News

To what extent do government protocols covering social work with children in need, with their accompanying form-filling, hinder rather than help effective front-line work, asks organisational research analyst Suzanne Regan.

In the duty area of a busy London borough social services office, baskets are overflowing and filing cabinets stacked high with papers. The team manager, pointing to the various piles of work explains: "This is the basket for new referrals taken during the day by duty social workers. I have to make a decision about what action needs to be taken on them.

"This basket is for urgent ongoing child protection work which I have to allocate. The referrals in here, (pointing to filing cabinet drawers marked 'Awaiting Visits/Office Appointments' and 'Children in Need') require further tasks to be undertaken by the duty social workers."

I ask the obvious question. "Why aren't duty social workers doing more of this work? It's really piling up and you seem to be making all the decisions here."

Having analysed the organisational features of more than 50 statutory child care duty and intake settings over the last two years, the answer comes as no surprise.

"The social workers are too busy. I have one staff member off on long-term sick, I'm carrying two staff vacancies and two remaining staff are tied up in care proceedings - which really should be done by the long-term teams, but they can't take them on. Another social worker is doing her PQ Childcare Award and needs time off. Also, we're coping with agency staff who can't use the computer systems. We just can't recruit child care social workers any more."

While the advisory group members responsible for the Framework for the Assessment of Children in Need and their Families¹ congratulate themselves on producing a document designed to amplify the voices/rights of "children in need," managers and social workers have been bracing themselves for yet another organisation and practice innovation. The problems confronting this team manager on a daily basis are shared by many others around the country: chronic shortages of staff, instability and variability of skill in the workforce, backlogs of unallocated referrals and the demand for social workers to attend compulsory post-qualifying training. The causes of the current malaise in child care social work, however, run much deeper than this.

Far from producing clarity and reducing uncertainty, new models of reform tend to produce a peculiar sort of unreason where organisational arrangements and procedures emerging from government reform bear little resemblance to situations routinely dealt with by social workers. It appears to me there are two main reasons for this. The first relates to fundamental shifts in the nature of exchange between the state and its citizens.

To the careful observer of change in social work organisations it would appear that contemporary models of reform no longer reflect any of the broad principles of collectivism which were embodied in former legislation. Under the National Assistance Act 1948, for example, the local authority had a duty to provide accommodation and other welfare services. Within the terms of the reforming National Health Service and Community Care Act 1990, the duty of the local authority is to provide an assessment of individual need. There is no comparison in the respective value of these two forms of exchange. One imposes a moral duty on the local authority to provide benefits of material value to people who need them, whereas the other represents a symbolic (and literal) form of exchange. Here, the production of a needs assessment form is held to be both the service and the benefit. This process of substitution which privileges the production of paper forms (assessments, care plans, protection plans etc) offers a partial explanation of why so many social workers consider that their work has been emptied of substance and their labour appropriated for tasks which are devoid of value and lacking in moral purpose. Put simply, form(s) can be seen to substitute for substance in new modes of exchange between state and citizen.

There are many difficult questions raised by this new mode of exchange. What exactly is the intrinsic value of an assessment? How does a welfare programme of national assistance compare with a programme of national assessment? Difficult as they are, these questions lie at the heart of the current malaise in social work because they raise fundamental questions about value and the benefits of reforms. Many social workers joined the profession not to assess but to assist.

Secondly, new social policy reforms are like branded products in that they embody elements of fantasy and simulation. Framework for the Assessment of Children in Need and their Families presents social work agencies with yet another simulated model which prescribes structures of action in an idealised world and not in the grim complicated reality of the real world. In "assessment world" social workers and other professionals are told how to plan for an assessment - 11 steps (3.38); carry out the assessment - eight steps (3.39); how to communicate with children - five steps (3.42). Embedded in the implementation of these "steps" is social work the likes of which could only ever exist as a fantasy. For example, in the section entitled "Communicating with Children," workers are advised that "the child's responses and interactions in different situations should be carefully observed wherever possible, alone, with siblings, with parent/s, caregivers, or in school". Much more could be said about the taken-for-granted theoretical and methodological assumptions concerning child development and attachment which underpin this reform. Suffice it to say that the transformation of social workers and other professionals into child psychologists with the requisite skills to observe and report upon age-appropriate activity, to recognise developmental milestones and to assess levels of attachment in situations where caregivers may be reluctant participants, only reinforces a view of reform as fantasy. (A worrying development, especially when considered in the light of child protection reforms which assume that workers can routinely detect crime and punish them when they fail to do so).

