Is Care Management Social Work?

How much of social work exists in the Care Management model? It’s a question I’ve been toying with for a fair amount of time – especially as most of my work, post-qualification anyway, has been situated very much within the care management model. Although now, I have a slightly different role within Mental Health services, the domain of care management even within a multi-disciplinary team is seen very much as that of the social worker and the place of both is something I have been considering over the past few weeks.

One of the CPNs in the team I work in (bless her) constantly talks about ‘doing social worker’s jobs for them’ or ‘using social work’ language. She’s a great nurse with very high standards and we get on well, but she doesn’t think much of ‘social work’ in general (individuals notwithstanding!) and certainly not when she feels she is being asked to do this at the expense of therapeutic or clinical work.

My current role does give me more therapeutic leeway, although I am very much a product of the ‘care management system of social work’ as I trained when the NHS and Community Care Act (1990) was already very much entrenched in the systems. People spoke fondly and wistfully of ‘old style social work’ but beyond vague helping notions, it wasn’t something I could necessarily link immediately with the work I was being asked to do. After all, the idea of the new legislation was to be a provider and buyer of services that would give the end user a better quality and variety of care and would allow the care manager to manage on a strength-based model – that’s how it was sold to us when we were studying anyway…

When I was operating in an environment where I was primarily a care manager above and beyond all else, thought I felt that any individuality and professional competencies that I had worked to achieve were being sucked out of me almost before I’d started to work. All ideas of ‘buying services’ was throttled out of my by service level agreements and commissioners dictating which providers could meet the needs of the local authority in terms of pricing.

I was going into people’s houses, judging their needs against dry ‘Fair Access to Care‘ Standards – which were very tightly controlled by commissioning bodies.

stephmcg stephmcg @ flickr

I was then matching those needs against a local authority list of times (I did actually have a physical list) – so 30 mins was allowed for a shower in the morning, 45 mins if breakfast was to be prepared as well – all mechanical, all prescribed. Anything above and beyond that time allowance would have to be justified in triplicate.

Paperwork completed, a few phone calls made and the package was in place.

No real need for any professional competence derived from graduate level study. Not really. Of course, the profession likes to make you think there is, the academics like to make you think there is. But I am confident that any non-qualified community care assistant could do an equal job , if not better job – especially after a few years. When the need for critical appraisal and considerate reflection is lost on a day to day level, the elements that identify the profession seem to fade.

Supervision was a list of what you had done that week/fortnight/month in terms of targets – and what you still had to achieve.

Of course, communication is necessary. You have to talk to people to make them feel better – to help garner information successfully but it’s hardly something that demands a rigorous academic approach and discipline.

This frustrated and continues to frustrate me.

Of course there is more complicated work coming in and there would be some marginal therapeutic work around, in some situations – but it is almost the mechanism that frustrates than the work. The de-skilling seemed to be more or less complete.

It felt like I was bestowing the beneficence of local government funding and for all the academic discussion of strengths-building and relationship-building – you’d likely only see someone a couple of times – to assess and then to review unless there were particular difficulties.

I remember once trying to explain to a woman that I visited why I couldn’t explain what Pension Credits she might be entitled to (I can just about manage Attendance Allowance or Disability Living Allowance – any other benefits remain a blur in my mind) and then, why I didn’t have access to any cash to give her (the social worker who had helped her when she was a foster parent had given her money directly so what kind of a social worker was I if I couldn’t provide cash?).

There was a hope that Direct Payments would go some way to solving this – but direct payments, while extremely liberating for some younger disabled adults, have proved harder to ‘sell’ to older people and those in mental health services.

Namely, they are easier to sell to those who want to be sold to. When there is someone who needs more support in order to start having direct payments – the care manager isn’t, in my experience, given much leeway to have the time to explain, assist and support – well, certainly not in older person’s services where timescales are tight because of targets and turnaround is expected and pressured.

