“It cries out to be released from present day 19th-century asylum-based narratives of social care reform.” Dr Mervyn Eastman has spent over 45 years in and around social care and social work. What does HE see as the way forward for this vital service?
Over the decades we have experienced and endured countless restructurings and re-imaginings of policy and practice developments. Perhaps the most bizarre was that of Andrew Lansbury, Secretary of State (2010-12) who rightly, in the view of David Brindle, tried to “introduce enormous, and ultimately unworkable, NHS structured change.” (1)
For me, it all started back in the 80s with a shift from direct service provision to a market-based mixture of providers which favoured the private sector, underpinned by a New Right philosophy of an enabling state. Through the White Paper, “Caring for People: Community Care in the Next Decade and Beyond” (DH 1989), it was for many of us driven by the erroneous belief that the public sector was costly and ineffective and required the wonderful world of capitalism to “fix” Social Care.
What exactly was being fixed, remains for me, the key question. Indeed, it is argued by many that Social Care remains to be “fixed”.
Austerity and Pandemics notwithstanding, one significant debate that actually was around in the late ’60s was to structurally merge Health and Social Care. I well recall debates about returning Health provisions to Local Authorities, interestingly, from whence it came!
David Brindle reminds us that, “We have gone through person-centred care, systems integration, choice and control, free personal care, funding options and Dilnot.” I’d say, worn and faded deck chairs have been patched up and moved around the deck…. you get my drift. Brindle writes far better than I: “We have had 20 years of disappointment over social care and a roll call of Health (and Social Care) Secretaries, who often by their own admission, have not left much of a mark.”
Regardless, there remains the consistent policy intention to increase the integration of health and social care. But what on earth does it mean?
Poor Law thinking
To my mind, nothing changes. Social Care and Social Work, in terms of understanding what they are, remains rooted in Poor Law thinking. How we think about its interrelationship with communities, social justice, poverty, social class, equality, Human Rights, financial security, housing, employment, leisure, transport…. I could go on.
Along the way, protecting the role of Community Development and its workers has been sacrificed on the altar of right-wing political ideology.
That said, the constant over the years has been the rhetoric that integrating health and social care will somehow “fix the problem”, whilst at the same time, ignoring the wider socio-economic context in which Care exists, and that of Social and Community Work. “The mantra of Integration makes sense and we need more of it.” Really? I ask: what’s the evidence that structural and system integration, as defined by present policy and practice, actually creates effective “partnership(s) of organisations coming together to plan and deliver joined-up health and social care services, to improve the lives of people who live and working their area”? (2)
So what IS integrated care
Sarah Scobie asks what we mean by integrated care, how has it changed, and does it work? (3) It is a good starting point.
Both health and care services are broad in their scope, even purpose, and they are governed and funded separately, and by different legal entities. In addition, and in contrast to the majority of health services, individuals are means tested for care services and have to meet the pernicious rationing eligibility criteria imposed by commissioners.
Sometimes called “collaborative working”, integrated care necessitates social workers, in particular, to work in new ways. Integrated Care also requires multi-disciplinary working across the participating agencies, which in turn requires cooperation throughout the whole system.
Yet we still have little consensus as to what it all means from political leaders, national and local, practitioners and their managers – let alone service users. Does it actually matter to Joe Public, as long as what they need is available, accessible and relevant?
The challenge for me, is that it matters a lot to everybody else!
Again, Sarah Scobie concisely unpacks the levels of integration, and hence offers a useful framework for us to measure and evidence effective and efficient collaborative working. (4)
- Organisational: co-ordinating structures and governance, mergers or contractual or cooperative arrangements
- Administrative and Financial: back office support, accounting, data sharing and information systems
- Service Integration: via multi-disciplinary teams and simple systems for referral and assessment
- Clinical Integration: becoming a “single and coherent process”
It is all very sensible and to be welcomed, but we need a reality check. Emeritus Professor, John Harris and independent consultant Vicky White identify factors that threaten or undermine collaborative working which, I argue, is relevant when examining Integrated Care. I recognise however that there will be some who would equally argue that collaborative working and Integrated Care are different. I disagree.
Turning to threatening and undermining barriers, Harris and White are instructive: (5)
- Structural: Fragmented responsibilities between the agencies and practitioners. Does Integrated Care deal with this in practice?
- Procedural and Financial: differences in planning and budget cycles. Integrated planning and merged budgets are dependent on what resources are, in reality, released from the participating agencies where decisions about resource allocation are taken within and by the agency. In other words, the cake being cut is determined by Councils and Trust Boards etc, and thus “unified” budgets are in reality, a slice.
- Defensiveness: in response to perceived threats to professional status, autonomy, and legitimacy. For me, this, and those factors below are too frequently ignored when considering and evaluating Integration. Multi-agency bodies are brought together to strategically plan, agree on priorities and carve up the slice is not an algorithm or some AI process which leads us to.
- Professional and Power Differences: differences in ideologies, values and professional interests, conflicting priorities, meeting different targets and performance management systems, data collection and factors that threaten to undermine collaborative working, fostering blame and antagonism rather than goodwill.
I believe that these factors taken as a whole need to be considered when exploring Integrated Health and Social Care policy and practice. For me the jury is not out, it hasn’t even been brought together. How do those directly engaged in making strategic, priority and spending decisions experience integration? How do managers and front-line care professionals experience integration? What level of engagement and participation is there with patients, social care users and their families and the community?
For professional social workers and the profession generally, there are concerns about identity, values and ethics. Harris and White give a prime example, referencing “the conflicting beliefs and values underpinning the medical and social models of disability.” (6)
So, Houston, do we have a problem?
