things but sometimes I miss sushi.  “fortnightly local shop. Collect list. Leave change”.

 

It’s nice when it’s shopping day because it means something different happens. Mostly I just sit and watch TV. That’s my meaningful activity.  I have a personal budget. Look how well self-directed support works for people like me. What do you mean it’s no different? This is innovation. I know how much my care package costs now. That’s changed my world.

 

I can’t wait until dinner. At 5.30pm my carer comes and makes me something ‘light’. But this time it’s a hot meal. Spaghetti hoops on toast. I like that. Sometimes I put some cheese on the top but have to be careful with the toaster. I can’t manage it on my own. At least I get another cup of tea and help to the toilet. Sometimes I miss coffee.

“5.30pm – 6.15pm Prepare dinner – leave with cup of tea. Help to toilet if necessary”.

After dinner I watch TV for a while. Usually I fall asleep.

The carer wakes me up when she comes at 9pm to assist me to bed.

 

So that’s what the day looks like. I get up later at the weekend. That’s nice. But I like getting up early.

 

Now coming back to my present self, I wonder how my own care plan would look in the language of, as Mark calls it, ‘Carespeak’.

So snapping out of reality, this is my current ‘care plan’. I wake at about 5.30am and interact constructively with other household members, which is problematic to those who don’t want to be awake at 5.30am. This is evidence of my self-centred nature and need to mind my anti-social behaviours around waking early. Sometimes I don’t have breakfast. This presents a risk to my nutrition and hydration. Occasionally I might eat an unhealthy breakfast, like a croissant. This is high in fat and could lead to unhealthy habits and putting on weight which could affect my health.

I have a shower and this means that my needs related to hygiene are met. I ensure that I wear clean clothes which are appropriate to the season. Although sometimes I judge poorly before leaving the house and this means that I may not be protected from the risk of inclement weather. I don’t own an umbrella. This is a risk as it often rains in London. I am able to meet my personal care needs.

I go to work. Now, I’m accessing the community and engaging in a meaningful activity because I have economic worth. Although sometimes it isn’t meaningful. Sometimes it’s sitting in front of a screen staring at spreadsheets. It has economic value and therefore it is meaningful. Daytime activities, I have them, you see. All is good.

I might go out after work. This means I am socially active. I am engaging with my informal support network i.e people who are not paid to be with me. I can tick off my ‘social network’ tab on my care plan. I have friends.

When I get home, I should really clean the house a bit. But I sit on the sofa and fall asleep in front of the TV. This is a risk. This means that I have not been able to meet my domestic care needs. The washing up is in the sink. I am, therefore, in a house, where there is a concern that I am not managing domestic care sufficiently. This worries those people who write care plans. All is not well.

I go to bed at a reasonable time. I don’t have any problems with sleeping and am not worried or concerned by my lack of sleep. All is well.

 

So why is it worth considering? These two care plans say different things but in the same way. We can look at aspirational documentation and what we should strive for. I always want to strive for better. But those who are striving, don’t forget the people like me or the future me. Don’t get carried away with the language that can actually mean less than it should. A personal budget does not mean choice. Choice does not mean choice as often as not. If we want to solve problems, we have to know the problems and how they would affect us.

 

It’s worth considering how are lives are and how they would be in the context of ‘care planning’. Would we plan care for others, the way we would want it planned ourselves? And if not, why not?  Food for thought.

Personalisation in Practice

(Note – I wrote this for something else where it was not used but thought, I’ve put the work in and might as well see if anyone else finds it useful/interesting! That’s why it’s a slightly different style from my usual rants and definitely drier#.. and why there’s a bibliography!)

Personalisation policy and the principles of developing person-centred care have promised a great deal in terms of increased choice and control for service users, and a change in focus towards greater user participation in services. While putting people at the heart of services is fundamental to a progressive and ethical social care culture, the gap between practice and policy in relation to the personalisation agenda can look like an insurmountable chasm to the practitioner. This is an area where promises have bounded ahead of practice experience.

What is personalisation?

Personalisation is a process which puts people who use services at the heart of decision-making about what is right for them and how their care and support needs will be met. The opaque jargon of social care can be a barrier to communicating key concepts, and defining ‘personalisation’ is crucial as the term is used in different ways and attracts meanings which can depend on the agenda of the speaker. Sometimes personalisation can be used as a synonym for person-centred practice and support. Gardner (2011) explains that ‘personalisation’ incorporates “different strands of ideology, theory, policy and practice”(p2). Not all definitions are inclusive of the groups of people who may lack capacity to make decisions for themselves about their care needs so it is easy to see how the rhetoric can overtake the reality.

The ‘personalisation’ agenda as it has been known is more than moving people to ‘personal budgets’ and the roll out of direct payments as a default mechanism for delivering social care. It is about moving the paradigm of ‘power’ away from the centre and towards the individual. The development of this personalisation agenda took place in the context of a great deal of excitement and promise. In the early stages where the Independent Living Fund (ILF) was created in 1988, allowing for the first time people who used services to directly commission and purchase their own services. This continued through the various configurations of direct payments (initially introduced through the Community Care (Direct Payments) 1996 Act) as they made their way through different user groups and the scope extended, leading to Putting People First (2007) which pushed through the ‘transformation agenda’ in adult social care to move towards personalisation for all.

