Manual The critical practitioner in social work and health care

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It did not suggest that enhanced professional status would result.

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However, it only covered training for social workers in health and welfare departments, and the Central Training Council in Child Care continued with its work. In the mids the government rejected a proposal to develop a three-year qualification for social work Payne, The election of a Labour government in saw the introduction of a number of measures which together appear to have raised the profile of the social work profession, within the broader context of social care. The Council has seventeen members and is required by law to have a majority of lay members and a lay chairperson.

The Critical Practitioner in Social Work and Health Care

Both these facets of lay involvement are worthy of note, given our questioning of the control exerted over the profession by those outside of it. In the GSCC published the first code of practice for social care workers and code of practice for employers. In April the first social workers began to be included in the register of qualified social workers.

Together these developments established the profession alongside others that had had similar provisions for some considerable time. They also offer developments that clearly impact at the most fundamental level on issues of profession and regulation. However, as we can see, the title is contingent upon registration. It must be acknowledged that the process of registration is controlled by the Councils, which are government-sponsored bodies, as opposed to the profession itself.

The GSCC, although formed in part from the ashes of the CCETSW, is noticeably more distant from the professional worker than its predecessor, which is illustrated, for example, by its own minimalist approach to the development of the curriculum for the social work degree. The GSCC has a much broader remit, for example in respect of social care, and a clearer, more formal regulatory function.

One cannot equate the profession with the regulatory body. Here they are two distinct entities and it would certainly not be true to say that the GSCC fully reflects the interests of the social work profession which it regulates. Registration In order to be registered, social workers must meet the criteria laid out in Section 58 of the Care Standards Act , demonstrating they are of good character, physically and mentally fit for the professional role, have completed an approved course and agree to abide by the Code of Practice.

Reasonable adjustments and a caring response rather than a bureaucratic, medically framed reaction would be more fitting with the values of the social work profession. McLaughlin, b: 6 The social care register is itself a public document and can be accessed at www. The register records the geographical area within which a registered social worker practises. Re-registration is a further requirement of registration and must take place every three years. Social workers must undertake a minimum of ninety hours or fifteen days post-registration training and learning in order to re-register.

This is an interesting development and follows a similar pattern to some health professions. How much stronger would it have been to require the achievement of a post-qualifying award within that time frame — or even within the first six years of practice? The emphasis, it appears, is on the control dimension of regulating the professional workforce rather than promoting its continuing professional development. There is also a Code of Practice for Employers which governs the agencies in which they work.

The GSCC requires that social workers must: 1. Protect the rights and promote the interests of service-users and carers; 2. Strive to establish and maintain the trust and confidence of service-users and carers; 3. Promote the independence of service-users while protecting them as far as possible from danger or harm; 4. Respect the rights of service-users whilst seeking to ensure that their behaviour does not harm themselves or other people; 5. Uphold public trust and confidence in social care services; and 6.

Be accountable for the quality of their work and take responsibility for maintaining and improving their knowledge and skills. However, one can see that regulation and standard-setting is also an integrated part of this agenda. Some authors query whether how social workers conduct themselves in their private lives is any business of the GSCC, how well it is equipped to take on the role of moral arbiter and with what agendas it approaches that task McLaughlin, b.

Interestingly, McLaughlin points out that there was surprisingly little criticism of the codes following their publication — or indeed since. Given that being struck off the register prevents social workers from future employment in that sector, one might have expected a more forceful response, yet in one survey most social workers believed registration would raise the profile and standards of the profession McLaughlin, b.

The Code of Practice for employees also includes a requirement that social care workers are responsible for maintaining and improving their knowledge and skills. This should include undertaking relevant training towards that personal development as well as their contribution to the learning and development of others Requirement 6. There is a matching requirement in the Code for Employers Requirement 3 , which states that employers must provide training and development opportunities to enable social care workers to strengthen and develop their skills and knowledge.

The vision embodied in the Green Papers for both the child care and adult social care workforce DoH, ; DoH, includes the idea that all staff should have Fraser-Ch Employers are expected to deploy a significant percentage of their staff-training budget on workforce development and individual employees are expected to contribute to the cost of their own development. Social work degree The introduction of the three-year undergraduate degree as the basic requirement for social workers to become qualified and eligible to practise is a significant policy change and results from a long campaign to establish a degree qualification for social work.

