Effective Social Work with Older People
This report is part of the review of the role of the social worker commissioned by the Scottish Executive to inform the work of the 21st Century Social Work Review group. Their prime focus is the role of the social worker across different service systems and national contexts.
CHAPTER SIX CONCLUSIONS AND IMPLICATIONS FOR EFFECTIVE SOCIAL WORK WITH OLDER PEOPLE
6.1 This chapter draws out the main conclusions of the review, focusing on outcomes, skills and tasks in effective social work with older people. It also considers how the six social work roles identified by Asquith et al (2005) might be applied to work with older people.
NEEDS FOR SOCIAL WORK
6.2 First, it is important to stress that older people do not require social work support simply because of their age. Older people are not a homogeneous group with one set of needs. This paper has highlighted the potential limitations of the term 'older people' as a category or 'service user group', echoing similar reservations expressed during the course of the 21 st Century Social Work Review.
6.3 Many people only come to social workers' attention when they develop illness or frailty in old age. Others may have experienced a range of difficulties, vulnerabilities or needs during adult life which can be exacerbated by, or combine differently in, old age. They are more likely to seek - or be referred to - social work help because they develop needs arising from combinations of condition and/or circumstance, for example, learning disability and dementia, depression and physical impairment, or multiple losses following bereavement.
EFFECTIVE OUTCOMES
6.4 The effectiveness of social work (like other areas of professional activity) is increasingly judged by its outcomes. However, meeting clinical or financial targets and 'measuring' performance are insufficient markers of quality (and may not always be particularly useful). Social work with older people should not be considered effective unless older people themselves are satisfied. It is not always easy to gauge satisfaction, partly for methodological reasons, partly because older people may be reluctant to voice reservations or criticism of the support they receive. In addition, they may not always pick out the contribution of a particular professional within their care package.
6.5 Research and development work has found that social care is more effective when its intended outcomes are identified at an early stage - when carrying out assessment and care planning. Older people must be closely involved in this process, with outcomes based on their wishes and priorities as far as possible. Rather than accepting maintenance of the status quo as a desired outcome, wherever possible effective social work will aim to bring about positive change, such as improved physical and emotional well being.
6.6 Service users want to be listened to and respected as individuals. Most also want to have choice and some control of their support arrangements. Many older people share traditional social work values, such as a concern for relationships, and appreciate social work skills, for example, in carrying out comprehensive assessments and regular reviews. Thus, the social work process is important to older people, as well as the outcome.
6.7 More evidence is available about the effectiveness of social services for older people than about social work. Research shows that older people value services which can support them in various aspects of their lives, not just with personal care and relationship needs. Preventive 'low level' services are very important. These need not involve social workers, even at the assessment stage.
EFFECTIVE SOCIAL WORK
6.8 Other work published by the 21 st Century Review has described the context of social work. In this paper, our brief look at context is limited to issues significant to work with older people, notably ageism and poverty - poverty of income, of quality of life and indeed of expectations about services. These issues have long been highlighted in the education and training of social workers, promoting the holistic approach to the whole person in their environment which older people say they value. The other contextual issue to which we have drawn attention is the shift towards multi-agency and multi disciplinary working with older people. The single shared assessment, to quote one example, was introduced for older people in the first instance. This, and the development of multi disciplinary teams under a single manager, creates an imperative for the profession to be clear and confident about its distinctive role. Demographic changes are also important, not simply because of increasing demand, but also because of the importance of knowing where best to deploy social workers with older people, to ensure their distinctive contribution is directed to those who most need it.
6.9 Given the need for effective deployment of social workers, and the fact that other staff can deliver the low level or preventative support many older people require, it follows that the major focus for social workers should be intensive care management with people who have complex, fluctuating and/or rapidly changing needs.
6.10 In effective social work with older people, key tasks will always be underpinned and informed by a set of core skills and values. Therefore, the demands of care management must not prevent social workers from engaging meaningfully with older people and developing a sensitive understanding of their lives, needs and wishes. The core tasks and statutory duties of assessment, care planning and review have been dismissed by some writers as merely administrative and bureaucratic. Social work managers should ensure that pressure to manage resources and establish eligibility do not reduce the individual worker's capacity to use the full repertoire of their social work skills in an holistic way with older people.
6.11 There is much scope for social workers with older people to adopt a positive and proactive approach, for example through income maximisation, promoting individual strengths and resilience, and helping people to regain their confidence or rebuild social networks after periods of transition or change.
6.12 Anti-ageist practice is an important feature of working with older people: social workers must guard against both their own and others' ageist assumptions and stereotypes. Issues of gender, class, race, disability, mental health and sexual orientation are as important in working with older people as any other service user group.
6.13 Social workers bring a unique mix of skills and expertise to situations of complexity, uncertainty and conflict - which they work with on a daily basis. Effective social work with older people requires both practical skills - securing resources, co-coordinating care packages, negotiating contracts with service providers and so on - and 'people' skills - sensitive communication and listening, starting where the older person is, taking time, supporting people through crises associated with loss and change, as well as collaborating with other professionals in a multi-disciplinary context.
6.14 Social workers must work creatively with risk. Here they need finely tuned skills to achieve the 'right' balance between, on the one hand, promoting an older person's independence and self determination while, on the other, ensuring that vulnerable individuals are adequately protected. This will involve establishing trusting relationships, carrying out holistic assessments, discussing a range of options, building in safeguards as appropriate and ensuring regular reviews and monitoring take place. Arguably, social workers more than other professionals support older people to live with acceptable levels of risk, rather than trying to eliminate it altogether.
6.15 There are various situations where social workers are legally required to intervene in people's lives, for example, under the new mental health legislation, the Adults with Incapacity Act and other initiatives to improve the protection of vulnerable adults. The evidence suggests that these statutory duties are generally performed well and that social work has a particular role to play in working within, and communicating the legal context of, social care to service users, carers and other professionals.