It is important that we don’t confuse ‘personalisation’ with ‘direct payments’ nor ‘personal budgets’. Different models of providing people with more choice and autonomy over decisions which are made regarding their care can be done in many different ways and in some ways, the handing out of money and telling people to get on with it – with or without the requisite support – is a very narrow attitude to take in terms of allowing choice. Choice has to include a choice in the way that we can choose about what we receive, but there has been a political emphasis on direct payments as the gold standard of choice and that leaves some at a much greater disadvantage than others in terms of having control over their own support packages. The jargon and language attached to the change in adult social care creates a layer of professional knowledge so that in itself, it removes elements of knowledge and control from people who use services.

Gardner (2011) states that “Personalisation reinforces the idea that the individual is best placed to know what they need and how these needs can be best met. It assumes that people can be responsible and make their own decisions but people need information and support to do so” (p34).

Personalisation is about far more than ‘cash in pocket’. The system embraces models for establishing different routes to choose but in practice some of these are scarcely developed. For example, using individual service funds to buy support for older adults and people with mental health needs. This focus on the individual being at the heart of the process of choosing and having more control over the care that they are provided with and establishing a framework for person-centred practice lies at the heart of the ‘personalisation’ agenda. However, the path towards a goal that it is impossible not to support wholeheartedly has become muddied with the realities of spending cuts, local authority processes and challenges which have been continually ignored rather than addressed.

The policy has been driven by the wish to overpromise in terms of extending personal budgets (and hence the ‘personalisation’ agenda) to all within specific time frames where the reality has not been able to keep up. So we have seen the reinterpretation of ‘personalisation’ to represent care and support packages that in reality look no different at all to those which were delivered 5 or 10 years ago but with a different layer of language and bureaucracy layered on top of them. This creates further disillusion within the profession, especially as the social work profession is committed to increasing person-centred practice and empowerment of individuals in the face of the ‘system’ which can sometimes be oppressive and dictatorial.

The implementation challenges for the personalisation agenda have been extensive. While this is to be expected in any process involving widespread changes behind both the philosophy of a system and the systems themselves, the agenda of promoting user involvement, choice and co-production has moved at different rates for different user groups. For example, while the roots of the personalisation agenda lie in the Independent Living Fund and the processes built on driving forward choice and control for adults with physical disabilities and learning disabilities, SCIE report 40 (Newbronner et al , 2011) explains that “There is a risk that people in later life are being squeezed into a ‘one size fits all’ model of personalisation designed with and for younger people with physical and/or learning disabilities”.

Practitioners on the ground who are often the key to success of failure of these policies in practice perceive that there is little interest in addressing their experiences or hearing their feedback.

Why personalisation?

Personalisation is an important policy aim and it is important that it works. The idea of self-directed support (or personalisation) has been a process and direction through which policy has been travelling for decades. It touches on the fundamental aims of what social work is about and how it is used in practice. There have been many changes in the way adult social work has operated since the NHS and Community Care Act (1990) was rolled out and particularly as ‘social work’ developed into ‘care management’ through this period. So why was ‘personalisation’ needed? As local authorities disavowed themselves of delivering services directly, the logical step, as purchasers of services would be to ask people who used those services to have a greater input and role in making decisions about which services were commissioned. That, at the heart of it, is personalisation. One of the main criticisms within the care management model of services and care plans being written by social workers with services being defined by block contracts was that there was that this was very much a ‘one size fits all’ attitude which left people with little choice apart from accepting or declining the services which were on offer (Maclean, 2011).

The policy move to change this and to shift the ‘power’ from the provider to the user has been wholly positive. There is no professional expertise in deciding what meets the needs of individuals that cannot be trumped by the individual deciding for themselves. For this policy to move into practice, there have been accompanying bureaucratic and process-driven changes, such as the introduction of self-assessment processes and attempts at rationalising resources with some transparency (with mixed effects) around the amounts of money spent on care so that people can make their decisions about the services which best suit them. While the direct payment model is the most touted, there are also routes through local authority managed budgets and individual service funds (ISFs) where budgets are shifted to service providers to deliver as required by the service users.

How is personalisation?

The barriers to extending personalisation have been addressed in numerous research literature. There is much evidence which seems to repeat the same conclusions that the progress of different models of delivering care, because ‘personalisation’ is about more than direct payments. This leads to frustration among practitioners that the current barriers are exactly the same barriers which were identified to the same groups of people as those to direct payments five years ago with little progress in some areas.

SCIE carried out research (Newbronner et al , 2011) focusing on people with mental health needs and older people which were the groups of people where the take up of personal budgets has been slower to gain traction. They looked at the different ways that personal budgets were offered: namely those which were directly commissioned and managed by the local authority, third party managed accounts, direct payments or a mixture of these things. They found that there was a risk that inherent processes to assess and allocate resources such as the RAS (resource allocation system) and the assessment process which may be initially a self-assessment or a facilitated process of assessment depending on the local authority and the individuals’ needs, needed to be tailored more finely towards the relevant user group.

“Where a generic system [for RAS] was used it highlighted inequalities for resource allocation between client groups. Older people, especially those with high care needs, appeared to be the most disadvantaged.” (Newbronner et al , 2011) p9

This lack of equitable access through the ‘front-door’ leads to increased disillusionment with a process which is supposedly designed to be enabling and supportive.

