Social workers ‘face tension between promoting choice and independence’

Achieving service users' preferred outcomes may not be best measure of success because of low aspirations, says social care finance expert

Social worker and service user
Photo: John Birdsall/Rex Shutterstock

Social workers face a tension between supporting people’s choices and helping them to regain independence, a social care finance expert has warned.

John Bolton said that service users sometimes had limited aspirations for themselves because of the limits that services had put on them in the past, meaning their preferred outcomes did not necessarily involve regaining independence.

“There is a question in all of this whether the user is in the best possible position to define their outcomes, their aspirations and whether we should all go along with that as the measure of what happens,” he said. “The critique of that is that many users may lack confidence or aspirations for themselves and may therefore downplay or dampen down opportunities that may be there for them.”

Bolton, a consultant who specialises in helping councils improve the efficiency of their social care operations, is a former the Department of Health’s social care finance chief, a director of social services and a social worker. He made the remarks at Community Care Live Birmingham in delivering a session on outcomes-based commissioning in adult social care.

Good practice

Bolton said he had recently been impressed to see a social worker in Derby working with a group of people with learning disabilities with a history

of receiving institutional care, to raise their aspirations.

He said she was “helping people redefine their aspirations and was getting amazing results”, adding: “If you had asked those people they would probably have said that they were happy and content. There’s a tension in policy and practice about how we listen to our customers and then help them aspire to what they haven’t had before.”

This tension is embodied in the Care Act 2014, which requires local authorities to take account of people’s preferred outcomes during assessment, care planning and review, but also to arrange services to prevent, delay or reduce people’s needs, and provide people with information and advice on doing so at various stages in the customer journey.

Outcomes-based commissioning

Bolton said that, currently, most local authorities did not commission for outcomes but procured services at the lowest cost. He said that there was a strong case for councils to move towards outcomes-based commissioning as other options for saving money, such as simply cutting the prices paid to providers or reducing social workers, were no longer feasible.

“We can’t take anymore price out of the market; we can’t cut any more social workers,” he said. “We have to look at what outcomes we are delivering and whether we can deliver better outcomes at lower cost. That’s what I believe.”

Bolton set out four different ways councils were developing outcomes-based commissioning in adult social care:

  • Building outcomes-based performance indicators into a contract with a provider but not offering a financial incentive for meeting them, as Coventry council has done with its domiciliary care service.
  • Agreeing a set of outcomes with the service user following assessment and then calculating a fee for the provider based on the estimated cost of delivering them, to incentivise the provider to do so as cost-effectively as possible. This is the approach taken by Wiltshire for its home care service.
  • Giving providers multi-year contracts whose annual value reduces over time, incentivising them to support service users to become more independent. This is being applied by Nottinghamshire council in relation to community support for people with learning disabilities.
  • Commissioning a lead provider to be accountable for delivering outcomes for a particular population, sub-contracting work to other providers as necessary. This approach, which Bolton said was being developed in Torbay, transfers accountability and risk to the provider, incentivising them to promote independence within the population in order to reduce cost.
  • Key role for social workers

  • Bolton said there would be a key role for social workers, under the lead provider model, in advocating for service users and ensuring they were not being exploited by the provider.
  • “If the customer felt they were being exploited by the provider, the social workers are the people who hold the rein and say to the provider ‘what you have done with this person hasn’t promoted their independence’ and we need to do this and that because that is what the law requires.” Social workers have a key role with a lead provider in advocating for the client.”

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3 Responses to Social workers ‘face tension between promoting choice and independence’

  1. Anonymous May 13, 2016 at 12:39 am #

    I keep talking about the social worker maybe asking the clients about their own best interests. Unfortunately for me, and probably others, unless you’re willing to talk about career, diet, or money, you don’t stand a chance. We’d all like to think that social workers are at our beck and call, but honestly, mine lacks empathy. And that doesn’t help me move forward. You’re lucky if you have one who actually listens. I’m just about ready to cut off all contact with her. Life has never been harder.

