by Dr Chris Mimnagh
My first encounter with a social worker as a qualified GP was at a case conference. I attended despite my GP partner’s protestations, because I was invited to. When I arrived, however, everybody was surprised to see me – and didn’t really seem to know what to do with me.
Of course, I didn’t only go along because they’d been kind enough to ask. I went because, though I was new to the practice, I’d dealt with the family concerned over the previous two years in hospital posts from gynaecology to medicine, from paediatrics to A&E.
I said as much when asked to introduce myself. The response from the senior social worker coloured my view of social services for the next decade.
“It’s not about who’s the best friend of the patient – it’s about making the best decision,” the social worker said. While that is correct, I hadn’t, in my introduction, implied friendship, only that as a clinician I had a few years’ experience with the family covering the breadth of their health needs.
Back at the practice my senior partner laughed, certain now that I understood why it was foolish to attend a case conference: “They put them on at short notice, right in the middle of surgery – we’re not meant to go.”
Making relationships a priority
Fast forward 10 years. As a primary care trust director in Knowsley I found myself joining a team drawn from both the council and the NHS. I sat alongside colleagues whose careers started at the coalface of social work, whose hearts still pounded the beat of universal and targeted services and whose passion for people was boundless. My chief executive Anita Marsland always remained a social worker at heart.
For me this period was a steep learning curve. Everything I knew about social services was tested – and in most cases discarded. The insight into the pressures of the job, the constraints on powers, the failure of health and social care to get on the same side of the client or patient was the reason why Knowsley integrated the health and social care pound. In effect, working alongside the DASS in an integrated team for six years I became the medical director of social services.
What did my time in post teach me? First, that our interfaces are often too small to be meaningful. I always recall the scene in the film Babe when the little pig is told by the dogs that sheep are stupid, and by the sheep that dogs are stupid. This view is confirmed when every interaction takes place in slow, small words because sheep or dogs are clearly stupid.
It can be much the same for GP/social worker interaction. Small conversations, brief messages, all likely to arrive at inopportune moments. “I’m concerned about this child, can you assess?” is a comment that can travel in either direction.
Perhaps we should consider the need to develop relationships as an ongoing priority. Waiting until things are needed right this second is never going to generate trust or an understanding of mutual professionalism.
Second, both services are stretched; on the edge of collapse. In such circumstances the tendency will always be to reduce work to the priorities, but if these priorities are not shared more work ensues. So we need to at least gain some insight into each other’s worlds.
Right now 90% of the work of the NHS is carried out in general practice, which is barely coping with 7% of the budget. Many practices are surviving on goodwill, mistaken dedication and fatalism. Recruitment is next to impossible, with promises of an “extra 500 GPs” being too little, too late and more than offset by the exodus created by pensions, taxation and contract changes. Set against the swingeing cuts to social services the NHS has been relatively protected, but the GP/ social care interface is an interface of the disaffected and disempowered.
Finding common ground
I’ve got a couple of simple suggestions towards making things better. Start by looking to create common ground. Not via lanyard-wearing round-table discussions, but with relationships created, curiosity shown and understanding gained. Approach local GP training practices and ask them, do they want a tutorial for their registrars on social work? I bet you nobody says no. Build on that start with shared information and support.
Social prescribing is something that’s being hailed as the new messiah of self-care. Despite the naff name, which perpetuates the medical model (I prefer to think of it as social resource empowerment), here GPs are not best-placed to lead. Most councils have better networks across more diverse voluntary and third-sector groups than most GPs.
I use the hated phrase ‘best-placed’ because all too often it comes from the mouth of a pressure group seeking to load more work onto a creaking primary care system in the belief that their particular grinding axe is not getting its fair share of primary care. That said, I don’t think social services are truly best-placed either, but my strong suspicion is that a triumvirate of health, social and third-sector is the way to empower self and social care in order try to cope with the tsunami or an ageing population and static or falling budgets.
Finally, it doesn’t take a genius to realise that the NHS and social care are on the edge of a revolution. The law won’t change, but the era of the commissioning dinosaur is at an end, CCGs will merge, and our delivery will come through accountable care systems.
The single biggest way the relationship between GPs and social workers can improve is to recognise what we share in common: we are already accountable for our actions, we can be accountable for our population’s care and we will be holding each other to account.
I’m actually quite looking forward to the future now.
Chris Mimnagh is a Liverpool-based GP.