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Thursday, 03 November 2011

Engage: The impact of restructuring social care services in remote and rural locations

Written by Andrew Walker

Social worker and community councillor, Andrew Walker, shares his concerns on restructuring social care services

“The Western Isles already has the highest proportion of people aged over 65 in Scotland and there is projected to be a 50% increase in the over 60s by 2033 and an 80% increase in the over 75s in the same period.”

“In June 2010 the Comhairle considered a Report on the Management of Home Care Delivery Hours which indicated that … it would be necessary to introduce a waiting list for those service users whose needs were assessed as ‘substantial’.”
(“Best Value Review of Home Care Services”, Sept 2011)

I write to register my concern about the insidious and worrying development arising from the re-organisation of adult social care services, especially in the Uist and Barra areas of the Comhairle nan Eilean Siar.  Also, I fail to recognise the rationale behind some recent strategic policy decisions which do not acknowledge the increasingly complex needs of many service-users. The assessment and on-going review of service-user needs is a complex and skilled social work task, normally undertaken by trained, skilled and experienced social workers, registered with the Scottish Social Services Council. The appointment of unqualified social work staff to replace social workers, with the title of “Social Care Assessor”, is a retrograde step.

Newly implemented organisational structures and changes in staffing will in my view have a deleterious impact on the standard of social care services to our elderly, disabled and most vulnerable service-users, at a time of significant increase in demand for community care services. Additionally, local authorities and Health Boards are pursuing a “transformational” agenda, a shift in the balance of care, which aims to reduce the provision of institutional care, with greater emphasis on care in the community. The introduction of “capping” of Home Care hours at, arbitrary, historic levels, fails to recognise and respond to increasing need.  

A recent Audit Scotland report (June 2011) on the functioning of the Western Isles Community Health and Social Care Partnership, highlighted major areas of concern at both strategic and operational levels.

Current examples of local policy changes can be seen in relation to mental health services and the present Western Isles Health Board consultation proposing the reduction in the number of in-hospital psychiatric care beds. The stated aim is to provide more community-based services for those patients. More concerning, the Joint Services Committee of the Western Isles Community Health and Social Care Partnership, made a decision in Sept 2010 to hike-up the thresholds/eligibility criteria for Home Care Services, and to cap the budget at Feb 2010 levels.

Are our elected members sufficiently informed, to address and contribute to key policy changes? Are our health and social care services properly integrated, promoting efficient and joined-up services? Who is fighting the corner for key services for our frail elderly, the silent minority? Is the role and contribution of the Voluntary Sector recognised and encouraged? Is “resource transfer”, ie transfer of funding from institutional care to community care, on anyone’s agenda?

Rather than respond to assessed need and a “rise in demand”, in keeping with demographic trends, a decision is taken to “cap” service provision at Feb 2010 levels. There are presently over 100 service users resident in the Uist and Barra areas. About 50% of this cohort are assessed as having “complex” health and social care needs.

Only those newly-referred service users with assessed need in priority 1 category will receive an immediate service. The four nationally-agreed priority criteria of need are:

(i) Critical     (ii) Substantial     (iii) Moderate, and         (iv) Low


The Joint Services Committee, concurring with a report from the Director of Social and Community Services, inform us that those service users falling into priority 2 need, ie “substantial” need, will be placed on a Waiting List for Home Care Services.

The national definition of “substantial need” …

“…indicates that there are significant risks to an individual’s independence or health and well-being which is likely to call for the immediate or imminent provision of social care services (high priority).”

Are Care at Home services resource led, or needs’ led? I sought views from a neighbouring authority -

“…we are able to respond promptly to Priority 1 and Priority 2 requests. I can only imagine that waiting lists will lead to people quickly moving to P1 and an increase in crisis intervention – never satisfactory for the older person at the centre of it.”

Creating waiting lists will inevitably lead to an increase in crisis intervention. Crises of this nature normally result in unplanned hospital admissions, hardly in keeping with the Scottish Government objectives, and most certainly not cost-effective, nor respecting the value base from which services should be delivered.

Assessment of need is a skilled task, the outcome of which will be crucial to the individual service-user and family concerned. On-going review of care planning is also a skilled and professional task, undertaken on a multi-disciplinary basis, and up until recently by qualified and experienced social workers normally appointed as “care managers”.

The Community Care team (Uist & Barra) now comprises a Senior Social Worker based on the Island of Barra and a trainee social worker based on the Island of Benbecula. There is also one full-time and one part-time “Social Care Assessor”, employed at a much lower grade of pay than social workers. The original, generic, Uist and Barra social work team comprised five, experienced and qualified social workers. Compare this situation with only one qualified social worker/manager now remaining in the re-constituted Adult Community Care team, dividing his time between management and practitioner tasks.

Assessment and care planning functions are now carried out by employees with the title of “Care Assessors”. This is clearly an outcome which will result in a de facto dilution of standards and practice, with the main aim being to save money.

