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Brave New World: Social workers'perceptions of care managementJulie Irving And & Pauline GertigPublished online: 01 Feb 2008.

To cite this article: Julie Irving And & Pauline Gertig (1998) Brave New World: Socialworkers' perceptions of care management, Practice: Social Work in Action, 10:2, 5-14, DOI:10.1080/09503159808411481

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Brave New World: social workers’ perceptions of care management Julie Irving and Pauline Gertig

This article is based on research carried out by the authors in 1996/97 with social workers who were either care managers o r had significant care management responsibilities in three local

authorities in northern England. I t identifies current concerns to practitioners including the dilemmas they face about their professional identity and use of traditional social work skills. Previous research concerning resistance and alienation to change is challenged. Far from opposing the changes in role, our findings indicate that social workers are actively striving t o incorporate the principles of care management into their practice.

ith the emergence of care management as a distinctive W process, the relevance of social work skills and indeed the long term future of social work is now being openly debated. The threat to professional identity and independence of social work has been raised before in this journal, with concerns about the reduction of social work to a series of mechanistic tasks ‘con- trolled by protocols and guidelines’ (Simic, 1995). A very differ- ent view has been taken by others such as Payne ( 1995) and Sheppard (1999, who assert social workers have the necessary skills, knowledge and value base needed, and are particularly well placed, to claim care management as a legitimate area of work.

This debate is taking place against a background of continual change in a number of different yet interrelated areas in welfare. Pressure on public finances, exacerbated by the vagaries of market forces, have coincided with conflicting ideas on the implementation of care management in different local authorities (Lewis, 1997). Combined with the upheavals and change created by competency based training in health and social care, it is hardly surprising that social work itself is under scrutiny from both within the pro- fession (Dominelli, 1996) and without. The demise of CCETSW and comprehensive review social work regulation and education by central government can only lead to further uncertainty.

We conducted a series of semi structured interviews with 15 experienced qualified social work practitioners across 3 local authorities, all of whom had care management responsibilities. They were selected from a range of adult field settings, such as area offices, hospital settings or primary care teams. We were interested in finding out about their views and perceptions of the changes in practice since 1993, with particular reference to any

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changes in the skills they used, relationships with service users and other professionals and the relevance of social work values and training to their role.

Unsurprisingly we found that they had experienced a number of major changes in their role and practice, but what was perhaps less anticipated was the cautious welcome and approval given to the care management process. Other research has indicated that social workers in adult care services are alienated and feel excluded (La Valle and Lyons, 1996) but we found this was only part of the picture. Our findings indicate a range of views, both positive and negative:

social workers welcomed the clari9 und jimiulisa- tion of good practice that care nianagement had brought

having a social work background was seen u s essential in competently assessing and managing the inore complex needs of service users

care management had significantly reduced the amount of face to face work with individuals and increased the amount of time spent in the office

much of the traditional social work role and skills involved in building relationships and counselling had been lost, and while this was a matter of regret, it was perceived as inevitable given policy and budgetary constraints

Different role?

Despite the implementation of care management at a policy level across all three authorities, we found some variation in how this had been interpreted at team and practitioner level, even within the same organisation. All those we interviewed had statutory responsibilities such as assessing need, drawing up individual care plans and negotiating with service providers to meet those needs. However there were differences in the range of responsibilities devolved to the front line practitioner, depending on the policy of the particular authority. The use of the title of care manager itself was contentious. While social workers in one authority were universally referred to as care managerhocial worker, in another, the title tended to be used largely for convenience, for example when writing to GPs. It appeared to us that unless there was some management directive to use the term formally, its use depended on the attitude of the individual practitioner. Attitudes varied from:

“it doesn’t mean anything to nze at all - I don’t mind what anyone calls me”

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to “what I insist upon is being called a social worker with care management responsibilities. I think social work has something to offer that other professionals don ’t have ”

Regardless of how much the actual title of care manager was used, there was no doubt about the fundamental shift in practice that the role itself brought. This was seen in a number of ways:

I ) Accountability

There was general consensus for the view that care management had increased public accountability, both in terms of being explicit about one’s responsibilities and decisions to services users and in explaining and justifying one’s actions as public service employees. The emphasis on negotiating planning, specific objectives, monitoring and reviewing meant, as one person put it:

“it’s formalised good practice.. . which is no bad thing ”

There were no references to the need to maintain professional autonomy which might have been expected and which have been explored elsewhere (Simic, 1995). Despite the fact that some felt the issues of accountability were a ‘huge responsibility”, social workers welcomed the fact that care management is:

“a very inclusive process, there are no hidden agendas and.. . everything is discussed so that you are promoting the process and encouraging people j. involvement in it”.