  2. Ellie May 17, 2016 at 2:30 pm #

    Reading through this article made me think. There ARE reasons why Social Workers struggle to balance service-users’ needs – especially things like independence, and choice. These are NOT all reasons that Social Workers, themselves, should be blamed for. Indeed, many are a direct result of unnecessary bureaucracy creeping into the job. Others are the direct results of Social Workers having been forced to work amidst conflicting pieces of legislation, which make it hard to know how to act – again, the legacy of Bureaucrats who interfere with the job, whilst having no personal qualifications in Social Work, or no real experience of working in the field. I shall outline my thoughts, as follows:

    1. Social Work is one of the hardest hit professions when it comes to so-called “necessary” cuts due to “austerity”. It baffles me as to why the Public Sector professions (Including many necessary professions like teaching, medicine, nursing, policing, youth work, occupational therapy, psychology, psychiatry, physiotherapy…) are being made to face cuts as a result of a recession which THEY DID NOTHING TO CAUSE. It baffles me that bankers and estate agents – who DID have a huge amount to do with the cause of the recession – are still taking huge wages and huge bonuses. Nobody appears to have tackled the actual root of the financial crisis that allegedly hit this country. Which leads to…

    2. Because Social Work has faced so many budgetary cuts (pushed through Local Authorities, who may already be financially struggling, and who do not seem to get much choice over further cuts) the profession will naturally find it hard to perform to expectations. Staff are supposed to provide care for just as many service-users as ever, but with less money to finance care packages. The alternative is to cut services for people whose needs are classed as lesser. Or, another alternative is to cut staff. Either way, service-users end up suffering because there are, quite simply, not enough staff to provide care, and there is not enough care to go around. Lack of funding means also that staff facilities become poorer – cramped offices, outdated technology, “hot-desking”… Added to this, a lack of available funding may affect the availability of post-qualifying training for staff who are supposed to update their training regularly. Because Local Authorities are usually the ones to foot the bill for any post-qualifying training that Social Workers undertake, if money is scarce, the availability of training may become equally scarce. This has the knock-on effect of making it even harder for staff to maintain their registration, which is dependent upon them updating their training regularly.

    3. Poor staff morale, lack of training, lack of available services and care packages all add up to problems, which affect service-users too. The less services there are, the less Social Workers are able to offer choices to service-users. Also, where budgets are tight, more costly care packages may be sidelined in favour of cheaper options. This is not necessarily what Social Workers want to do, but they may be directed to do this by management (who are again directed to do it from Bureaucrats above). High staff turnover means that service-users have little consistency when it comes to who works with them. They may have multiple changes of agency Social Worker, few of whom stay long enough to truly get to know the service-user and their individual case. This, too, impacts upon the sort of care that service-users receive. It means that things become disjointed and there may be little continuity of care. It also means that service-users may never feel comfortable with their allocated Social Worker (because they change so often) and thus service-users find it very hard to open up to the Social Worker. This has the effect of stifling any dialogue that might occur concerning choice or independence.

    4. Conflicting legislation is a NIGHTMARE. It makes the job hard to do, makes decisions more confusing, and this delays the providing of appropriate care. It also adds to Social Workers’ fear of litigation, because there is the sense that you can never get things right. This is best illustrated by an example…
    Imagine that you work in a Hospital Discharge team. You receive a referral on behalf of an old lady who is in hospital recovering from dehydration, a fractured hip and a chest infection. She was admitted following a fall, and staff in the Hospital report a history of self-neglect, which is confirmed by interviews with the old lady’s relatives. The old lady is desperate to go home, but is also very confused and agitated whilst on the ward. She is hard to understand, and gets aggressive and frustrated if people use long sentences to talk to her. She is very forgetful, and often wanders off the ward (much to the concern of Nursing staff). The old lady’s relatives feel that she requires home care, but the old lady refuses to let carers in her house (last time she had a carer, she was abusive to the woman, and locked her out). The relatives feel the old lady may require residential care. You assess the old lady with a view to discharge planning, and find that her responses to questions about how she will care for herself once home don’t make sense. She says her neighbour will cook for her, but when you check with relatives, they tell you this neighbour dies two years ago, and that the old lady does not know her new neighbour. The old lady also seems to have forgotten that her bathroom is upstairs at home! Concerned, you undertake assessment of mental capacity (relying on the Mental Capacity Act). Now, the Act states you should always assume service-users HAVE capacity; however, it also states that capacity can be VARIABLE. So, the Act contradicts itself!. If capacity can be variable, then surely there are times when a person does NOT have capacity? So, does this old lady have capacity? The assessment suggests not. Thus, you feel it may now be worthwhile seeking further advice from your manager. However, on doing so, you are told that the case needs “moving on” as quickly as possible, as it now registers as a “delayed discharge”. You concern is that if you send the lady home, she may self-neglect again, and that the case could class as an “unsafe discharge” unless you seek the correct information, and undertake the required assessments to ensure the lady is safe, and receives appropriate care. You might like to liaise with Dementia services, as you feel that the lady does meet criteria for referral – especially as you note that in her file, she has “suspected early-stage Alzheimers”. However, to liaise with the right people takes time, and this case is already a “delayed discharge”. You are concerned to send the lady home; but do not feel it is necessarily right to impose residential care, as this might involve Deprivation of Liberty. However, you know that the lady would refuse home care, but would be unsafe if sent home without it. The legislation you work with is NO help at all. Your duty of care is to the old lady, and requires that you “do no harm”. DOLS legislation reminds you of the need not to deprive people of liberty. Delayed Discharge protocols mean the longer this lady remains in Hospital, the more your Social Services team may be at risk of a fine. Mental Capacity legislation was followed when you assessed the lady, but you are uncertain as to how to proceed because you suspect dementia, yet are not being afforded time to liaise with dementia specialists… You see where I am going with all of this? Oh, and yes! I have based this roughly on a REAL case that I had (naming no names, and identifying nobody). I ask? Does ANYONE think that Social Work is an easy job in such cases?!

