DRAFT BASW POSITION ON SOCIAL WORK AND INTEGRATION BETWEEN HEALTH AND SOCIAL CARE

Transcription

1 DRAFT BASW POSITION ON SOCIAL WORK AND INTEGRATION BETWEEN HEALTH AND SOCIAL CARE

2 Cntents Sectins Page Reasns fr develping a BASW plicy n integratin 2 Key Pints the imprtance f scial wrk in the integratin 3 debate Summary f BASW psitin n integratin 5 Effective Partnerships Key Questins 6 BASW s views n integratin 6 BASW Charter fr integrated wrking. 7 Actins 9 Appendix 1 10 Backgrund infrmatin n the integratin debate between health and scial care. Appendix 2 details: 15 A) The Scial Care Perspective B) The impact f integratin n scial wrk identity C) Resurces D) Inherent cntradictins in the system References 19 1

3 Integratin f scial wrk and health services BASW England plicy n integratin f services and the rle f scial wrk, the scial mdel and scial wrkers within integrated services. Je Gdden Prfessinal Officer Reasns fr develping a BASW plicy n integratin 1. BASW is develping a plicy in relatin t the integratin f health and scial care in respnse t develpments in natinal plicy by all the majr plitical parties. The key aim f the plicy will be t help scial wrk practitiners understand the cncepts f integratin and t examine the implicatins fr scial wrk and the scial mdel f care f the mve twards mre integrated health and scial care. BASW will cme t a view n the implicatins f integratin, which will becme a plicy. This paper aims t help mve twards the establishment f a BASW plicy. The key current driver fr the integratin f scial care and scial wrk with the health service is the crisis f capacity in the health service mainly fr lder and disabled peple needing discharge and supprt within the cmmunity. While there has been a fcus n the difficulties f A&E and cmmunity health services in the current crisis there is als a lnger term challenge in the ability f scial care services t meet the needs f a grwing ppulatin. Wider demgraphic and scial changes have increased the number f lder peple with cmplex cnditins and disabilities dependent n ever scarcer scial care services and weaker supprt within their family and cmmunity. Infrmal supprt systems in families and cmmunities are recgnised in recent plicy frm Gvernment as essential fr the health and scial care systems t be able t cpe and there are initiatives t try and supprt cmmunities via early interventin and preventative services in rder t reduce the pressure n health and scial care supprt services. Yet changes in family structures and increased gegraphical mbility wrk against that visin being materialised. Current natinal plicy discussin runs the risk that the rle f scial wrk and scial care services is/are seen as being adjuncts t health services. The pints in Sectin 2 belw highlight issues raised by BASW members regarding the integratin debate. 1 The term integratin is used in a very nn fcused way in the literature and discussin f health and scial care. The term is used in this paper t refer t changes in the way that services are rganised in rder t bring clser wrking relatinships between health and scial care fr the benefit f users f services. Hwever the general term integratin des need t be further defined. See Sectin 5 fr further explanatin. Integratin can be used t describe partnership wrking, withut full rganisatinal mergers. 2

4 2. Key Pints raised by BASW members a) Scial wrkers are already wrking clsely with health agencies in a range f settings including mental health trusts, hspital discharge teams and GP practices. Scial wrkers are als members f interagency yuth ffending, drugs and alchl teams and child mental health and child prtectin (MASH) teams. The level f integratin and perceived effectiveness f these arrangements varies but prvides scial wrk as a prfessin with useful experience t cntribute t the natinal debate b) The level f integratin varies acrss the UK and therefre useful lessns can be learnt. In Nrthern Ireland there is a lng established structural integratin, in Sctland and Wales a mre recent partnership mdel has been develped c) That there are ften substantial differences between a scial wrk perspective and a health perspective. Scial wrk has its rts in an empwering mdel f wrking with peple, the health service has a traditin f being much mre hierarchical. These cultural differences need t be carefully addressed in rder t imprve services fr peple wh use scial care and health services. Scial wrk is als rted in the traditin f relatinships, a key skill t slice thrugh the intractability f inter-agency wrking is t fcus n the imprtance f healthy relatinships. When they wrk well yu get innvatin and new fresh ideas and ways f wrking. It's abut listening and learning frm each ther and is based n mutual respect. d) Scial wrkers have pineered the imprtance f putting the needs f users f service and carers at the centre f service delivery by trying t wrk with peple, rather than fr peple. This apprach is less develped in health and sme ther agencies e) BASW recgnises that service users and carers can be subject t multiple assessments, with fractured care pathways, pr cmmunicatin leading t serius incidents and the dangers f sil wrking. We therefre supprt flexibility and creativity t imprve the service user / patient experience f pathways. Hwever scial wrkers have skills and knwledge that they uniquely bring t the table and they shuld be supprted t implement them. Equally there are skills and knwledge that scial wrkers aren t equipped with, such as in depth practical knwledge f persnal care and nursing skills. Scial wrkers shuld nt be undertaking thse rles f) A cre functin f scial wrk, and ne that scial wrkers are especially skilled in, is wrking with a range f agencies t address all aspects f a persn s circumstance. The agencies that scial wrkers wrk with include: health, husing, emplyment, finance and educatin g) The implementatin f the Care Act prvides an pprtunity t develp the multi-agency rle further with the new respnsibilities f lcal authrities in prviding supprt t carers, wider family and cmmunity services t vulnerable peple in their wn hme and a fcus n preventing peple requiring health and scial care services 3