In returning once more to the overflowing filing cabinets and baskets, closer inspection reveals that the backlog in the "children in need" drawers is considered to be non-urgent in comparison to activity on child protection referrals. Herein lies the hornet's nest. Referral categorisation in many agencies remains highly problematic, resulting in many referrals still being unnecessarily dealt with as child protection². When uncertain, social workers are likely to "play safe" and choose the child protection track to avoid carrying out "inquiries" without the need for parental consent. It also leads to less paperwork as following investigation most referrals quickly become NFA (no further action). The prospect of producing a 23-page "core assessment" with a reluctant customer is daunting.

The government could have leapfrogged the assessment quagmire and focussed squarely on badly-needed intervention strategies for the highly problematic situations which have already been identified by social workers and evaluation researchers. Instead, in the coming months, if not years (as was the case in child protection), valuable time, attention and scarce resources in local authorities will be targeted on the bedding down of this new addition to the current stable of standardising reform measures, involving staff carrying out yet more prescriptive, repetitive and time-consuming procedures with little benefit accruing to either practice knowledge or to service users.

Where is the evidence that better assessment leads to better outcomes? The main beneficiaries will be the myriad of consultants and training agencies claiming expertise in assessment techniques, attachment and child development theories.

Overall, in contemporary child care social work, child protection and the spectre of a part 8 child death review³ still recklessly override new initiatives for change. The model of implementation of the Framework for the Assessment of Children in Need and their Families mirrors the programme of child protection in its misguided belief that prescriptive processes and procedures produce change, despite overwhelming evidence to the contrary.

It is driving forward with eyes firmly fixed in the rear view mirror.

Dr Suzanne Regan is an organisational research and development analyst at St Martin's College, Lancaster.

References

¹ DoH, Framework for the Assessment of Children in Need and their Families, Stationery Office, 2000. See www.doh.gov.uk/pdfs/frass.pdf  

² Thorpe, D, Evaluating Child Protection, Open University Press, 1994

³ Working Together to Safeguard Children, DoH, 1999

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Vital statistics

Understanding the trends in the supply of long-term care for older people is being made easier thanks to a study involving 1,200 residential and nursing homes in the North West. Kevin Miller and Pat Ball report on the results of their latest survey.

The North West Elderly Care Project has, for the past seven years, tracked changes in the residential and nursing home market in the North West. Local homes in 21 social services authorities now submit figures on placement activity, and registration units in health and local authorities supply detailed material about changes in local market capacity.

The project is believed to be the largest longitudinal study of its kind. In the latest full year reported, 1999-2000, information was supplied by 1,200 homes providing more than 35,000 places.

There is much national interest in both supply-side trends and the statutory agencies' patterns of commissioning. Both feature prominently among the government's interests in managing peak pressures in health and social care systems. The project's annual report is essential reading for those needing to understand trends and local variations in major conurbations and large rural areas.¹

One of the areas the project clearly highlights is a decline in capacity. Total capacity has fallen by 10 per cent - almost 7,000 places - since 1993. The fall has been fairly steady, probably a reaction to the oversupply created in the loosely regulated market pre-1993. In some places, however, shortages in capacity are occurring. Where the advent of local authority assessment regimes initially delivered the intended brake on expanding supplier capacity, local commissioning strategies now need to focus on how to keep valued care providers in the marketplace.

Capacity in the directly managed public sector has fallen most - 38 per cent, since 1993. In contrast, independent sector residential care capacity has grown by 3 per cent. These conflicting trends are linked with externalisation and closure of local authority homes, resulting in business opportunity being transferred to the independent sector and helping to secure its greater stability.

Nursing home capacity has been transformed since 1993. Designated nursing places have fallen by 15 per cent, reflecting falling occupancy levels since 1993. However, there has been a six-fold rise in places in dual-registered homes in the same period. There are now more places in dual-registered homes than in nursing-only homes, providing strong evidence of a response by nursing homes, to widen their business opportunities.

While capacity has fallen, the number of homes closing has risen. Since 1993 home closures have exceeded new homes opening by a factor of 9:2. Overall, the total number of homes has fallen by 18 per cent, with independent sector residential care homes accounting for more than half of that.

