Integration and Disintegration between Health and Social Care

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There has been a lot of talk about the need for greater integration between health and social care. It’s been happening for as long as I’ve been in social care.

It seems obvious to me anyway, that as long as there are different pots of cash between health and social care, the proverbial ‘buck’ will continue to be passed and the differences in the funding systems has potential to lead to great distress in terms of services delivered.

While NHS services remain free at the point of delivery, social care services are means tested and chargeable and the line between ‘health’ needs and ‘social care’ needs relating from health needs can be very complex.

The answer is integration. Integration of budgets and integration of costs. Integration so that savings made by preventative work today in social care are evidenced in the budgets of the health service – and vice versa. A poor and speedy hospital discharge in order to protect hospital beds may result in a excessive needs in relation to social care. A lack of provision of social care may lead to greater health needs. It seems obvious.

But this is not new. However, in mental health services we possibly have some of the highest levels of integration between health and social care – for the moment.

As a local authority social worker, I (with some of my colleagues) am seconded into the local Mental Health Trust, working alongside NHS employed colleagues.

The position of embedding social workers in NHS trusts has been a long one and was needed for a number of reasons. It may be that there is a genuine feeling that embedding social workers in Community Mental Health Teams improve outcomes for users. It is a move away predominantly medical models of mental health and an acceptance and understanding that social models of illness and disability have a place around the ‘table’ in a multidisciplinary team.

I genuinely believe that as a seconded member of staff, I have a slightly different ‘take’ on some of the hierarchies that seem to exist within the NHS structure. I rather enjoy challenging doctors and I think most of them quite like being challenged too – it’s all respectful of course but from a basis of a different branch and approach of expertise. While understanding that all members of a CMHT, whether doctors, nurses, occupational therapists or psychologists, can work towards social models – the training of a social worker is quite unique in this setting and adds something very different to the mix of the team.

The other reason that led these integrated teams to exist was related to the provision of ASWs (Approved Social Workers as they were) under the 1983 Mental Health Act (pre 2007 amendments).

Local authorities were responsible for employing  and authorising Approved Social Workers in their areas. This led to the ‘secondment’ system working.

However with the 2007 amendments the new AMHP (Approved Mental Health Professional) role did not need to be employed from outside the NHS. So with the NHS being able to employ their own AMHPs and AMHPs no longer needing to be Social Workers, the absolute need for secondment waned and some Trusts have seen it as an opportunity either to TUPE the social workers into the NHS Trusts and employ them directly – or to ‘disintegrate’ teams and move Social Workers back into Local Authority Teams. This, you see, both can save money for LAs who have been paying for the social work staff in these Mental Health teams while not entirely convinced they are getting ‘value for money’ in terms of the new targets they have around ‘personalisation’ – particularly as take up from mental health users has been traditionally poorer than take up in some of the more ‘traditional’ local authority adult teams.

The problem with disintegration is that it is both counter-intuitive in terms of the less concrete targets that might exist and is potentially counterproductive – we should be working together in the most seamless way to provide and deliver services to users who deserve better systems which work. We need to work in Community Mental Health Teams which have a strong dose of social work-trained professionals because we bring a unique perspective to the role and can temper some of the push towards overmedicalisation  or pathologising of mental health.

So where now? Some local authorities and NHS trusts are ‘divorcing’ while the rest of the sector glibly bangs drums about ‘integration’.

Personally, it feels like the move towards and away from integration can only be won on the arguments of cost in terms of cash.

Unfortunately there’s an ethical consideration about cost in terms of better care, better treatment and better delivery of services which is being lost.

Social Work and Health need to integrate not disintegrate – in all areas but the implications of the divorcing that is happening in mental health needs to be pushed to the front of the agenda.

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5 Responses to “Integration and Disintegration between Health and Social Care”

  1. In my service I’m seeing disintegration rather than integration. This isn’t being done because it’s seen as a better way of working. It’s being done because of money. Decades of wisdom about “seamless delivery of care” between health and social services is being torn up to balance a budget, and I’m very angry about it.

    • Exactly. It is solely money and financial reasons which is why the broader shouts of ‘integration’ feels so hollow

  2. Here we go round the mulberry bush! As you say, ASWs were invented because broadly trained generic field social workers were not and could not be up to the task. In their turn, GFSWs appeared as a result of the Seebohm Report, 1968. Until then, there were welfare officers, mental welfare officers, child care officers, medical social workers (formerly lady almoners), and psychiatric social workers. All of these became GFSWs employed by the local authority. Educational social workers (formerly school attendance officers) and probation officers remained separate. As far as mental health was concened, there were (NHS) MWOs and (local authority) PSWs. The former were mostly concerned with sectioning and sectioned patients, and derived from the duly authorised officer of the Lunacy Act and the Mental Deficiency Acts, and ultimately from the parish beadle (Mr Bumble, for it is he). PSWs were mainly concerned with patients’ home conditions and generally went and and to carry out an inspection from a distinctly superior standpoint. Before the NHS they also had to assess patients’ ability to pay. They had a watered-down Freudian training, called themselves ‘caseworkers’ and considered themselves a cut above the MWOs (who were generally RMNs with 5 O Levels and a driving licence). Others called them “middle-class ladies in stockings” – I might add tweed skirts and twin sets with ‘sensible’ perms.

    Meanwhile, radical thinkers in the NHS, such as Maxwell Jones at Dingleton Hospital and, later, The Henderson Hospital, postulated a new, integrated profession combining social work in mental health, mental nursing, and OT in mental health. ‘Social therapist’ was suggested as a title. However, what with Seebohm, Sir Keith Joseph (who became Secratary of State in 1970 and tried to subordinate all health services, rigidly separated from social services, to the district geberal hospital), and medical model triumphalism, this idea came to naught. Since then, there was one bodge after another. The notion of properly educated and trained AMHPs and ‘responsible clinicians’ appeals to this old fogey as the pre-Seebohm/Joseph proposal brought up to date. I would, however, in acute units like to see nurses (not just HCAs) out amongst ‘em doing arty or other occupational things instead of lurking in the office.

  3. I’m a social work student currently studying in first year and I found this blog really interesting as I have just finished a module which looked at integration between health and social care. I personally think its really important that we all integrate within the services and that it is a better way of working. It’s left me questioning why cost of funding seems to be put before the needs and care of the service users.

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