The social work degree was introduced in autumn and produced its first graduates in Its key characteristics include the removal of age restrictions for qualifications, the introduction of compulsory CRB and health checks for applicants, and literacy and numeracy standards required for entry. In terms of learning there were also requirements around preparation for placement, evidence-based practice, inter-professional learning and a greater amount of time spent in practice. The number of days on placement for qualifying students increased from to days on the degree, more days, but proportionately the same.

To meet this demand, practice-learning opportunities are being created in agencies that have traditionally not taken social work students and a variety of new ways of offering practice-learning opportunities are being developed Doel, Students on the degree can expect to undertake practice in more than one setting, working with different service-user groups, and have experience of statutory intervention DoH, The NOS for social work are, in one sense, the single, clearest statement of what it currently means to be a social worker.

As is the case with other competency structures, the National Occupational Standards indicate what workers should be able to do in order to demonstrate that they have met the standards set. They consist of broad statements of key functions or roles within social work as practised across a range of settings. There are six key roles in Fraser-Ch Functional analysis was employed to identify what workers must be able to do in order for the key roles to be performed across a range of settings. The analysis was completed in a series of stages with the levels of performance becoming increasingly more detailed and explicit at each stage.

The key roles are thus split down into twenty-one units which are again subdivided into seventy-seven elements of competence. Each element is then expanded into performance criteria. To achieve an element of competence students should be able to demonstrate that they can do everything that is spelt out through the performance criteria.

This can lead to a concentration on the minutiae and a loss of appreciation of the whole because the whole is often greater than the sum of its parts. Dominelli argues that it is a dogmatic and inflexible approach which reduces complex social interactions to snapshots and moves away from relationship-building which, she argues, is the fundamental core of the profession. Indeed, a significant debate has continued in social work education since the early s about whether a competence-based framework should be applied to the complexities of the profession.

Constructions such as the National Occupational Standards for Social Work include a range of skills and knowledge which learners must demonstrate and be able to evaluate critically and apply in practice. Failure to acquire the knowledge which informs competence could lead to robotic performance with little understanding of the reasons why intervention has gone well or badly and poor ability to justify actions and predict outcomes. In short, it could lead to robotic performance and a de-professionalising of the role.

But by the same token, an overemphasis on performance criteria can lead to shallow, unimaginative and essentially unprofessional practice Thompson, Notwithstanding the problems of differentiation in multi-professional settings, social work has experienced difficulty in identifying specifically what its purpose is compared to other professions Wickwar and Wickwar, ; Butrym, ; Barclay Report, ; Clarke, ; Clark, This is pertinent to education and practice. The challenge is clarifying exactly what its area of expertise is.

It could be argued that social work expertise should be negotiated between the professions, recognising that there are areas of overlap. If we pursue this line of thinking, we might need to question whether some of the broader claims about the primary focus of social work could only be achieved as a consequence of the integrated and connected work of a range of professions in the current context.

It might follow that if the areas of expertise which are said to differentiate social work are those which at some point could be adopted or integrated by other professional groups, we would move towards a situation where social work becomes very differently constructed. Alternatively, in respect of Fraser-Ch Does this turn the focus of the profession away from the service-users at the root of vocation and values, or would it allow social work a new foundation on which to build a stronger profession? There are, of course, at least two sides to the coin of differentiation.

One looks at what social work does to differentiate itself from others; the other side can be what social work does to prevent others from colonising its professional territory. One of the enduring observations in social work is that social workers intervene with people at the point at which the individual interacts with their environment Younghusband, ; Hollis, ; Stevenson, An ecological systems perspective is one of the models which are currently used to make a holistic assessment of complex social situations Jack, To maintain a sense of differentiation in this arena, social work might need to identify the particular way in which it adopts its holistic approach, especially in the context of an inter-agency approach.

It may be useful to explore whether there is a contrast in the way that other professions increasingly work with individuals in the context of social and environmental factors, whereas social workers have the expertise to engage directly and in a sustained way with the complex and often conflicting relationships that exist in those networks.