5 h) In rder the carry ut the functins f preventin and early interventin as detailed in the Care Act scial wrkers need t wrk clsely with wider cmmunity services and be in a psitin t advcate independently fr vulnerable peple and their carer s in the cmmunity rather than being absrbed int health structures. This will require scial wrkers t spend time in lcal cmmunities, frging relatinships and netwrks rather than being ver cnstrained by care management r the health service i) Over the last fur years there has been cnsistent feedback frm BASW members wh are lcated in health teams that many f them find that prfessinal scial wrk supervisin, training and supprt are nt adequately prvided and that the scial wrk perspective can becme marginalised j) Lessns learnt tell us that initiatives t integrate services have had a varied histry. Many initiatives have had a shrt term time span ften due t shrt-term plitical and financial cnsideratins. A mre sustainable strategy is needed with a clear visin. BASW urges crss party cnsensus t avid future unnecessary change and rerganisatin and supprts mst f the recmmendatins f the Barker Reprt, (Barker K. (2014) k) The research evidence n integratin is remarkably thin. BASW are cncerned that plitical plans are driving change, rather than prperly researched and evaluated pilts. 3. Summary f BASW psitin BASW supprts jined up wrking in equal partnership with the health services. We hwever d nt supprt full scial wrk and scial care integratin/absrptin int the health service. We feel that scial wrk shuld supprt changes in the health service and cntribute t the develpment f imprved persn centred care while still having strng links with lcal gvernment including husing and public health services. The vast majrity f cmmunity based prvisin fr scial care and increasingly health is prvided by the private sectr. Partnership wrking als needs t take place with that sectr. We acknwledge that scial wrk and health care are being drawn clser tgether and that many scial wrkers wrk successfully in the health envirnment, althugh nt necessarily directly emplyed by health. We recgnise that the public expect us t be wrking tgether and are nt tlerant f interagency differences where health and well being is at stake. Our preferred mdel is a partnership mdel with jined up services nt full structural integratin int a single rganisatin. The meaning f the term partnership being: A relatinship between individuals r grups that is characterised by mutual cperatin and respnsibility, as fr the achievement f a specified gal. (The free dictinary.cm). Whatever mdel is develped there is a strng case t ensure that scial wrkers maintain an independent prfessinal structure and vice with line and senir managers cming frm a scial wrk backgrund. Scial wrkers als need access t relevant training and scial wrk develpment prgrammes, including prgrammes that cnslidate issues f prfessinal identity. (The experience f integrated services in mental health reinfrces the imprtance f prfessinal supervisin). The Care Act 4