Another barrier is that of attitude of social worker and organisation, which is mentioned in an Age UK report “Personalisation in practice” written in 2011.

“There was a concern among support providers and some LA/Trust staff that many PB (personal budget) holders, especially older ones, were being steered away from direct payments and towards managed accounts or services by the LA (local authority” p9.

This indicates that some of the ‘blockage’ on progress and implementation is within the systems which are meant to promote it.

The intransigence of social workers and the lack of desire to embrace new models of service provision which move the locus of ‘control’ away from the professional and towards the person who uses the service has often been argued as a reason for the poor take up of direct payments first ( (Littlechild, 2002) where they say, in relation to direct payments, the forebear of the current personal budgets “it is not disabled people making informed decisions to reject the idea of a direct payments package, but their social workers effectively depriving them of access to direct payments by failing to provide information and support” (p138). This is a harsh judgement to put at the feet of practitioners but it is one that is popular among policy drivers as it is easier to blame the attitudes of practitioners than to evolve methods to promote and simplify the methods of delivery of the personalisation agenda.

Unfortunately the ‘blame’ agenda took hold early in the development of policy making and has led to greater alienation of practitioners who do want to try and make things work. There is a sense of being blamed for not embracing personalisation when the system is flawed, not because they are negative but because the processes are inexorable and have been built to reflect the needs of particular service user groups whose needs, priorities, and abilities are not universal. Effectively, policies are designed to fit some service user groups at the expense of others. Glasby (2012) states “one danger [of the roll out of personalisation] may be that current policy rhetoric is so strong that it is difficult for people with legitimate concerns and questions to raise these in an open and safe environment. Speaking to front line practitioners, some feel as if expressing doubts can be seen as ‘heresy’ and they are reluctant to say what they are thinking. While this may not have been the intention of policy makers, it could be a significant barrier in change if people feel concerned about a policy but don’t feel comfortable exploring this further, and simply disagree in silence.” (p8)

In some of the legitimate concerns, (Newbronner et al , 2011) explains that there is an inherent biases present. Referring to resource allocation schemes (RAS) the study found that “Where a generic system was used it highlighted inequalities in resource allocation between client groups. Older people, especially those with high care needs, appeared to be the most disadvantaged.” (p6)

There are therefore, many legitimate concerns which have been evidenced through research into ways that personal budgets have been used with different user groups has shown. It is vital that the cautions voiced by less enthusiastic practitioners and service users are embraced by those who are guiding policy, rather than being written off as being ‘negative’ without having the chance for their voices to be heard and for lessons to be learnt as a result.

Another challenge that is faced in practice is one of time. Quality support planning needs the investment of time. In the ideal world, presented by those who ‘run with’ the agenda, everyone is able to take an active part in making decisions for themselves and choosing their own care to meet their needs, as defined by themselves. The reality is that some groups have not been able to engage in the process of taking an active role in their own support planning; they are effectively excluded. This may be because they lack the capacity to manage a direct payment or organise a personal budget themselves, or because they lack support systems around them, such as family to help them do this.

SCIE report 40 (Newbronner et al , 2011) emphasises the fact that older people are more likely to need care during a crisis. People undergoing a crisis are likely to be less able, at least initially, to engage in the process of planning and organising their own care. Intermediate care teams typically assess and set up a temporary interim care plan and budget. Support planning then takes place a second time once the person is in a more stable situation and able to take stock. The time taken to set up a more personalised care plan in terms of the administration hoops to jump through are a significant barrier to some people and some ways of providing support.

Where does Personalisation go?

The ideology behind personalisation is sound and needs to be embraced wholeheartedly.

As practitioners we want work to support, involve and include people who use our services. The future must involve a stronger focus on services and delivery of services in conjunction with people who use them, but in order to get there, we need there to be a realistic, no-blame space for discussion between those who make policy and those who implement policy, as well as those who use services who lie at the centre of the social care system. There is still a disparity in terms of those who are best served by current practice. People who have benefited most from personalisation are those with the best advocacy and loudest voices. For the policy to embed itself in practice, it needs to offer the same quality and opportunity for flexibility to all user groups including those who are not able to raise their voices and who don’t have family advocates to speak for them. That’s where the role of the social worker has scope to be established to a much greater extent. As practitioners on the ground they have some of the most acute understanding of the challenges faced by people they work with, particularly people who are not able to best articulate their own concerns. If personalisation is going to work for everyone, we need to hear the voices from practice.

 

Biblography

Age UK. (2011). Personalisation in practice : lessons from experience. London: Age UK.

Netten et al (2012). Personalisation through Individual Budgets : Does it work and for Whom? . British Journal of Social Work , 1556-1573.

Gardner, A. (2011). Personalisation in Social Work . London : Sage.

Glasby, J. (2012). The controversies of choice and control – why some people might be hostile to English Social Care Reforms . British Journal of Social Work 1-15

Littlechild, J. G. (2002). Social Work and Direct Payments. Bristol : Policy Press.

Maclean, S. (2011). Personalisation and Person-Centred Care. London : City and Guilds.

Newbronner et al . (2011). SCIE report 40 : Keeping Personal Budgets personal : learning from the experiences of older people, people with mental health problems and their carers. London: SCIE .