    5. In some instances, SERVICE-USERS themselves, when given choices, pick the one that LEAST promotes independence. They may feel safer doing this. They may underestimate their ability. They may be depressed, or simply have “given up”. Some service-users may even be somewhat passively “suicidal”; by which I mean that they are so fed up of having to rely upon care packages, and so sick of being stigmatized by having to have care, that they no longer bother to make choices and decisions that are helpful to themselves. Indeed, they may even self-sabotage; or they can be extremely defeatist. Some service-users really ARE people who prefer the idea of being in residential care, as opposed to being at home. This is because they no longer feel capable of looking after themselves. When working with a service-user like this, of course it is hard for a Social Worker not to face tension between promoting choice and independence. When given the choice, the service-user picks the care package that promotes least independence. So, what does the Social Worker do? Override the stated wish of the service-user, in the hope of promoting independence? Or, go along with what the service-user says they want, but which will decrease independence? Erm! It’s a “catch 22” isn’t it?!

    6. Increasing fear of litigation (combined with the above issue of conflicting legislation) creates an environment in which promotion of choice and independence becomes riskier. Staff face disciplinary action, sanctions, loss of registration, or dismissal if the place service-users knowingly at risk, or act in ways that may lead to questions about practice. However, the way in which a person practices is very much open to differences of perception. Whilst a Social Worker might be striving to promote a service-user’s independence, the service-user’s nearest and dearest might see differently. They might think the Social Worker is placing the person at risk, and make a complaint. For example…
    Imagine a service-user is partially sighted and has mild to moderate learning-disabilities. The service-user wants to go swimming on his own, yet he is so far only permitted by his family to go swimming when accompanied by either his parents (with whom he still lives), or his sister (who is away at University). The Social Worker suggests that the service-user could go swimming accompanied by a support worker, so that he does not always have to rely on his parents to go. After much to-ing and fro-ing, the parents reluctantly agree. Everything seems in order, until one day, the service-user slips whilst running from the changing rooms to the pool, and fractures his wrist. Whilst the service-user is not bothered, and does NOT blame his support worker, his parents are furious. They ignore the fact that the service-user openly admits he was wrong for running, and should have waited for his support worker. Instead, they file a complaint against the support worker for being negligent, and a complaint against the Social Worker for producing a care agreement that put their son at risk. Can you imagine what kind of a mess this could lead to? But, in our increasingly litigative society, this is the sort of thing that happens.

    It’s not hard to see why Social Workers face such a struggle. There are so many things that combine to make the job unnecessarily hard. I’d be interested to see what others have to say.

  3. Dee June 8, 2016 at 11:46 am #

    While I agree with the analysis of the social worker’s central dilemma John Bolton takes a very marketised view with a range of disturbing assumptions about providers of social care. The idea that ‘incentivisation’ is needed to make providers more cost effective completely fails to recognise that hourly rates are already at rock bottom across the UK- driven down by a decade of price- based procurement.

    Bolton’s central assumption is to site the problem with social care providers. The usual points are made about needing to be more accountable; more cost effective etc. He thinks the way to do this is by crude ‘incentivisation’ with social workers taking on yet another soft policing function to protect service users from ‘exploitative’ providers.

    Here in Scotland voluntary sector providers of care and support routinely score higher on quality measures than both in-house and private sector. This is despite the fact that in- house provision is priced at up to 150% more per hour than externally sourced support. If there are ‘cost efficiencies’ to be made authorities should perhaps consider their own processes and services instead of placing all their focus on external provision.

    The answer is not ‘here’s an extra pound if you get Mrs Smith making her own tea by next Tuesday’. The answer is commission for outcomes; collaborate on service redesign and pay a reasonable hourly rate for care and support. Oh and. ditch the financial incentives. Learning from other sectors shows that financial incentivisation leads to system gaming and unintended outcomes and we don’t need more of that in social care!