6.16 Work with older people requires of social workers an ability to engage sensitively and effectively with people approaching the last years of their life, and who may be near to death. Social workers are more likely than other professionals to be routinely working with grief and loss.
6.17 Tibbs (2001) argues that some older people, for example, those with dementia, 'have special needs which require specialist expertise'. She goes on to describe 'problems' that might occur without specialist knowledge such as
"difficulty in making the initial contact with the person, achieving the balance between the person's right to autonomy, and their need for help, and their need for emotional support throughout the process."
This is one of the few references found in the literature which relates to an on-going debate amongst those responsible for planning service delivery. In the terms of this review, is social work more 'effective' with older people if it is delivered as a specialist service? If so, should this service comprise teams of social workers, or multi-disciplinary teams who only work with people over 65 (irrespective of their particular need or condition) or - introducing a further layer of specialism - should there be teams working only with people over 65 who have mental health problems, or dementia, or learning disabilities?
6.18 We have been unable to identify research which convincingly points one way or the other. Our conclusion that older people's need for social work may arise from a combination of needs suggests that a generic base better supports the holistic approach, particularly for assessment, that the 21 st Century Review's Interim Report appears to support. Tibbs' argument may be best understood as a plea for specialist knowledge and expertise to be built onto the core skills and knowledge of the generic social worker. Just as there are core values which are distinctive to social work, and form the basis for effective practice, so also there are core skills of assessment, planning, risk assessment and management, intervention and review, carried out within the multi-disciplinary and interagency context. Work with older people, whatever their presenting problem, requires these tasks to be completed, as in work with other service user groups. In some situations, for example where dementia is further advanced or is associated with other needs such as those arising from learning disability or sensory impairment, then additional 'specialist' advanced knowledge will be required, but built on a foundation of generic knowledge and skills.
6.19 This paper was commissioned as part of the 21 st Century Review of Social Work and reference has been made throughout to the review's Interim Report. We conclude by looking at how the six social work roles identified by Asquith et al (2005) might be applied to work with older people.
6.20 The role of Counsellor is perhaps the most prominent. Social workers will often be working with older people as they try to take major life changing decisions, such as giving up their own home to move into a care home. Everyone involved may well be aware that this will be the last move for the old person, but the social worker should have the skills to articulate that and enable the older person and their family both to express the feelings associated with the change and come to terms with it. Such situations are rarely straightforward, potentially exposing feelings of anger and betrayal in an old person, guilt or resentment in relatives. The decision may have been precipitated by a crisis such as the onset of illness or impairment or the loss of a partner or main carer. The skill of a social worker in enabling such feelings to be managed and explored will be essential, if the move to a care home is to achieve a rediscovery of purpose and a degree of quality of life.
6.21 The roles of advocate and partner have a particular application in effective social work with older people. Most of those who experience delayed hospital discharge are older people. The pressure to 'free up' a bed, so that activity levels, waiting list targets and emergencies can be managed, can become intense, particularly in areas where the speed and resourcing of alternative community services has not matched the loss of 'continuing care' beds for older people. In these circumstances, it may be the social worker who advocates for the older person's rights - her rights to a choice of a care home, her rights to information about options and resources, her rights of appeal. While the social worker may share this responsibility with family members, it is also possible that she may need to mediate between the older person and relatives who have a different view of the risks involved in discharge home.
6.22 All the social work roles will have a particular challenge when the older person is suffering from dementia, none more so than the role of assessor of risk and need. In chapter three, we explored the complexity of the assessment process with older people, in a context of pervasive ageism, low expectations, poverty and resource constraints. It is hard to underestimate the challenge of conducting a comprehensive assessment of need in that context. Social workers regularly have to balance their assessment of the risk and vulnerability of an older person against the individual's rights to choose her own way of maintaining an independent lifestyle, at home, with support. The complexity is increased when neighbours or family do not share the same view of the risks involved (or of the older person's right to live with those risks).
6.23 The role of care manager is at times dismissed as an aspect of the new 'managerialism' required in the business of community care, one who merely 'arranges services for users in a mixed economy of care'. This ignores the complexity of situations requiring care management (as defined in the circular and in the research), that is to say, where the needs are complex and/or fluctuating, where there may be conflict between client and carer, where a complex 'care package' must be co-ordinated or where a major life change is involved, such as a permanent admission to care. In addition, complex care arrangements need regular review, to ensure that minor and major changes, or that failings in one part of the package, are properly recognised and addressed, and to ensure that the range of needs continue to be met. As Tibbs (2001) comments:
"The social worker in this field has to be able to live and work with the fact that a great deal of hard work completed one week may all have to be done again in a slightly different form in three weeks time. The whole care plan might have to be completely changed in another month. Flexibility is one of the most important attributes for a social worker who works in this field."
6.24 The role of agent of social control, who helps maintain the social system against the demands of individuals whose behaviour is seen as problematic, is less in evidence in social work with older people than in fields such as criminal justice. Social workers with older people are however familiar with the expectation that they will 'do something' to reduce the challenge presented by an older eccentric person whose lifestyle - perhaps hoarding, perhaps unhygienic, perhaps merely bizarre - is uncomfortable for or even unacceptable to the local community.
6.25 In conclusion, the 'core roles' of a social worker identified in the Interim Report of the 21 st Century Review are highly relevant to effective social work with older people with all sorts of needs. It is the ability to address complexity of needs and assess and balance risk, combined with a holistic approach and an anti-ageist value base, which provides the foundation of the social worker's distinctive and effective contribution to work with older people - one of the most stimulating and rewarding of all the fields in which social workers practice.
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