It is also suggested that social work can be distinguished by its values Shardlow, The concept of and belief in social justice is a strong premise within the social work profession and is perhaps one starting point for comparison with other claims for a similar value base. A social justice perspective for social work practice has two strands which relate respectively to the empowering of individuals at the micro level and to the significance of structural disadvantage at the macro level. The first strand emphasises the basis of social morality which, it is suggested, should fundamentally inform social work practice.

The second strand relates to the discourse of structural disadvantage. Jordan takes this a step further, urging an emphasis on the social work role in the resolution of structural problems. Social work, in these ways, becomes a political practice, engaging with those confronted by unjust social relations, including those with social institutions such as the state and the family that are divergent from the norm Butler and Pugh, It can therefore be suggested that social work, in its pursuit of social justice, must not only be concerned with individual empowerment, but with political activity in pursuit of that empowerment which is presented as an ethical endeavour.

It seems surprising, given our comments about social justice and professional values, that so little work has been done to develop a care ethics approach to social work, especially given that care is obviously a central concern in human life Banks, Yet it can be argued that care in its sense of virtue does not require the social worker to connect with the person receiving the care Banks, This is not to suggest that we are necessarily focusing on the relationship between the social worker and service-user.

Social workers have expertise in relationships not only in the traditional sense of between themselves and the service-user, but in respect of the way in which people are cared for, by others and by themselves, they facilitate those relationships. Social workers therefore have to develop expertise in communication skills to enable them to engage with service-users to empower people to maximise their potential. They can be expected to facilitate carers, service-users and significant others to care collaboratively and resolve conflict.

For individuals who experience stress, there may be an impact on their ability to engage in the reciprocal social relationships which facilitate social functioning. Social workers can use their social sciences knowledge and practice experience to facilitate the achievement of individual goals for each service-user.

So here we see a number of themes coming together.

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This, perhaps, is a unique aspect to its professional claim. The complex nature of relationships between and among members of a family, significant others, the broader community and society are all, in this analysis, within the frame of understanding and working with the service-user.

How far does the impact of bureaucracy allow the profession to develop its expertise in this area? If we consider the social worker as gatekeeper to services and as case manager, it could be argued that this has led to a distancing of social work from the individual, becoming less rather than more concerned with social justice and the ethics of care. Nevertheless, the discussion earlier in this chapter suggests that there has been a change in the extent to which social workers have discretion in respect of how they deploy their knowledge, skills and values.

We have particularly considered the regulation social work has recently experienced in relation to social work education, the codes of practice and the requirements of registration. These have been broad, legislative forms of regulation that have impacted in very real ways on the nature of training and the ethical base of the profession. The question remains whether these forms of regulation, with their concerns over quality, consistency and equity, allow the professional sufficient freedom to exert judgement and respond to the increasingly complex scenarios that make up professional practice.

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Can social workers assert, for example, a case for suitability for services, as opposed to eligibility? Flynn suggests that, Ultimately professionals assert the authority of expertise and claim disinterested integrity … knowledge and skills may be codified and systematized but they cannot be completely programmed; outcomes of intervention are to varying degrees uncertain, and the particularity of individual cases and clients requires professional discretion. Flynn, 34 The concern about the increasing influence of managerialism and regulation is that the nature and forms of control over what a professional does is so complete that professionals become de-skilled in respect of what they expect of themselves and what they can achieve with service-users.

Social workers need to look beyond the specific requirements which are made of them in an organisational context and from a managerialist perspective, to develop a creative approach that maximises the use of social work knowledge and skills. Nevertheless, social workers are themselves at different stages of their own professional development and the extent to which they are able to work in an increasingly autonomous way will depend on their current stage of professional development.

Similarly, it could also be argued that different elements of the profession are at different stages of development. In conclusion, one might wonder whether the student of social work will have found the Fraser-Ch The continued drive for regulation appears to have picked up pace although some elements clearly have beneficial outcomes for the profession.