6 delegatin f functins means there can be a variety f prviders f scial wrk services. Fr example GP practices/ alliances are able t emply scial wrkers alng with Health Trusts. The standards fr emplyers f Scial Wrkers in England 2 are nt cmpulsry and there are n cmpliance checks ther than the vluntary health checks in place. Cmmissiners ften d nt include a practice gvernance framewrk as cmpulsry and therefre the envirnment in which scial wrkers will wrk and the supprt they receive will be very variable and ptentially negligent f the needs f the prfessinal wrkfrce and may result in prer utcmes fr individuals in sciety. BASW believe that there are substantial benefits fr service users in partnership wrking, but the imprtant perspective f scial wrk and the scial must be prtected against the dminant health (r illness) mdel. BASW shuld use the pprtunity f the current debate n the future f the health service and devlutin f health and scial care pwers t regins, t seek crss party cnsensus and prmte the rle f scial wrk in shaping the future develpment f health and scial services. 4. Effective Partnerships Key Questins Frm ur experience f previus integratin r partnership initiatives we feel the fllwing issues need t be cnsidered in any integratin / partnership prject and wuld advise members t raise these if a scheme is being cnsidered in their area: A clarity as t the nature f the prpsed relatinship between health and scial care, r ther partners. Are the prpsals fr full structural integratin, giving ne rganisatin the rle f lead partner, r are the prpsals t cntinue with tw autnmus rganisatins, but with agreements abut hw wrking tgether is t be realised? Sustainability and Cmmitment. Is the prject being cnsidered as part f a lng term strategy? Hw easy wuld it be fr either partner t withdraw n the basis f shrt term plitical r financial factrs? Prfessinal Identity: Hw far are scial wrkers guaranteed a scial wrk jb descriptin, supervisin, and a structured prfessinal develpment framewrk that emplyers must fllw? Are scial wrkers in integrated structures represented at the health Bard Level? Regardless f the rganisatinal mdel will there be the necessary investment in jint training and staff develpment t ensure mutual understanding f all prfessins? This investment needs t include tasks and rles that scial wrkers and ther prfessinal grups can and cannt undertake 2 Standards fr Emplyers f Scial Wrkers in England Lcal Gvernment Assciatin 5

7 Infrmatin systems and data. Will infrmatin systems be integrated t avid duble inputting and will scial care data be cllected and cnsidered alngside health data? Gvernance. Will plicies and prcedures be aligned and represent the scial wrk mdels f wrking? Wider Cmmunity Partnerships. Hw will these be prmted and extended. These may include husing, leisure and health prmtin? Appendix 1 sets ut backgrund infrmatin n the integratin debate between health and scial care, including an explratin f the definitins f integratin and a descriptin f a mdel f seeing integratin as a cntinuum frm c-peratin at ne end f the spectrum t a single rganisatin at the ther end. The histrical cntext f integratin is described as well as a summary f Gvernment plicy and a brief reference t the internatinal situatin regarding integrated wrking. 5. BASW s views n integratin BASW wants t create better services fr peple acrss health and scial care and ther related rganisatins such as husing, criminal justice, educatin, plice, yuth wrk etc. We supprt wrk t enable better c-peratin between rganisatins and where apprpriate t integrate services structurally. (Althugh the evidence f the benefits f structural integratin is limited as reprted by the Kings Fund 2015). We believe that the utcmes fr peple wh use health and scial care services shuld be the paramunt cncern. Hwever we have significant cncerns abut the directin f travel taken t achieve these utcmes. We live in a wrld where plitically and ecnmically the health agenda massively dminates the scial care agenda and we believe that this dminatin can be t the detriment f the vital scial care perspective, which will be t the detriment f peple wh have scial care and health needs. Our cncerns abut the verall directin f plicy are: A. The risks t the scial care perspective frm integratin with health B. Impact f the plicies n scial wrk identity and cntributin C. Adequacy f resurcing, which is inadequate nw and culd becme wrse if scial wrk and scial care funding is subsumed within health and is inadequate nw D. The inherent cntradictins in the way that health and scial care systems wrk E. Benefits that scial wrkers bring t integratin These pints are explred in Appendix 2 6. BASW Charter fr integrated wrking BASW has drawn up a charter fr scial wrkers wh are wrking within frmal integrated systems r within a partnership arrangement. The charter applies acrss varius mdels f 6