On Capacity and Deprivation of Liberty

Having been a Best Interests Assessor since the position came into being, I have a particular interest in how the deprivation of liberty safeguards (DoLS) work (or don’t) in practice. I am a fan of the Mental Capacity Act (2005) to the point of becoming quite defensive in the face of opposition to it. This is because having worked in older adults services (and more specifically in dementia services) since before the Act came into force, I’ve seen the big changes that it has made in codifying and protecting the rights of people who may lack capacity to make specific decisions at certain times in their lives.

What was a previous reliance on ‘common law’ principles of professionals/family members making decisions which were more often than not ‘in people’s best interests’ changed to become codified and provide protections to people who are in these situation where no specific legal reference existed before. While the ‘Daily Mail’ crowd grumble about decisions being made by ‘shady secret courts’ or even shadier ‘professionals’, the reality is that for decisions to be made on behalf of people, all those involved including family members and professionals where necessary, should decide together what is in someone’s best interest on the basis of previous wishes where they are not able to explain. The legislation and code of practice sets out, what was lacking before, in terms of expectations (nay, demands) of involvement and the responsibilities for decisions about capacity to be made by the most ‘appropriate person’.

Criticisms come, of the Mental Capacity Act (2005) through the Deprivation of Liberty Safeguards. I have written before about them here as I’ve been involved in making decisions and carrying out assessments. There is no doubt that the system in place is flawed. We identified some of the flaws when we did the training before the provisions came into force. Subsequent case law has not always been helpful. In the light of the CQC report published this week about the use of Deprivation of Liberty Safeguards, I thought it would be useful to reflect on some of my personal experiences of using them and observing others using (or not using them) rather than look through the report which others do far better than I would be able to.

The Deprivation of Liberty Safeguards (DoLS) were intended to provide a level of protection to people who lacked capacity to make decision about care and treatment either in hospitals or care homes, regarding situations when they were being deprived of their liberty and therefore had no recourse to any appeal process – unlike, for example, people who are detained under the Mental Health Act (1983) who have access to a tribunal system. Deprivation of Liberty Safeguards have their own Code of Practice (which is useful but got out of date rapidly in the face of changing case law). There are particular processes required for an authorisation to be made (by the supervisory body – which is the local authority) and it is based on assessments made by two people. One is a Best Interests Assessor (which was the role I took) and the other is the Mental Health Assessor (who  is a doctor with special training although I wouldn’t lay too much confidence in the ‘special training’ as I’ve known it to be as little as a day). Having attended some joint training with Mental Health Assessors, I have to say, I wasn’t inspired with a great deal of confidence about some of the understanding of the processes but perhaps that’s changed in the year since I’ve practiced.

Problems with DoLS

One of the main problems I see with DoLS is that people are told ‘They are complicated’ and that seems to act as a disincentive for managing authorities (the care homes or the hospitals who may be depriving people of their liberty) to actually think about them too much.  Or staff who work in these areas think they are ‘someone elses’ business. I’ve come across that before – hospitals who have one DoLS/MCA lead who is seen as the only person who needs to know about them. I would say that’s possibly not the most helpful way to think about it. As long as people think they are complicated, they will ignore them in the face of busy work environments.

I try to tell people, when and if they are interested, that everyone doesn’t need to know the intricacies of whether a particular practice is a deprivation or a restriction before making a referral – it is the job of the Best Interests Assessor to make that call as a part of the Best Interests Assessment and it is something that will depend, very much, on the individual circumstances of an individual person. What is important though, is that staff can identify some key issues that may come up that could trigger a referral at the very least. If staff are to be provided with such a list by their employers (which I’ve seen) then at least those employers should ensure that they update this checklist frequently in line with case law and they emphasise that it is not exhaustive. As frontline practitioners, we talk about hating check box lists. This is exactly an area where a check box list is supremely unhelpful unless it is changed frequently and concerns strong provisos – allowing some professional judgement.

The name is a bar too, of course. Deprivation of Liberty Safeguards – people seem to concentrate on the deprivation part and ignore the safeguards bit so they are seen negatively. Actually, it’s a way of protecting the person whose liberty is being deprived and without the safeguards they would not have the same level of protection. When I see the Mail/Express headlines like this we can see the danger of misinterpretation of the language. I don’t believe for a  moment we have ‘more people subject to chemical cosh’ or ‘older people being tied up’ or ‘people denied from seeing their relatives’ than we did 10/20 years ago. We just have more understanding of when it’s happening and some of those people have had specific assessments to determine whether it’s in their best interests – where before it would just be a decision made without those safeguards.  The language is troubling to tabloid news journalists who don’t look beyond the ‘deprivation’ word. Mind, it’s not just tabloid journalists – it’s care home managers who see it as a ‘bad thing’ if they make an application. Personally, I’d be delighted to see more referrals drip through as it means that there’s a possibility that some people will have access to the protections.

Some people want a list of things that are a ‘deprivation’ and what isn’t. The lack of such a list leads to an ‘it’s complicated’ charge. The reason there isn’t a list is what may be a deprivation of liberty to me, might not be to you. I’m generally quite a solitary person and am quite happy spending a day pottering around at home, doing not very much. My partner needs to go to the supermarket every day to get fresh fruit and vegetables. He will not buy fruit or veg a day in advance and doesn’t believe in weekly shopping (this is sometimes an issue between us!). Not allowing him out of the home (if we both lived in a care home) would have a far greater impact on his liberty than it would on mine because of our usual habitual behaviours. Whereas keeping me away from a television for more than a day would have a big impact on me but wouldn’t bother him in the slightest. Silly examples but it’s the reason we can’t make blanket decisions or say ‘locked doors = DoLS application”.