A complex picture is being drawn and some elements appear to be being erased. London: Association of Social Workers. Banks, S. Basingstoke: Palgrave. Bamford, T. London: Bedford Square Press. Bisman, C. Butler, I. Butler, J. Lovelock, K. Lyons and J. Aldershot: Ashgate. Butrym, Z. London: Macmillan. Carr-Saunders, A. Oxford: Clarendon Press. Clark, C. Challenges to Social Work. Davies, M. The Sociology of Social Work. Doel, M. London: Practice Learning Taskforce. Cambridge: Polity Press.

Etzioni, A. London: Coller Macmillan. Featherstone, B. Flynn, R. Exworthy and S. Folgheraiter, F. Fook, J. Friedson, E. Garrett, P. London: GSCC. Greenwood, E. Haines, J. London: Constable. Hall, S. Morley and K. Chen eds Critical Dialogues in Cultural Studies. Hallett, C. Harbert, W. Hadleigh: Holhouse Publications. Harris, J. Higham, P. Hollis, F. Roberts and R.

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Nee eds , Theories of Social Casework. Chicago: University of Chicago Press. Davies ed. Jack, G.

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James, A. Lyons, and J. Johnson, T. Jordan, B. Opportunity or oxymoron? Lovelock, R. Lymbery, M. Macdonald, K. Malherbe, M. McLaughlin, K. Merton, R. Community Care and Disabled People. Noddings, N. Halmos ed. Keele: University of Keele. Orme, J. Parkin, F. London: Paladin. Parsons, T. Parton, N. Payne, M. Birmingham: Venture Press. London: Palgrave Macmillan. Pilisuk, M. Sainsbury, E. London: Pitman. Shardlow, S. Adams, L. Dominelli, eds and M. Stevenson, O. Lymbery and S. Basingstoke: Palgrave Macmillan.

Wickwar, H. London: Bodley Head. Williams, F. Younghusband, E. When user and carer movements develop enough momentum they start to engage with, and challenge, the knowledge on which professional interventions are based. They also begin to challenge the gap between the status and rewards which accrue to professionals in comparison with their own, often precarious and marginalised, economic status.

Increasingly, service-users argue that their own skills and resources should be mobilised and are locating solutions within their own networks. This changing emphasis impacts on individual relationships but also affects strategic and operational aspects of social care provision with knock-on effects for their leadership, structure, culture, policy and practice in areas such as recruitment, training and resource allocation. Many people have contact with primary or acute health services on a more or less occasional basis — they visit their GP a few times a year, or are booked for day surgery or receive treatment over a short, contained period of time.

These contacts with services are normative and tend to go unremarked; usually they do not lead to significant changes in social roles or economic status. These groups may come to be defined by their use of services, by themselves as well as by others. As a result of it, they may find themselves squeezed out of other Fraser-Ch Their relationship to service providers has undergone major changes, to the point that these user-led organisations now offer services as well as use them.

Groups have taken on more formal organisational identities in order to interact with statutory agencies, within a contract as opposed to a campaigning culture. More formal statutory roles have been put in place through the Mental Capacity Act, which has introduced Independent Mental Capacity Advocates IMCAs to support people who need help in decision-making about financial, health or welfare issues. It is likely that the Mental Health Act will also include formal advocacy in this vein.

Throughout the chapter we will show how complex the interaction of roles has become in terms of both individual and organisational relationships. Conflicts of interest and difficult boundary issues arise at every turn. It is too medical for people with mental health problems and learning or physical disabilities. But users are not the only ones with an axe to grind. Carers also lay claim to a body of expertise which challenges professional dominance, but their distinct and sometimes Fraser-Ch Because the service is never explicitly acknowledged as being for the parent as well as for their son or daughter, their voices are easily silenced: they can be characterized as neither unbiased advocates for their relatives nor legitimate complainants on their own behalf.

Brown et al. These are rarely stated as potential conflicts of interest but they complicate the position of carers in relation to service agencies and create distrust. Carers come to be suspicious of high-sounding motives, especially when the implicit motivation for change is a financial one, shifting the share of care provided by social care agencies back on to the shoulders of unpaid carers, and thereby moving the responsibility from a public, shared sphere to a private and personal one.