Given the overall stability in independent residential care capacity, this may seem strange. However, it is the smaller homes that have suffered most and the increase in residential places has more than compensated for the decrease in places in single-registered homes. Of all registered homes with 15 or fewer places, 40 per cent have disappeared in seven years, and almost a quarter of those providing 16-25 places have gone. In contrast, homes providing 50 or more places have increased by a quarter. Such closures have clearly reflected business pressures, and the trend seems set to continue.

The figures on occupancy rates also reveal discrepant patterns. The regional average for independent residential care provision has been remarkably consistent, at 86-89 per cent, since 1993, with small rises in the past three years. However, council-run homes have had lower levels of occupancy with an overall average of 78 per cent at March 2000.

Nursing care places showed a steadily reducing occupancy, falling from 90 per cent to 79 per cent from 1993-7. However, this has reversed a little, climbing to 83 per cent at March 2000, influenced by reductions in the overall capacity of the sector.

For most of the past decade it was the nursing sector whose business viability seemed most at risk. Even now, many nursing care providers must be working at the margins of profitability. By contrast, independent residential care capacity appears robust.

Many councils appear, in response, to have refocused significant elements of their remaining in-house provision. Provision of local short-term care for older people is disproportionately concentrated in this sector. Of all short-stay placements, 42 per cent are provided in local authority homes. While this concentration suggests direct commissioning strategies by councils, it is not clear how much opportunity independent sector providers have been offered to develop specialist short-stay facilities through, for example, cost-volume contracts. This has particular implications for the development of a range of intermediate care facilities, which the government has made clear should be provided by a variety of suppliers.

One impact of the rundown of the local authority estate has been a significant swing in admissions patterns, including a 37 per cent fall in permanent admissions to such homes. In contrast, there has been a 37 per cent rise in admissions to independent sector residential care. Nursing care, though, has seen admissions fall by 12 per cent, reinforcing business pressures in that sector.

Continuing market realignment, user choice and growing dependence have also resulted in a persistent, and surprisingly high, proportion of elderly residents moving from one home to another. These account for 17-20 per cent of all permanent admissions, and more for nursing care. The proportion has barely changed over the years, confounding original expectations.

In a region of much poverty, especially among older people, public funding of placements is still the norm. At March 2000, 78 per cent of nursing care residents and 72 per cent of those in independent residential care were publicly funded. These represent falls of 6 per cent and 4 per cent respectively from the position in 1993, when altered assessment and funding regimes began.

However, the legacy of undifferentiated assessment regimes and wholesale reliance on Department for Work and Pensions funding support endures. Against many expectations about one in eight long-stay residents at March 2000 were still supported by DWP via the transitional funding regime put in place in 1993. This suggests a longevity among residents that many did not anticipate. It is clear some providers remain dependent on such residents for an appreciable part of their income.

NHS funding support for residents, invariably in nursing settings, remains modest - at about 5 per cent of the total - although it has grown slightly in recent years.

In some localities, however, there is little or no such funding support. Given this, it seems clear that the introduction of "free" nursing care from this month will involve a sea change in the scale of funding support available from health commissioners, to an extent possibly greater than originally envisaged by policymakers.

Public sector commitment to placement support has fallen, reflecting changes in overall market size and structure. The survey suggests a fall of 26 per cent in the number of publicly funded residents in nursing care from 1993-2000, and a 5 per cent fall in those supported in independent sector residential care provision. The survey does not collect data on fees paid by public agencies.

The project has done valuable service in charting key trends affecting the long-term care of older people. It seems clear that a combination of greater management control of public investment in this field, mainly by councils, and development of policies to promote independence have influenced market size and structure. The research provides evidence of greater stability in both commissioning and supplier activity. It does not support tales of imploding supplier capacity, but it is clear that some sectors are at the margins of business viability. More varied commissioning practice may be needed.

Further details on the North West Elderly Care Project from project consultants, Pat Ball and Janet Miller, on 0151 929 2815.

Kevin Miller is director of social services for Wirral and chairperson of the North West Business Management Working Group. Pat Ball is an independent consultant, North West Elderly Care Project.

References

¹ K Miller, P Ball, North West Elderly Care Project Regional Analysis, North West Business Management Working Group, 1993-2000