The interface between DoLS and the Mental Health Act (1983) is a particular bone of contention – in my experience. Having worked in older adults’ mental health services, I saw many situations on older adults inpatient wards where, if someone wasn’t battering down the door and actively attempting to leave at any opportunity, they were deemed to ‘comply’ with the detention without the need of any of those awkward legal-type powers. Unfortunately I haven’t seen a great deal of progress in this and some psychiatrists seem to dislike using the Mental Health Act (1983) to detain people who lack the capacity to consent to treatment/admission. DoLS does allow, potentially, another avenue although case law has been quite fluid in terms of where we stand. What I’ve seen FAR more of is a lack of use of either Mental Health Act or the Mental Capacity Act and somehow thinking that ‘informal admission’ is the ‘right’ answer if someone isn’t battering the door. Sometimes opposition to a detention can take other forms – increased levels of distress, lack of engagement with staff/family but I fear there is little flexibility in interpreting the ‘objecting’ patient when people are not actively saying ‘I want to go home’ every second – and even sometimes when they are ‘Oh, they are just like that’ or ‘that’s the dementia talking’.  The thing is, this needs to be challenged and sometimes hierarchies within hospital systems don’t allow it. This is why I think the BIA role is crucial and that hospitals, in particular, should engage with genuine understanding of DoLS and what their actual purpose is rather than assuming they know.

I have a slight problem with the assumption that the Mental Capacity Act is ‘less restrictive’ than the Mental Health Act. To the person who lacks capacity to consent to treatment or a hospital admission – they are being kept in a place they don’t want to be and treated against their will regardless what legal framework (or none) they are subject to. The Mental Health Act offers more and better appeals processes (and more automatic checks – and of course, although this shouldn’t be an issue, the right to s117 aftercare) than the Mental Capacity Act so saying that DoLS offers a least restrictive alternative, is, I think, (whether judges agree with me or not) a false premise. One thing is for sure, there needs to be SOME legal framework and having none, certainly isn’t the least restrictive alternative.

What would work better?

I think there needs to be a streamlining of the DoLS process – perhaps more along the lines of the Mental Health Act which is better developed – certainly in terms of rights to advocacy for all and a similar type tribunal system. There needs to be much better understanding of the processes and what RIGHTS mean to people who lack capacity to make decisions. Local authorities need to provide better information and access to advocates all the way through the process – they are supposed to but it sometimes gets lost down the line.

CQC need to actually inspect and enforce when organisations are not telling them and they need to understand the processes better to judge organisations against what they should be doing.

Changing the name would help too, something about protecting rights not depriving of liberty – perhaps that’s a bit flippant but language is important.

Everyone within organisations needs a better understanding of them from care workers/health care assistants to consultant psychiatrists who seem to regard them as an optional extra if they can’t be bothered to use the Mental Health Act because ‘they don’t do that’ when people lack the capacity object in the only way that they can recognise.

These aren’t new now and they aren’t optional but too many organisations seem to write them off as ‘too complicated’. Too many supervisory bodies seem to ‘pre-screen’ referrals. There are too many discrepancies nationally to think that they are anywhere close to being embedded in our health and social care systems (despite CQC’s positivity on this).

We need access to clear information including current case law in a central space – perhaps the Department of Health can offer up some space – in easy to read language which explains rather than complicates.

I’m sure there’s far more than needs to be done. I don’t have all the answers – not by any means, but I do know we all, who have any interest in this sector, need to do a whole lot better and understand what the current law is. These safeguards aren’t an optional extra and just nice for people to understand a bit better. They are the current law and the current law is failing for as long as no one is actually checking or caring whether they are used properly or not.

What I’ve learnt about Social Work

A couple of ‘anniversaries’ have come up recently for me. It’s six years since I published my first post on this blog. It’s one year since I left my social work job. These milestones have caused me to reflect on the nature of the profession and the sector that I work in in a number of ways.  I read my first post yesterday and it drew me back to why I started writing in the first place. I’d tried writing blogs before this one. I wrote a stupid little diary as an angst-ridden teen which was much more interesting when I looked back on it than while I was writing it. I made a conscious effort here though, to write about social work and social care.

Over the years, writing and publishing posts has helped me in ways I can’t begin to elucidate but I’m going to try. I’ve written about social work and social media many many times but in looking back over the six years and learning more as the conversations grow and develop, I’m going to indulge myself again and share some of the things I believe that writing here has changed and shaped my perception of the career I chose.

What I’ve learnt about social work by writing about it.