Carers who resist such moves can find themselves backed into a corner, arguing against progressive service development for their relative because it might have a negative impact on their own lives. Glazer described how, in the USA, limits on acute hospital budgets forced through by insurance companies obliged carers to take on increasingly technical tasks when their relatives were discharged earlier from hospital.

When tasks change hands in this way they are often accompanied by a shift in language or ideology that demotes complex areas of care and reframes them as less difficult. Tasks tend to be reassigned to the family solely because they are no longer paid for out of the public purse. When seriously ill patients are discharged early from hospital it is often assumed that family members will cope and little planning is done either around the caring work or the other responsibilities of those family members who are to take on this role.

Visiting professionals may assume that carers have no other commitments and avoid discussing the implications for them of the caring tasks which they are being expected to take on. Bibbings reports that: Although the physical burden can be heavy, many carers would say that their worst problems are of an emotional nature. Carers feel isolated. They may also feel angry, resentful and embarrassed by the tasks they have to perform: they often feel a sense of loss for the person for whom they are caring, and in addition they feel guilty for having these feelings in the first place.

Passing on skills to unpaid carers becomes a new and contentious task for professionals and can be complicated by these underlying inequities and the resentments that can arise when the worker is seen as having more knowledge, but so much less ongoing responsibility. Participation and involvement are not the same thing Participation and involvement are not, however, the same. The meaning of participation for children and young people in developing social care has also been elaborated by Wright et al. A research study, Looking on: Deaf People and the Organisation of Services, conducted by Alys Young, Jennifer Ackerman and Jim Kyle in , illustrated some of the barriers that stood in the way of more equal involvement of deaf people as workers in two mental health settings and in a school for deaf children.

The authors articulated a series of tensions at three levels, theoretical, interpersonal and structural.

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These themes are echoed in a range of other user-led initiatives and service settings and are explored below. Broadening the knowledge base Service-users have increasingly challenged the relevance and appropriateness of the knowledge base of the health and social care professions and are involved in generating theory about their position in the world, theory which rests on their analysis and lived experience. Nor does a medical perspective address the reactions of others to disability or illness, or the persistence of barriers in the social and physical world.

Social models, such as those developed by disabled academics and activists extend the scope of what is under examination, looking for broader, often interlocking explanations. Within the social model disabled people differentiate between their impairment and the extent to which it is allowed, by society, to disadvantage them that is, their disability. The authors explain that deafness has traditionally been thought about in terms of what is missing, but that this alternative view emphasises what is present — a living language and a unique community.

Deafness is defined in terms of a way of life, not in terms of a medical condition. Deaf people are valued for their own cultural identity … they are not seen as impaired versions of hearing people. Young et al. Disabled people are not disputing the accuracy of a biomedical model Shakespeare et al. For example, health professionals historically claimed the right to adjudicate beyond their initial rehabilitative remit into broader arenas such as sexuality, housing, benefits and employment.

They often ended up directly or indirectly through rationing practical assistance exerting control over all aspects of the lives of individual disabled people, not only, or even, specific healthrelated issues. The social model also leads to very different diagnoses as to what helpful interventions would entail. In relation to deafness, for example, the social model would question Fraser-Ch For instance, if I had been provided with a driver I would not have felt more disabled but more empowered as a disabled mother. They sent me an awful health visitor with very narrow views about disabled mothers.

The social model shifts the focus from personal inadequacy to the availability and adequacy of assistance. The benefits of user involvement Given that user and carer involvement is not always easy to facilitate, it is helpful to dwell on the positive outcomes that arise out of it. In the study of services for deaf people a number of very tangible benefits were identified when deaf people were recruited as staff to work with deaf mental health service-users.

The deaf workers fulfilled four important roles: in addition to their obvious signing skills and first-hand knowledge of deaf culture, deaf workers were thought to be able to empathise with the particular forms of exclusion experienced by deaf people, to provide role models for deaf people and to educate their hearing colleagues about deaf issues, thereby dispelling stereotypes. These advantages of user involvement in service delivery can be extrapolated to other settings.