On a more pessimistic note, there was some concern by practi- tioners that supervision by team managers was not always in sufficient depth to allow the reflection on practice issues that they would have liked. Increases in line managers’ responsibili- ties, particularly with regard to budgets meant time for supervi- sion was less than ideal.

2) Relationships with service users

One of the main reasons social workers welcomed the changes was their perception that service users are receiving a better service overall. Older people in particular are seen to have benefited from the emphasis on needs led assessment, as felt by one social worker who said:

“I know, working with people now who are in the community, that before care management they would have been in resi- dential care.. . it’s extremely rewarding working out a care package ’’

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Social work has always recognised the concept of self determi- nation (it is part of the values requirements of the competencies expected of qualifying social workers) but the formal obligation to recognise views of service users and carers are forcing social workers to confront this directly. Our findings suggest that this posed real dilemmas for practitioners. There was clear recogni- tion of the importance of user involvement at all stages but the practicalities and time constraints worked against a meaningful partnership. As one social worker said:

“you don ’t have the time, you hatch and dispatch people”

There is the additional question of how best to work with service users in an arena that demands a new ‘script’ and requires time and commitment to achieve (Baldock and Ungerson, 1994). The importance of managing this successfully has been given extra impetus with the increasing confidence of a growing consumer movement in health and social care and what is seen as a long overdue shift in paternalism (Wallcraft, 1996).

3) Relationships with other professionals

Another dimension to the changes in role is the relationship with other professionals in health and social care. With the greater clarity of purpose brought by care management, many social workers found that relationships with colleagues such as GPs and nurses were more productive. Having a pivotal role i n assessing and deploying resources meant that there was more a feeling of equality with other professionals in multi-disciplinary settings. As one social worker in a primary health care setting put it, there is:

“a bit more credibili ty... it’s a much clearer role”

There was less enthusiasm about some other aspects of co- operation, particularly with regard to service providers. New forms of relationships had to be negotiated which particularly appeared to cause difficulties with in house domicilary services. Although a formal purchaser/provider agreement would suggest that power lay in the hands of the purchaser, in practice this was not always the case because of the limited services available locally.

Relationships were also affected by the variation in the number of cases held by different practitioners, which was compounded by the differences in settings. Hospital social work services and field teams working with older people (whether in the short or long term) appear to be particularly affected by the rapid turnover of cases and increasing workload, making time for net- working and building relationships with other services providers and professionals difficult.

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Different skills? The type and range of skills needed by care managers has been the subject of much debate, but the need for a combination of interpersonal, management and (to a lesser extent) financial skills is a common theme (Lewis and Glennester, 1996: Beresford and Trevellion, 1995: Sherlock-Storey and Milne, 1995). The people we interviewed had very similar views about the skills they felt they needed to do their job.

Unsurprisingly, they stressed that interpersonal skills are essential to carry out a good standard of assessment. This confirms the view offered by Payne that basic social work tools such as effective listening are fundamental in addressing people’s needs (Payne, 1995). Social workers commented that good communication skills and the ability confidently to handle difficult and emotionally fraught situations are needed. For example, one social worker mentioned how important it was to develop interpretative listening skills, trying to ‘fit’ what the person is saying into the assessment format. Others felt that interviewing skills should be based on a sound knowledge and understanding of the needs of the service user group as well as an appreciation of both disadvantage and social exclusion.

The ability to use these interpersonal skills to access both formal and informal networks contributed to a good quality assessment and care package. However it was frequently mentioned that the shifting balances and priorities introduced by care management necessitated the development of good administrative skills in order to manage the volume of paperwork generated. The ability to use computers and information technology was seen as essential if not always put into practice!

Concern was expressed about the decrease in direct therapeutic involvement with service users with the subsequent decline in skills such as counselling. These sentiments accord with findings iden- tified in other research which mention the competing demands of administrative pressures and therapeutic work (Rachman, 1995; Lewis and Glennester, 1996). Many social workers regretted this trend which was articulated by one interviewee who felt that:

“...in no way should care management take us away from the more therapeutic part of the role. But at the same time, I see that bit being more and mure squeezed which has actualty fed me to be lacking in confidence about my own abilities when it comes to therapeutic work.. . ”

In contrast to the above, social workers found the skills they were increasingly using were around the management of cases