I never really ‘expected’ a career in social care when I started working in the sector. I didn’t know what I expected to be honest – possibly because I didn’t ‘expect’ very much. In all honesty, I was grateful to have a job that didn’t involve me having to work in a shop or an office. I was grateful that I could be paid to do something that I actually enjoyed doing. My expectations weren’t exactly stellar but I never really thought about ‘career’. That wasn’t for people like me. I’ve written a few times about how I moved from a support worker in residential care to a social work student and then a social worker. It wasn’t something I was planning or expecting but a happy coincidence. My first job after I qualified was busy and I constantly felt incompetent or that I should be doing something different or better – most of the times, I was probably right. My manager at that time ranks as one of the worst I’ve had. She was, quite frankly, a bully. I didn’t bear the brunt of it though. I kept my head down, did as I was told and relied a lot on the support from older and more experienced colleagues.

I went away, returned to social work and new legislation, procedures in a much better place. When I started writing this blog, I was finishing my ASW training. In the borough I worked in, we completed the training ‘full time’ with placements in other teams. I’d moved from adult social work into mental health social work for a few years and the ASW training was the logical next step. The service needed more ASWs. I wasn’t actually too keen. I remember a conversation I had with the service manager at the time when he told me that it would probably be the last opportunity I would get (I was on the last ASW training) before the rush of nurses and OTs and the shift towards AMHP training. Last chances. They can be quite a pull. I was struggling at work too for various reasons and to be brutally honest, welcomed the idea of taking some time out to do more training. I didn’t really think too much of the thought of what it would mean in the long run.

The course was the best I’ve ever done. Far surpassed my initial social work training in terms of quality of teaching, level of understanding, support and knowledge gained. I started writing here as my thoughts moved towards returning to work and a job I wasn’t sure I was even very good at. I’d had time out to study and I’d enjoyed it and I was worried about going back to the day to day ‘grind’ and becoming jaded. The ASW training lifted all the lingering inertia out of me. I wanted to do well. I wanted to learn. I was sad that the learning was coming to an end. So I started writing.

After the first few months, I forced myself to write something every day (giving myself weekends off). I wrote a post before work religiously for a number of years. Yes, the quality varies massively – but it forced me to find things of interest either in the news, from work or from my ‘outside work’ life to trigger. Some posts were longer than others, some more interesting than others. It was a good discipline, looking back and I don’t think I could return to it.

It taught me much more about the profession – I’d thought in terms of myself as a ‘adult social worker’ or a ‘mental health social worker’ but I hadn’t really thought about ‘social work’ per se because the work and the culture in childrens services, as I saw it, was so very different.

Then people seemed to be interested in what I was writing and I saw it was an opportunity to ‘sell’ social work. I explored for myself what being a social worker meant to me. I’ve been through the tunnel and out the other side with it to be honest. I’ve had, as we all do, those good and bad days. By writing I was able to share some of that. I was able to better reflect on what I was doing on a day to day basis and how it fit back in the profession as a whole more than my own little part of it.

As I wrote, I learnt how proud I was to be a social worker. That was something quite new for me. We joked about it but I didn’t realise, until I was writing for an ‘external’ audience, how important it was to me to represent the good work that is being done, by good people – often unnoticed – in the sector.

The blog also gave me a voice. I’ve made an issue of the fact that I’ve never been a manager. I was able to tell people who would never otherwise have listened, what it was like to work in the field and to have changes happening around you when there was no thought or consideration given to the experiences or voices from the ‘coal face’.

I was, and still am, amazed that people listened to me. Me. I’m not anything or anyone special. I don’t have any particular professional status. I haven’t written reams of peer-reviewed papers. But people seemed to read, listen and respond to me. That helped my confidence as an individual and as a practitioner enormously. So this blog and the other things I’ve written over the years, have given me confidence and have helped me to reflect on what it is to be a social worker, what it is to work in social care – and health services – and to realise that I could use my voice in different ways, even if I couldn’t always say things to my managers or in the Trust or local authority I worked in, someone, somewhere might listen and make things better in some ways.

I learnt a lot from blogs and comments from people who use social work and social care services particularly. I could never have the same interactions with people I worked with on a day to day basis because however pleasant and approachable I think I am, there is an undeniable power that I had in my statutory role. Reading about how people feel when they are detained under the Mental Health Act or have treatment forced on them, is an insight which – while hoping I was always sensitive – I could not get from other sources. Listening to how people felt when they experience crappy social workers or crappy carers or crappy systems, reinvigorated me to stop feeling so powerless in relation to the organisations which I worked in and realise the immense power I have in other people’s lives and to make sure I used it well. I may not be able to help those who have experienced the worst of statutory powers but my growing awareness of the impact would, I hope, help those who crossed my path.

Ultimately, and ironically, writing about social work, understanding its important and having more confidence in my own voice and opinions is what led to me having the confidence to leave it behind me. Isn’t life funny.

What I’ve learnt about social work since leaving it

I’ve written  my ‘goodbye’ piece to my Trust and local authority so won’t go over that ground again. It’s been an interesting year as I’ve left behind  a specific ‘social work’ job and moved into a job that doesn’t require a professional registration. In some ways, it’s solidified my determination to identify and pretend I’m still a ‘social worker’. It’s also though, allowed me to see the profession ‘from the outside’. When people meet me now, they don’t necessarily know what my professional background is so I have heard some interesting perceptions about social workers and can distance myself when I choose to.