8 integratin, frm structural the creatin f a single integrated rganisatin, thrugh t partnership arrangements and c-peratin agreements. BASW is supprtive f partnership wrking where it is dne well and prperly and is apprpriate. As stated abve the evidence base fr fully integrated systems appears t be weak as the reprts by the IPC, SCIE, and the Kings Fund shw. What cmes acrss is that a fcus n the needs f service users and carers and their invlvement in develping jined up services is essential. It wuld appear frm this evidence that structural changes are nt necessarily the answer t c-rdinated and integrated care. Regardless f what the rganisatinal arrangements are BASW states that the fllwing need t apply: There must be genuine service user and carer invlvement in bth the creatin f partnerships / integrated services and in the n-ging management f them Scial wrkers and scial wrk managers shuld be engaged frm the utset in the develpment f plans t recnfigure and change services Cmmissining managers must recgnise that scial wrk is a prfessin with its wn principles and cde f ethics and unique knwledge and skill set. This knwledge and skill set includes safeguarding, the law, case management and persnalisatin, but als relates t wider knwledge emanating frm research and practice. This includes a high level f understanding f the scial mdel f disability and a cmmunity apprach t interventin Interagency grups must be established t versee agreements Regular gvernance meetings at senir management level must take place t mnitr partnership r integratin arrangements There needs t be scial wrk representatin at senir management meetings f rganisatins and partner rganisatins. This representatin shuld be frm smene wh clearly wns the lcal authrity scial care prtfli That clear lines f accuntability, leadership and supprt t middle managers are set up in rder t take the scial care agenda frward The scial mdel f disability and knwledge f scial care services and the scial care perspective must be incrprated int the training f all partner prfessinals Scial Wrkers must be supprted t retain their ccupatinal rle undertaking scial wrk tasks as described in the PCF, HCPC and Knwledge and Skills Framewrk There must be active prmtin f the value f the scial care wrkfrce Everyne respnsible fr persnnel issues, if frmal agreements are set up, must be trained in the requirements f the Care Quality Cmmissin and HCPC Scial care leaders shuld ensure that that supprt services are in place fr scial wrkers IT HR, finance, learning and develpment. This includes ensuring that 7

9 scial wrkers, whether secnded t partners r directly emplyed, have the tls t engage with partner agencies (such as access t all partner internet and intranet and recrding systems) Rbust arrangements must be put in place t ensure that scial wrkers receive gd quality supervisin frm qualified scial wrkers, which includes: prfessinal supervisin within the team frm an experienced scial wrker supprt fr the experienced scial wrker frm an external mentr There shuld be an adequate number f scial wrkers in multi-disciplinary teams There shuld be a scial wrk frum in each lcality that is separate frm ther prfessins in rder t build and sustain identity That scial wrkers are supprted t have an independent vice. This needs t be applied in supervisin and supprted by prfessinal cdes f practice and teaching and learning strategies. It can be hard as a member f a multi-disciplinary team t criticise the decisins f ther prfessinals. Scial wrkers need t be supprted when they refuse t undertake smething that they see as unethical, wrng, r indeed in sme cases unlawful Agencies emplying scial wrkers in integrated settings, need t undertake an audit n a regular basis f the experience f scial wrkers. The audit t develped by the DH fr mental health scial wrkers is helpful (DH Jan 16) Actins This dcument will infrm: The supprt given by BASW and the SWU t scial wrkers wrking in jint teams r faced with prpsals fr integratin. Discussins with a wide range f relevant bdies including Skills fr Care, the Department f health, ADASS, Devlved Reginal Authrities. Any Media input Plicy briefing papers and guidance leaflets will be develped fr this purpse based n this dcument. BASW will cntinue t review and develp this plicy in cnsultatin with members wh are affected by changes It will be helpful fr members t ntify BASW f practice issues bth difficulties and examples f gd practice in jint wrk with health and ther agencies. Yu can e mail j.gdden@basw.c.uk r england@basw.c.uk yu can als use the BASW frum n the member pages f the BASW web site. 8

10 Appendix 1 Backgrund infrmatin n the integratin debate between health and scial care. The term integrated care is used widely in Gvernment plicy statements. Althugh the term can apply t integratin with husing, health, scial care, the plice, prbatin etc. it is mst ften used t talk abut integratin between health and scial care. This paper fcuses n the latter hwever there is als sme relevance fr integratin between ther services, particularly with husing, which ught t include wrking with the residential and nursing hme sectr. The term integratin is rarely tightly defined, but in current plicy use is used t bth describe utcmes fr the peple using services and structural cncepts. The structural cncepts describe the rganisatinal arrangements. Definitins are ften lse varying frm descriptins f unified single structures, with single management arrangements and single budgets t much lser definitins which refer t multi-agency wrking r partnership wrking. In the literature there desn t seem t be clarity as t whether integratin is abut utcmes, r structures. The fllwing statement is clear, but nt all are as clear as this: Integrated care and supprt isn t the end. It is the means t the end f achieving high quality, cmpassinate care resulting in better health and wellbeing and a better experience fr patients and service users, their carer s and families (Integrated Care and Supprt (2013). The Health and Scial Care Act 2012 set ut specific bligatins fr the health system and its relatinship with care and supprt services. It gave a duty t NHS England, clinical cmmissining grups, MONITOR and Health and Wellbeing Bards t make it easier fr health and scial care services t wrk tgether. (Cited in: Health and Scial Care Integratin DH (2015). The use f the term integrated care is als ne that is used acrss specialities. Fr example lder peple s care primary and secndary levels, mental health cmmunity and hspital, learning disabilities cmmunity and hspital and als is used in children s services, particularly specific integrated r multi-disciplinary teams t supprt aimed at safeguarding children (and families). The Stevens Reprt Five Year Frward View (2014) mentins scial care several times, including the statement that The NHS will break dwn barriers in hw care is prvided between health and scial care. The diagram belw gives a visual presentatin f the range f ptins that are available t bring health and scial care services clser tgether; COLLABORATIVE ARRANGEMENT Wrking tgether. Better crdinatin. Budgets nt pled. Teams may be virtual r wrking in ne place MORE FORMAL PARTNERSHIP Teams c lcated, sme degree f jint management. Sme degree f sharing f budgets. Legally separate A FORMAL PARTNERSHIP Pled budgets. Teams c lcated, definite single management arrangements Pled budgets. Legally separate INTEGRATION One rganisatin e.g. Care Trust. All staff emplyed by the Trust, (r this is an intentin). One budget. Legally ne Legally separate 9