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and administration. For all interviewees this represented a shift in focus in their everyday practice from direct work with service users to more office based activities. These included accessing resources, deciding priorities, negotiating with a wide variety of service providers from both the statutory and independent sector, and form filling. Time management was therefore a crucial skill, a point brought home forcibly to one social worker after attending a time management course. She recognised that:

“my face to face contact with clients was very minirnal. So I had all this activity going on, on behalf of the person but it was largely away from the person themselves. Obvioiislv that is a very eerie concept given that a large proportion c-rf’my career so far.. , has been about engaging them in participa- tion, making it m e a n ~ n ~ u l for them, helping them &el confident in asserting themselves etc. )’

The contradictions in some aspects of the care manager’s role were also highlighted by an increase in the gatekeeping function. Although this aspect was seen more as a result of financial pressures rather than directly through a change in role, i t does not sit easily with the duty to place service users and carers at the centre of the assessment process. How practitioners managed this tension depended very much on their own value system as well as the support they received from colleagues and their own line managers.

The area of financial skills and managing budgets directly appeared to be more the province of first line managerdsenior practitioners rather than the basic grade social workers we inter- viewed. However, given the general awareness that the level of service on offer is “financially driven” the consensus was that these skills will need to be developed.

Different values, different identity?

The key qualities required of professional social workers are well known and have been set out in CCETSW’s Paper 31 and expanded upon in many general social work texts (Thompson, 1993; O’Hagan, 1996; Vass, 1996). What is interesting, however, is how whole sections of the policy guidance on care management reflect many of the fundamental social work prin- ciples (DOH/SSI, 1991). Indeed it has been argued that the essence of social work values has been subsumed into this and other legislation. (Jones et al. 1996). This supports the belief that the title of social work itself is ‘obsolete’ (Langan, 1993) as it now has reached the point of being so broadly based that it can no longer claim to have a distinctive field of expertise.

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However only one interviewee supported this view that social work had lost direction:

“social work started off with a fairly small focus and it has expanded and expanded and expanded, until, for a time, it was doing nothing at all well, and opportunists, other profes- sionals rushed in and focused very sharply on an area that had been missed”

This view was echoed in less profound terms by one or two others. Their concerns about professional status originated from the fact that social work is not identified in the NHS & Community Care Act 1990 as the required qualification. This was compounded by the significant numbers of unqualified or differently qualified workers acting as care managers. As one social worker put it:

“you can see the writing on the wall ”.

Increasing demand, the lack of time and resources, as well as the prescribed nature of care management reluctantly led some workers to feel that social work should, but could not survive as a distinctive profession:

“I think social work is being eroded, I think all our values and training are being undermined.. . ”

The majority of social workers in our study took a different view: for them, being a social worker was an essential part of being an effective care manager. Their professional identity was inseparable from their role. They had no difficulties in articu- lating the values underpinning their practice, a point that appears to conflict with the views expressed recently in Practice (Baldwin, 1997). Indeed one social worker was emphatic that:

“care management is about managing and allowing people to manage their lives so it cannot be anything bur hinged on values ”

It is argued that their professional identity is actually retained by explicitly promoting the social work value and theoretical base. As a social worker put it:

“ I do think it’s important not to lose our own professional identity.. . if I don ’t continue to champion the cause for the values that I have in terms of working with people then yes, it would be very easy for that professional standing to be unim- portant and inappropriate, certainly not necessary. ”

These social workers maintained that being an effective care manager involved defending their particular contribution and

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articulating their professional expertise. For example, social workers in multi-disciplinary settings felt their colleagues:

“value the idea of someone coming looking at things from a different angle and therefore it becomes niore important to hold on to bits of social work identity. ”

These beliefs support the argument that care management is i n truth the new social work with its special blend of knowledge, skills and attitudes (Payne, 1995).

Conclusions drawn from the research

This research suggests that social workers are ambivalent about the effects of care management on their day to day practice. The majority felt it offered a clearer, more open and less judgmental framework in which to operate. This was viewed as more fitting for the 1990’s and more likely to encourage responsiveness to consumer views than hitherto possible. This formalising of good practice had led to better working relationships with other profes- sionals. The benefits of a system that gives power to consumers, whatever the difficulties, was unequivocally welcomed.