A few weeks ago, I was at a meeting with various people from various places. When we drew to a close and had that brief chat before we headed off in our separate directions – we were talking about some of the difficult situations that had arisen. The person sitting opposite me said “You should try being a social worker”. In the skip of a heartbeat, I responded “I am… I mean, I was.. er.. I’m still registered”. Then I realised, coldly, that of course, no one in that room apart from me knew that. That was an odd feeling. I had, so long, identified as a social worker than having it not be either immediately obvious or relevant was another step away for me.

I get pangs of wanting to go back. Particularly, I miss some of the day to day work with people that I don’t get now. Then I try to remember what it was like, last summer, when the cuts bit hard and the stress levels were enormous. I’m happy where I am now, really I am but it’s not quite the same as sitting in someone’s front room – building a relationship with them and their family – and being ‘there’ to help see through some of the complications of ‘services’ to make things work out a bit better. Or meeting someone in hospital – or when you rock up to carry out an assessment and being able to follow it up through discharge to a better place. I have to admit i’ve occasionally glanced at social work jobs just to see if they tempt me back. I wouldn’t say ‘never’ but the longer I am away from the ‘coal face’ the harder, I think, it will be to go back. Maybe I’m kidding myself into thinking I will. I need to have that comfort blanket of believing that if I applied for my old job tomorrow, I’d be able to slot back into it.

I’ve learnt that social work is about so much more than local authority social work or social work within the NHS. I knew this, theoretically, of course – but now, as one of the ‘outsiders’ I see how important it is that social work doesn’t become pigeon-holed into only meeting statutory social work with a job title that includes ‘social worker’ in it.

I am using all the skills I gained through my training and my experience in my current job. Being a social worker, I believe, with my knowledge of assessment processes, experience, use of legislation and value base make me able to to what I do. Could someone without that do it as well? Yes, they can and they do – sometimes far better – but for me, it’s a good fit.

I now have a little distance from the profession which allows me to cast a more critical eye too. I was incredibly frustrated by the battles between BASW and the nascent College of Social Work back in the day. I see some kind of impasse has been reached now but I do wonder how sustainable it is to have two organisations – in a profession which has never particularly clung to representative organisations – battling for the same space.

With initiatives such as Frontline and the posts of the Chief Social Workers (who, it seems, have turned out to be mouthpieces for the govt – but I wait for them to prove otherwise to me) it has become really important for social workers to help define social work and not allow it to be defined for us by the Department of Health and the Department of Education. It isn’t only about child protection social work. It isn’t only about statutory social work. I am still as much of a social worker as I was last year, even though I don’t NEED to be a social worker for my post – perhaps I need to convince myself of that too but if we allow others to define the profession too narrowly, we will all lose out by it. In a world where I see the profession increasingly fragmenting, the real strength and voice can only come in unity. That’s what I’ve learnt.

In all, I remain incredibly proud to be a social worker. Although I was desperately sad to leave my last job and can’t help feeling tinges from time to time about whether I did the right thing, I can’t go back now. I have landed on my feet and the amount of learning I’ve done over the last year has been enormous. Mostly it’s about building on the skills, knowledge and values. You can’t be a social worker without all three of those. I’m still working on all of them and so very much locate myself within the profession. Will professional organisations, voices and representatives acknowledge that? I hope so.

Social work allowed me to create a ‘career’ when I never really thought I would have one. It’s allowed me to build confidence in myself so I can better represent and advocate others. It’s given me a great gift and I never expect to lose sight of that, forget the opportunities I have been given and stop fighting for the necessity of good social work. That’s done together though and we can build a better ‘social work’ with more voices.

That’s what I’ve learnt.

As I move on with both the writing and the career, I can’t help but feeling rather self-satisfied too. I am proud of what I have achieved so far but know there’s a long way to go. Pride isn’t particularly pretty but I’m hoping the confidence I’ve gained can be used to better represent, advocate and drive improvements for others as well as for me, rather than allow me to sit in a self-satisfied space and relax.

Parting Shots – Why I left my Social Work Post and What I’d change

I left my job as a Mental Health Social Worker, AMHP, BIA, Practice Educator and all that I wrote about here last December. While I can’t be too specific about my current role, it’s (unsurprisingly really) in a related field but it’s moved me into the background and away from a direct role with people. It’s been nearly ten months now since I changed jobs and it has led me to reflect on what ‘being a social worker’ meant to my identity and how I viewed myself as well as how others viewed me. It hasn’t always been easy but every time I look back with a hint of regret, I see newspaper articles like this one today and remember what it was that led to me leaving behind what was, and what remains in many ways, my ‘perfect’ job. I loved working with older people, I loved working in Mental Health – and while I didn’t enjoy (you can’t ever enjoy) the detention and assessment part of the AMHP role, there was a unique camaradie with other AMHPs and the access to continued support through forums and legal updates was unrivalled.

I felt I could make a different to some people’s experiences of mental health services by explaining them and guiding them through what was a scary and difficult period of their or their family member’s life and if I could take them out the other end, well, there’s no better feeling in the world.

But it got harder. We know there were cuts in the service. Despite the government’s mealy mouthed promises about there not being cuts in frontline services – there were cuts in frontline services and significant cuts. I want to explain why I made the decision to leave – and it wasn’t a decision I made lightly.