The British Association of Social Workers, has this month commented on the deletion of qualified social workers in key service areas:

“The issue of social workers’ diminishing role in adult services has been going on for years, with potentially devastating consequences.….  There is an erroneous belief that adult care is not complex and can therefore be carried out by less qualified (and often cheaper) staff.”

Restructuring in this council area has resulted in the loss of two social workers and a Team Leader in the Uist and Barra team, and a singleton social worker from the Harris office. A Head of Service is not being replaced, and a Service Manager relocated to children’s services.

Key strategic policy decisions are delegated to the Joint Services Committee of the CHaSCP. This group commands an annual budget in excess of £90m. The Social and Community Services department of the Comhairle is the second highest spending department yet we have no designated committee to promote, monitor and review strategic policy in a key area of social work and community services.

I am now inclined to ask the question: are service-users within this constituency receiving proper representation at a political level? Are all 31 councillors of the Comhairle aware of these changes in structure and policy within the Social and Community Services Dept of the Comhairle, and of the inevitable impact on service-users, their families and carers?

Social work services, and social workers, re-deployed or not being replaced, now find themselves subsumed within other departments (Libraries, Sports Halls and Museums). Social workers are inevitably struggling for an identity, and are not being replaced by qualified staff.

The Comhairle nan Eilean Siar is responsible for employing the smallest numbers of social workers in Scotland (behind Orkney and Shetland): remote, isolated, and in my view the Uist and Barra team hardly viable in its present structure. There is a perception that social work now relies too heavily on the assessment tasks now being expected of community nursing and other Allied Health Professional staff.

A Scottish Executive report entitled “The Need for Social Work Intervention” made reference to the work setting in which social workers are employed:

The organisational context in which social workers operate is significant in determining:

•    whether good practice is in spite of, or because of its support
•    whether the management of practice is fit for purpose in a particular context
•    the nature of the teams within which social workers are operating
•    whether there is a learning environment that supports good practice so that social workers are confident about their knowledge and skills

I am inclined to strongly recommend that all social work service-users undergoing assessment/review insist that this task is in the first instance completed by a qualified and registered social worker. The care plan emanating from such an assessment carries in some cases the responsibility for life and death outcomes. This is often stated for children and families’ social workers engaged in critical decisions with regard to children considered to be at risk of neglect or ill treatment. Surely the same principle applies for social workers engaged with vulnerable adults and older people?

The Association of Directors of Social Work warned about possible outcomes arising from re-organisation of social work services:

Social Work Within the Local Authority

Protect, safeguard and develop the unique contribution of social work as a profession within the local authority.

It is crucial that in seeking to promote the integration of social work services with other services and professions that the outcome is not the disintegration of social work services and a more complicated “journey” for our clients to receive the services they need. The most vulnerable users of social work services rarely fit into one service area. Fragmenting social work means creating distances between services such as children and family care, criminal justice and mental health.

Have the worst fears of ADSW become a reality here in Comhairle nan Eilean Siar? Are our social work services now so fragmented that service-users, and other agencies, are confused about “who does what”, and are professional standards being sacrificed on the back of a policy agenda driven purely by costs?

It took years and dedicated commitment by many to build and develop a skilled and experienced social work team in the Uists & Barra areas. Re-organisation has dismantled this team “at a stroke”. The profession of social work has been seriously undermined and undervalued.

I qualified as a social worker over 40 years’ ago. I entered at a time when the post-war local authority departments of (i) Children’s Dept. (ii) Probation Dept. and (iii) Health and Welfare Dept. were all re-constituted into a unified umbrella organisation called the “Social Work Department”.

Since then, the Social Work Dept has chosen to “specialise”, into the three hitherto functions of “Probation” (now called Criminal Justice Services), “Children’s Services” (now called Children and Families Services), and “Health & Welfare” (now called Social & Community Care Services).  The one main difference being that local authority boundaries have been significantly altered since 1968. I have a sense of déjà vu – back to the future. Have we come full circle?

Perhaps we should now prepare for another round of tampering with local government boundaries.  ADSW said in 2005 –

The 21st Century Review asks us to look 20 years into the future. In such a time-frame it is inconceivable that Scotland should still have 32 local authorities and 15 health boards

(and now also 8 Criminal Justice authorities across Scotland)

Officers of the Comhairle formulating strategic policy, must give more thought to the impact of some recent decisions: principally, capping of Home Care Hours at arbitrary levels, irrespective of need, and reducing the numbers of qualified social workers. The need for a Committee structure to monitor and review policy decisions and expenditure, and to champion the needs of the most vulnerable citizens in our community, is a prerequisite for remedial action being taken.

Andrew Walker
Isle of Benbecula
(Andrew is a member of BASW, recently appointed as a community councillor, and also a Director of Tagsa Uibhist.)