The impact of care management on social work identity was an issue, but (perhaps unsurprisingly) most social workers felt that being an effective care manager actually derived from acknowl- edging and actively maintaining their professional identity. especially in multi disciplinary settings. For many, the introduc- tion of care management had strengthened their view of the importance of social work values in achieving the formal objec- tives of promoting individual choice and encouraging partner- ship between users, carers and service providers. One worker spoke for many when she said:

“ I wholeheartedly agree with the principles of care rnanage- ment.. . (it) creates flexibility which is great. We can now organise and be much more creative in how you work, so that’s the positive side of it. ”

Social workers felt that some of their skills had been sharpened and given more significance, particularly in the areas of assess- ment and problem solving. New abilities, such as costing of care packages and formally monitoring progress have been developed. These have provided fresh challenges and led to a sense of purpose that some saw as previously lacking in their work. This recognition of the importance of setting goals and achieving targets must be welcomed at a time when all services are expected to measure outcomes under community care (Nocon & Qureshi, 1996).

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However most social workers had genuine concerns about the space and time available to carry out a quality assessment based on need and organise the kind of care package they ideally see as appropriate. One interviewee spoke of the:

“emphasis on throughput.. . keeping the stats up”

At a time of increasing financial constraints, the pressure on social workers to process their work, meet targets and keeping up with demand has increased pessimism about their ability to meet public and consumer expectations.

When we began our interviews, we anticipated some views about the conflict between social workers’ professional values and the values being promoted by the statutory organisations by whom they were employed. However this was not the case. What social workers appear to be struggling with is the dichotomy between the explicit values promoted in community care legislation itself, and the reality which prevents them implementing those values in practice.

Despite the huge changes in social work, care management does not yet appear to herald the end of social work but rather a re- evaluation of role, skills and professional identity. Our findings suggest that practitioners are actively incorporating the princi- ples of care management into their practice in order to meet the challenges of the Brave New World.

References

Baldcock, J. & Ungerson, C. ( I Y Y 4 ) Becoming Consumers of Community Care: Households within the Mixed Economy o j Welfare Joseph Rowntree Foundation

Baldwin, M. (1996) ‘Is Assessment Working? Policy and Practice in Care Management’ Practice Vol. 8 No. 4 pp53-59

Beresford, P. (eds.) Social Work Education and the Community Care Revolution National Institute for Social Work

CCETSW ( 199 1 ) DipSW Rules and Requirements for the Diploma in Social Work (Paper 3 1) 2nd edn. Central Council for Education and Training in Social Work

DOHBSI (1991) Care Management and Assessment: Practitioners Guide HMSO

Dominelli, L. ( 1 996) ‘Deprofessionalizing Social Work: Anti- oppressive Practice, Competencies and Postmodernism’ in British Journal of Social Work 26 ppl53- I75

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Jones, M. & Jordan, B. (1996) ‘Knowledge and Practice in Social Work’ in Preston-Shoot, M. & Jackson, S. (eds.) Educating Social Workers in a Changing Policy Context Whiting & Birch

La Valle, I. & Lyons, K. (1996) ‘The Social Worker Speaks: 1 - perceptions of recent changes in British social work’ P ractice Vol. 8 NO. 2 pp5-14

Langan, M. (1993) ‘New Directions in Social Work’ in Clarke, J. (ed.) A Crisis in Care? Challenges to Social Work OU/Sage

Lewis, J., Bernstock, P., Bovell, B. & Wooley, F. (1997) ‘Implementing Care Management: Issues in Relation to the New Community Care’ British Journal of Social Work, 27 pp5-24

Lewis, J. and Glennester, H. ( 1996) Implementing the New Community Cure Open University Press

Nocon, A. & Qureshi, H. (1 996) Outcomes of Community Care for Users and Carers Open University Press

O’Hagan, K. (1996) (ed.) Competence in Social Work. A Practical Guide for Professionals Jessica Kingsley Publishers

Payne, M. ( I 995) Social Work and Community Care Macmillan

Rachman, R. (1995) ‘Community Care: Changing the Role of Hospital Social Work’ Health & Social Care in the Cornmuni~ 3 ~ ~ 1 6 3 - 1 7 2

Sherlock-Storey, M. & Milne, D. (1995) ‘What makes a good care manager? An analysis of care management skills in the mental health services’ Health & Social Care in the Commimiiy 3 ~ ~ 5 3 - 6 4

Sheppard, M. ( 1 995) Care Management and the New Social Work: A Critical Analysis Whiting and Birch

Simic, P. (1995) What’s In a Word in Practice Volume 7 Number 3 PPS- 16

Thompson, N. ( 1995) Theory & P ractice in Health and Social Welfare Open University Press

Vass, A. (1 996) (ed.) Social Work Competences Sage

Wallcraft, J. (1996) ‘Empowerment and User Involvement’ in Trevillion, S. & Beresford, P (eds.) Meeting the Challenge: Social Work Education and the Community Care Revolution National Institute for Social Work

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