Change

In my six years in older adults’ mental health services we had been through three major reconfigurations. What had started as three teams covering localities within the borough I worked in, became two and then became one unified team. This was partly by design (the switch from three to two) and partly by circumstance (from two to one when managers didn’t actually have enough people to have two separate teams so had to merge them). We had some ‘almost’ reconfigurations when there were proposals to eliminate the ‘older adults mental health’ team as a separate strand and move everyone into ‘age blind’ services. This didn’t happen fortunately as I think it would have been disastrous for the client group we worked with. In our older adults teams we worked in different ways and had a particular expertise in working with people with cognitive impairments and against ageist services that are deeply embedded in the National Health Service. Suffice to say, I was used to change.

I don’t think my employers were bad or the worst, by any means, indeed, I have considerable warmth for them. My managers were decent people who were incredibly supportive and the organisation provided some excellent services. Then the changes came again. The internal consultation process was tough – not least because the executive team treated us, as staff members, as if we were stupid. I worked in the same office as the ‘executive team’ and there isn’t one of them that would have passed a greeting to those of us in the CMHT. We were clearly beneath them. I don’t mind that to an extent, except when we are trying to make particular points about the quality of service that we are able to deliver and there’s no value or credence given to our views. But enough of that – so the consultation was about more changes – this time even more radical. There had already been ward closures but more were proposed and this time, it was justified because the community services would be able to provide better support. The tiny little problem with this was that it would do so with fewer qualified members of staff. Who needs qualifications anyway, they’re overrated.

As a social worker seconded into the Trust, I was slightly protected. Our local authority confirmed it wouldn’t be cutting any of our posts and in any case (although this really was moot as they were clear that the social work posts were never in danger) the AMHPs were even more scarce so I’d never have been in danger. However, we’d be losing nurses and occupational therapists. Instead we’d be getting lots of new band 3 and 4 support workers. I’m all for support workers. We never had them before – but I’d thought they would be an addition rather than a replacement to the core team.

So this was the improved model. The thing was, that so many people were unhappy and miserable about having to reapply for their jobs after many years and through not being consulted even in a cursory fashion that they .. or rather we.. looked for other jobs. Actually, I didn’t look for a job at this point. It wasn’t until a bit further down the line. People who were eligible for early retirement took it. Some people took redundancy. Others took different jobs elsewhere. It was often those with most experience that left. The replacements didn’t come quickly.

There were days last summer when I was the only qualified member of staff covering my CMHT – no other social workers, nurses, OTs – sometimes even no doctors – that was mostly because some people worked part time so it wasn’t very regular but the fact that it happened at all was worrying. I was doing more Mental Health Act Assessments yet my caseload was expected to be up to date. ‘Duty’ became a bit of a fantasy because it felt like I was constantly on duty. I can deal with stress and manage it but when you worry that the work you are doing is not safe anymore, it becomes time to look away.

A message to the Executive Team

So in looking back I’d say this to those executive directors who never had time to stop and listen despite us collectively telling them how worried we were about the quality of services we were providing and how we felt we were being asked to work in ways which were increasingly risky. If you want to provide a really good quality service you have to listen to people other than those within your own echo chamber of management or leadership who are invested in agreeing with you. Staff want to work in ways which are fulfilling. We want to provide good care to people but the systems we work in are stripping that potential away and if we can’t do that, we can’t continue in it. We don’t want to be cramming people into wards which are further and further away because you’ve decommissioned local beds. We don’t’ want to be providing what we know are poor home care services because the council will only pay minimum wage and commissions on cost rather than quality.  We don’t want to have to look further and further away for poorer and cheaper residential and nursing care. We want to be doing the creative support planning with personal budgets but then, it’s hard to be creative with 5 hours care when someone needs to use that for support with washing and dressing for the whole week. We want to be advocates and we want to drive and provide good care but have no access to good care. We want to support families and carers but we don’t have the time or the resources to.

And for you?

You need to listen. You need to listen because sometimes the people who are going out there and providing the services you, as executives are responsible for, know what they are doing and know the communities better than you do. You need to listen to people who access the services and their families and actually change things on the basis of what you are told – rather than just listening to MPs or local press as the people who contact MPs are not more valuable than those who are unable to – they just have different skills. You need to be honest – most of all. We know the cuts are coming but when you tell us this is about ‘service improvement’ we can’t ever trust you again.

On the outside

Since I’ve left, I have been pattering between sadness and frustration. The things that pushed me to my own limits were working in ways I didn’t feel were sustainable. I struggled with my place in this system which was built like a house of cards but I don’t want to leave this post in despair as I have hope. I needed to take a step back and having done so, I realised for the first time, how much stress I was under. I just thought that was the way things were but moving into another role has made me see how much of my life was wrapped in constant stress. It doesn’t have to be like that. I miss the job and the people. I worked with wonderful people and great colleagues. I know there are fantastic social workers, nurses, OTs, psychiatrists and psychologists out there who are making a difference to people’s lives every moment and whose hearts are fully concerned with how to work better. The sadness is that so often they are engaged in battles with the organisations that employ them too. I would very much recommend social work and mental health social work as a great career move. You have opportunities to walk alongside people through their most difficult moments and learn from them about how you can take them through an often complex system that sometimes feels like it is falling apart.

The sadness is that sometimes the most difficult challenges come from within the organisations that employ us – it doesn’t have to be that way though. I’m sure there are many other experiences. While I don’t regret leaving, not really, I do wish I’d been listened to more. That more than anything, would have led me to stay.