Mental health service-users who return to work in services may be more sensitive to and tolerant of, other users who are experiencing distressing symptoms. This has been encouraged within a network of services which all sign up to a charter that enshrines userinvolvement in running and managing service provision called the Clubhouse movement.

Self-help groups, whether for survivors of abuse or people with alcohol problems, also work on this basis. There may be particular issues to be faced in facilitating user involvement in services for older people, which have yet to be articulated but the same principles clearly apply. While the presence of people who use, or have used, services in caring and leadership roles may not in itself be enough to guarantee a good service, their absence certainly undermines any stated commitment to empowerment in mission statements or public rhetoric.

It robs people who use services of valuable insights, it leaves them without role models and it prevents disabled adults from passing on their stories. One disabled activist remarked that she Fraser-Ch If there is no collegial equality, there is unlikely to be a feeling of respect for the client group, albeit on an unconscious level.

The two systems risk developing in parallel without enough overlap. There are tensions in locating the engine of service planning in informal networks, and equity of provision may become the first casualty. Middle-class, well-resourced families may indeed be able to mobilise a helpful team, whereas other more beleaguered communities may struggle to become, or to stay, motivated.

The Valuing People document and the Social Care Green Paper all signal that these new forms of funding are to be encouraged. Service-users in these schemes employ their assistants directly, manage the worker directly, and cut across existing career paths and employment patterns.

Black service-users in one study were shown to be even more in favour of direct payments than their white counterparts 43 , perhaps reflecting their even greater disempowerment in relation to traditional service providers. About broader service development issues Clearly there is a distinction between running an organisation and being asked to give your views on the services offered to you — the difference between being a member of the board and a regular customer.

It does not extend, even at Marks and Spencers, to inviting customers on to the board, nor to consulting them about investment or even about what should be on the shelves, let alone in their products. The supermarket model certainly does not mean that retailers help customers sue manufacturers of products that have caused harm. Conflicting assumptions tend to surface in these consultation exercises, which are often ill-defined and badly timed.

Many service providers opt for high-profile public meetings in preference to ongoing involvement and consultation, but while commissioners often favour the concept of the public meeting, consultees feel particularly angry if they sense that decisions have already been made or that they are being invited to rubber-stamp a proposal and not help to shape it. Moreover, they tend to give disproportionate space to more vociferous sections of the community.

If participation is to succeed it is important that there is an infrastructure that enables the views of all sections of a community — particularly the most vulnerable, including women and children, and Black and other minority ethnic service-users see Campbell and Lindow, — and for arrangements to be in place so that their views can be reliably channelled through to decision makers. Hundal has questioned whether this is what happens, arguing that: One of the main barriers to an open discussion is the system of representation.

When the first generation of African-Caribbean and Asian migrants came to this country, politicians did not make much effort to engage them or understand their concerns. In recent years, as the numbers have grown and socio-economic issues have come to the fore, politicians have changed tack. Rather than engaging with these communities locally and constructively, they want so-called community leaders to do the job for them. She is also a Mental Health Act Commissioner and runs a training and consultancy business.

She worked for 20 years as a qualified social worker, latterly as a senior manager. She has worked extensively in Adult Social Services, primarily within mental health, practising as an Approved Social Worker and Senior Manager in an inner city multi-disciplinary setting. SAGE Amazon. Sandy Fraser , Sarah Matthews. SAGE , Conveying the diverse nature of this work The Critical Practitioner in Social Work and Health Care takes a comprehensive and reflective look at key areas of practice and the challenges professionals face in training and in their working lives.

The chapters focus on the skills and values fundamental to the caring role and helps readers understand the importance of being able to adapt to changing demands and expectations. Key features of the book include: " a multiprofessional approach, incorporating examples from health, social work, and social care " an integrated approach to theory and practice " a range of case studies to illustrate key themes and issues " coverage of core topics such as: ethics, management, supervision, teamwork, interprofessional working, practice with service-users, research, policy issues, accountability " strongly supports underpinning knowledge for the National Occupational Standards and subject benchmarks.

Role of the Social Worker in Health Care Case Management

Chapter Five Counting the Costs. Chapter Seven Values and Ethics in Practice.