Mix and match

Partnerships between primary care and social services are not
new. But as Caroline Glendinning and Karen Clarke explain, the
WellFamily Service – combining advice and support services for
families within primary care – may be one of the best.

There is a long history of local experiments where social
workers or care managers have been attached to GP practices.
However, these have usually been aimed at improving the
co-ordination and continuity of health and social services for
older people, particularly those who are at risk of admission to
hospital or residential care. There have been very few initiatives
targeted at families with children – or, indeed, which offer a
generic service, regardless of age or family circumstances. So what
is different about the WellFamily service?

The WellFamily service, run by the Family Welfare Association,
bases family support co-ordinators (FSCs) in GP practices or other
primary care settings such as health centres or community
hospitals. The FSCs offer help with a very wide range of problems.
In particular, they tackle the complex and all-too-common mixture
of material and psychological problems that do not fall neatly into
the remit of medical or social services.

An evaluation of the service from the University of Manchester
showed major benefits, both for the people who use it and for the
GPs, health visitors and other nursing staff in the primary health
care teams where it based.¹

The FSCs aim to provide support, empower users to gain
confidence and tackle their difficulties. They often work with the
whole family, not just the individual who is referred to the
service. The FSCs work closely with the primary health care team to
establish referral criteria and ways of sharing relevant
information about current cases and their solutions.

The FWA established the first WellFamily service in a Hackney GP
practice in 1996. In 1998, a grant from the National Lottery
Charities Board enabled the FWA to extend the service to Croydon,
Newham borough in London, Luton and rural Norfolk. In each location
an FSC was attached to one or more GP practices and worked closely
with members of the primary health care team.

The FSCs came from a variety of backgrounds – social work,
nursery nursing, play therapy, counselling and health visiting. All
had previous experience of working in health settings. Interviews
were carried out with service users, the FSCs, GPs, health
visitors, other practice staff and health and local authority
managers throughout the 30 months covered by the evaluation.

Nearly 1,300 referrals were made to the five FSCs over the
thirty-month period. Two thirds of referrals came from the primary
health care team – health visitors in particular appreciated being
able to make referrals directly rather than having to go through
the GP. A quarter of users approached the service directly,
sometimes on the GP’s advice but often on their own initiative – an
indication of how accessible the service was. More than half of all
referrals were seen within a week – indeed, a third saw the FSC the
same day.

Typically, service users were women of working age. Users were
more likely than the national average to be lone parents, or living
in a household containing someone with a long-term illness or
disability. Users’ ethnic origins reflected the populations in each
area.

Users presented the FSCs with a variety of psychological,
emotional, intra-family, material and medical problems – the
average number of problems recorded by the FSCs after the initial
interview was 2.9.

The FSCs’ responses to these problems were equally varied and
included counselling, liaison with local statutory and other
agencies, information and advice-giving and advocacy. In a third of
cases the FSC also worked with other family members as well as the
person who was initially referred to the service.

Much of the help given was short-term; 20 per cent of cases were
dealt with in a single session and two-thirds were concluded in
less than five sessions.

Users appreciated being able to see the FSC quickly, in contrast
to long waits for specialist counselling and mental health
services. Being able to make appointments through the GP practice,
at the same time as other surgery appointments, was highly
valued.

Moreover, a service based in primary care was not felt to carry
the same kind of stigma as statutory social services or specialist
mental health services – a particular benefit for people
experiencing family or parenting problems, who feared becoming
involved in child protection procedures.

The generic nature of the service was also valued, so that users
could avoid having to approach different agencies about different
problems, with all the consequent problems of co-ordination.

A service that could provide emotional support, counselling and
advice as well as practical help with housing, welfare rights,
immigration and other material problems was particularly
appreciated, in contrast to GPs who could only offer
anti-depressants or the non-interventionist approach of
counsellors.

FSCs could also offer longer to listen and discuss problems than
GPs, who were restricted to five or seven-minute appointments. The
quality of the relationship between users and the FSC was also
valued.

Consequently, people using the WellFamily service felt they had
been able to prevent their problems escalating; were more in
control of their lives and able to tackle difficulties with other
family members; were able to reduce contact with their GP; and had
an alternative to dependence on anti-depressants. As well as
feeling better themselves, the holistic approach of the FSC often
also led to improved relationships within the wider family. Even
where only one family member was seen, users noted the knock-on
effect on the family as a whole.

The fact that the FSCs were employed by a national voluntary
organisation did not seem to impair the leverage they could exert
on other services to, say, speed up rehousing or secure an
assessment of a child’s needs.

Across the five sites, GPs appreciated being able to offer
prompt support and help to patients with complex, psycho-social
problems which were beyond their own expertise (and which often
fell outside the remit of other agencies as well). The service
filled a particularly significant gap between the work of GPs,
health visitors, counsellors and social workers. GPs and other
practice staff were aware of their own lack of expertise in areas
like welfare rights or immigration law and appreciated having easy
access to someone whose expertise complemented their own.

As a result, GPs, practice nurses and other community health
staff all thought their own expertise, skills and training were
being used more appropriately and effectively. Local social
services staff similarly valued the early intervention approach of
the FSCs, which helped to prevent family problems becoming so
serious as to eventually become a statutory responsibility.

Moreover, because the FSCs were employed by an independent,
voluntary organisation, they were considered less likely to become
absorbed into the culture of either general practice or statutory
social services.

These conclusions come at a time when collaboration between
health and social services is under the spotlight. For example,
last year’s NHS Plan for England called for social services to be
relocated in primary care settings, “as part of a single local care
network”, to improve collaboration and make services more
accessible for users.

However, the WellFamily experience has much wider relevance. It
is acknowledged that many of the problems presented to NHS primary
and community services originate in wider social, economic and
environmental factors – poverty, occupational stress, poor housing,
pollution, lack of transport, isolation, crime and community
safety.

Health and local authority organisations must tackle these
causes together, through their health improvement plans. Preventing
ill-health is also emphasised in the national service framework for
mental health; the first standard of the NSF is to promote good
mental health and prevent more serious problems developing.

This is a particular challenge for the NHS, where staff are
likely to have much more experience of treating mental health
problems than preventing them developing in the first place. Many
primary care groups and trusts will be looking to local and
national voluntary organisations to help them respond effectively
to this unfamiliar new agenda. Indeed, partnerships between
statutory and voluntary organisations are themselves actively
encouraged, and supported through a formal compact between
government and the voluntary sector.

Although the FSCs were employed by the FWA, each local
WellFamily service had its own steering group and this helped with
the search for continuation funding, once the lottery funded pilot
project ended.

In some areas, the WellFamily service has become integrated into
local plans for a healthy living centre. In Croydon, the primary
care group has recognised the relevance of the service to the
mental health NSF and extended the service throughout the primary
care group area, funding a total of five FSCs and a local project
manager. As the WellFamily service is gradually extended, the
challenge for the future must be to safeguard its accessibility,
flexibility and holistic approach, regardless of the source of
funding.

¹ K Clarke et al, The Family Welfare
Association’s WellFamily Service; Evaluation Report, FWA,
2001. Both the report and a companion Practice Guide to setting up
a WellFamily Service are available from FWA, 501-505 Kingsland Rd,
London E8 4AU, £5 each.

Caroline Glendinning is professor of social policy at
the national primary care research and development centre,
University of Manchester. Karen Clarke is lecturer in the
department of applied social science, University of
Manchester.