More than one. In fact, here’s my top twenty:
- The continuance of health and social care disparities
- The predominance of a medical model that pathologies and continues to shapes social care
- The prevalence of Human Rights violation
- Failure to underpin person centred approaches, with a life course foundation and perspective
- Poor data collection and hence tracing the effectiveness of Integrated Care against policy outcomes
- Social care is primarily seen and perceived as direct care tasks
- Geographical boundary differences between providers
- The patient and service users’ experience, especially in relation to long term care provision
- Different professional roles and identities and “social workers struggling to articulate their role” (7)
- Different organisational and professional cultures
- Power imbalances
- Interpersonal relationships between participants
- Lack of political will to see the challenges through a different lens than simply funding
- The continuance of institutional ageism, sexism, racism, ableism, and homophobia within professional practice and organisations
- Marginalization of small Voluntary groups
- Concealment of inadequate funding
- Confronting poor support, oversite and inadequate training and development of those working within Integrated Teams
- Political ideologies and short termism
- Failure to test the effectiveness of co-production, participation, “experts by experience” and service user involvement
- The “corruption of care”
I can hear some readers saying that Integrated Care systems and structures were not designed to address these issues. If that is true, then what is the point of it?
For me, the very purpose of Integrated Care is to improve health and care outcomes, address social inequalities, measure and evidence productivity and VFM, access to care, and support people to stay well and independent. It therefore cannot achieve this, if it ignores those factors that undermine its very purpose.
Where are you, oh social worker?
The key here is that social work offers a relational, not transactional, approach within the care system. I am not looking for a checklist assessment, or a signpost to God knows where. I want a social worker who reinforces my service rights and my citizenship, that does not “other” or commodify me. I want to be regarded as an equal, with the right to self-determination, mutual respect and trust, to help me navigate the health and social care system; someone who is also my advocate and responsible to me (whatever my circumstances) and not for me.
I do not want a relationship with a succession of workers I do not know, and whilst to have a relationship with a Department or agency is possible in broad terms, it cannot of course become a “therapeutic” one. The individual social worker builds trust and expertise in relationship building, which includes not just talking with me, but where I can share feelings and my concerns hopes and fears. Above all helps me be optimistic. The social worker is an expert with their feet firmly on the ground, do what they say they will and becomes a partner with me. I acknowledge that they have a responsibility to their agency and the wider community.(8) It is no easy feat. The pernicious growth of managerialism, authoritarianism and the marketization of social care, over the past decades, continues to threaten and undermine the social work relationship.
Here’s another list, this one is about Social Work taken from SHARE: A New Model for Social Work (2018)(9)and the social worker:
- A positive, optimistic outlook
- Understanding the reality of oppression from other professionals ( and I’d add our own )
- A belief in the possibility of change
- Commitment to a relational approach
- Supporting people to feel a sense of belonging
- An awareness of the dynamic nature of hope
- An ability to imagine a different way of doing things
- Skills in supporting people to develop goals and look to the future
Mirages, myths and emperors’ new clothes?
Collaboration and cooperation in Multi-disciplinary teams and organisations is hard enough for all professionals working within them, social workers particularly so. I have tried to explore Integrated Care Systems, which in essence, institutionalise joint working, but is seen by its advocates as a good and necessary development. It is a mirage, which does little, if anything, to address the threats which are a real and present danger, not just to
Social work, but to and for communities, individuals and the causes of social inclusion and justice. Perhaps it is not a mirage, but quicksand, a swamp.
To place Social Work and Care in their wider context, have a look at the writings of Cormac Russell and John Knight (10), Alex Fox (11) and Peter Beresford (12) all of whom provide a totally different paradigm to that presently underpinning Integrated Care Systems.
Social Work can potentially be both powerful and transformative, rooted in communities and neighbourhoods… if released from the bureaucracy and the false rhetoric of Integrated Care Systems. It cries out to be released from present day 19th-century asylum-based narratives of social care reform. It has to be freed to enable, rather than simply process and facilitate – thus recapturing the dynamic relationship between individuals, communities and the State, and by no means least, make a reality of the radical nature of participation and involvement.
- David Brindle. Changing Faces of Westminster “Who was not up to the Task”? Care Management Matters CMM (2023)
- Scobie S. “Integrated Care Explained” Nuffield Trust Explainer (2021)
- Harris J, Whitew J ” Collaborative Working” Dictionary of Social Work and Care. Oxford (2013) pp 101-102
- Ibid p 102
- Bark H, Dixon J, Lang J. “The Professional Identity of Social Workers in MentalHealth Services. A Scoping Review. International Journal of Environmental Research and Public Health (2023)
- Banks S. Ethics and Values in Social Work. Practical Social Work. (4th Ed) BASW (Mclean/ Palgrave) 1995
- Maclean S, Finch J, & Tedam P. SHARE: A New Model for Social Work. Kerwin Maclean Associates (2018)
- Russell C & Knight J. The Connected Community: Discovering the Health, Wealth and Power of Neighbourhoods. Berett-Koelher Publishers (2022)
- Fox A. “A New Health and Care System: Escaping the Invisible Asylum”. Policy Press. (2021)
- Beresford P. “Participatory Ideology: From Exclusion to Involvement” Policy Press (2021)
Dr Mervyn Eastman (inter alia) is a founder member of the Later Life Audio and Radio Co-operative and a presenter of Care Speaks podcast (hosted by Institute of Health and Social Care Management, in partnership with Later Life Audio and Radio Co-operative).