I can proudly say I was relatively successful in pushing direct payments out to older adults – more possibly than most in the team I worked in – because it was something I felt quite passionately about at the time. But even for me, operating in a target-driven system, it took time that I sometimes wasn’t allowed. All very well if the service-user is able to advocate for him or her self, contact the right people to assist with payroll and recruitment or has family around to help, but if they don’t – it’s a time issue for the care manager who is being pushed to targets, targets, targets.

Peter Beresford, writing in the Guardian, reviews a new book called The McDonalidization of Social Work by Donna Dustin. She writes (apparently because I haven’t read the book) of some of the effects of the care management that resulted from the 1990 NHS and Community Care Act.

The era of Personalisation is upon us which is apparently being welcomed as a move away from ‘care management’ and towards ‘individualised personal budgets’. The Care Manager is dead (so to speak) and long live the ‘traditional’ social worker. But I wonder how this accounts for social workers already burnt into the Care Management system who are too young to remember the glorious ‘old style social work’ era. What tools do they have to equip themselves with, years out of college but nested firmly in the bosom of the NHS and Community Care Act.

Social Work needs to reclaim some of the ground for itself in a target-orientated environment. If not, practitioners will become mechanic and complacent. Time needs to be given to workers to actively engage – but I can’t see the time ever being there as long as local authorities have tick-lists of ‘targets’ that need to be followed.

In my previous job we had a target to meet about adult protection investigations. If not enough people needed protection within a quarter, that was another target failed! There is nothing needs-led in the system of targets. It is completely service-led.

And I can’t be convinced by personalisation until I have seen concrete proof of its benefit to older people who are not able to speak or shout loudly about their needs. Within the pilot studies, I’d like to know how people with dementia are going to have their needs met or if personalisation is again, like direct payments, going to be a buzz word about individuals and choice – depending very much on who the individuals are and how much choice they are able to make without professional support.

4 thoughts on “Is Care Management Social Work?

  1. Hey, just came over to check on you. I’ve been wondering what I even went to school for lately. Sure I know more theory, but I don’t feel as though school prepared me for actual daily interaction with people. I just don’t feel like I know a whole bunch more than I knew by living in the system for almost 20 years. So now I’m thinking about going for the Masters…seems as though you can’t get a “good” job without one. 🙂

  2. Thanks for dropping by! (and anyone reading this who hasn’t checked out Prin’s site, click on her name – there’s a wonderful musical world to discover.. ). I think there are only some things that are ‘teachable’ in this field to be honest. In a part, it is a job that is almost trying to create a theoretical approach around it. It’s something I still struggle with to be honest, the marriage between the practice of social work and the academic study of it. I still haven’t resolved it intellectually!

  3. It’s interesting to hear your take on care management and social work. In our hospital, we social workers do not provide care management (what we call case management or discharge planners). We provide traditional clinical social work services to patients we receive referrals on…psychosocial assessment, brief bedside counseling, grief counseling, as well as connecting the patient and their families with community resources. There are a few MSW’s who work as case managers/discharge planners. My biggest beef with the hospital is that an RN who works as a case manager makes about $7/hour more than an MSW doing the same job. The rationale for that is that the RN can do utilization review, but how much that actually goes on I think is doubtful. We do discharge planning only for hospice patients and it is those times that I doubt that an MSW is needed for that portion of the job. Up until that point, our skills are definitely needed and beneficial but the discharge planning/care managing that takes place after the referral is in place can definitely be handled by anyone properly trained.

  4. Interesting – I actually find it fascinating to find out how things are done differently in different countries. Some things remain the same but some of the details differ. I have a lot less care management responsibility now than I used to have in my previous job – and actually, it’s a large part of the reason I changed – but I think the system has created a system of social workers who don’t practice ‘social work’. No wonder we (here, at any rate!) seem to have all these debates about ‘what social workers are?’ ‘what are the core skills?’ etc. Thanks for the input!

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