11 The Care Act 2014 uses the term cperatin rather than the term integratin. Fr example: (1)A lcal authrity must c-perate with each f its relevant partners, and each relevant partner must c-perate with the authrity, in the exercise f: (a) their respective functins relating t adults with needs fr care and supprt (b) their respective functins relating t carers, and (c) functins f theirs the exercise f which is relevant t functins referred t in paragraph (a) r (b).(hm Gvernment 2014) (2)A lcal authrity must c-perate, in the exercise f its functins under this Part, with such ther persns as it cnsiders apprpriate wh exercise functins, r are engaged in activities, in the authrity s area relating t adults with needs fr care and supprt r relating t carers. (The Care Act 2014) The idea f health and scial care wrking tgether is nt new. Ever since the inceptin f the NHS there have been calls and attempts fr the health and scial care sectrs t wrk tgether. (Bamfrd, T. (2015). Nrthern Ireland is ften quted as a place where integrated care ccurs. Kings Fund state Nrthern Ireland has had integrated health and scial care since 1973 but there has always been a cmmissiner prvider separatin thrughut this perid. (Kings Fund June 2015). It is ntewrthy hwever that BASW members wh wrk in the Nrthern Ireland Health Trusts reprt that althugh health and scial care is cmbined within ne rganisatin that services are separately cmmissined and that scial wrk and scial care can feel that health and scial care has divisins...althugh we have an integrated structure it desn t always slve the prblems. We have had in the past mney fr health ring fenced but mney fr scial care hasn t been. There have been varius attempts in England t bring aspects f health and scial care tgether by permitting and encuraging jint wrking, via Jint Cnsultative Cmmittees, jint funding, r pled funding arrangements. This has been applied since the 1980s. In the 1970 s and 1980 s GP attached scial wrkers were nt uncmmn, but reduced in number frm the late 1980 s. (Bradley, G. (2000) and Davies, M. (2007). The ptin f care trusts as a single lcal integrated care rganisatin, was intrduced as part f the NHS Plan 2000 (With nt much success in practice in terms f implementatin).the Health and Scial Care Act 2012, placed new duties n rganisatins t prmte integrated care and retain the previus legislative flexibilities fr pled budgets, lead cmmissining and integrated prvisin. The 2012 Act als intrduced health and wellbeing bards as a new lcal vehicle t prmte integratin. They have a statutry duty t prmte integratin, assess the needs f their lcal ppulatin thrugh a jint strategic needs assessment and agree a health. (Cited in Humphries, R Wenzel, L. June 2015). Within health and scial care the pled budget arrangements have mst cmmnly applied t mental health, cmmunity equipment and learning disability services, where since the 1990 s many lcal authrities and health authrities have pled their resurces. These services are ntable because they fcus n services fr peple whse needs spanned health and scial care. Usually the lead fr mental health has been health and fr learning disability services this has been scial care. Hwever as the King s fund detail, the simple fact f having a pled budget des nt necessarily 10

12 lead t an integrated service that has psitive utcmes fr service users. The King s fund say that fr psitive utcmes t be achieved the fllwing cnditins must apply: The structural integratin f the health and scial care system in England will bring few benefits unless it is accmpanied by ther changes, including: a willingness t challenge and vercme prfessinal, cultural and behaviural barriers actin t share infrmatin bth within the NHS and between health and scial care rganisatinal stability t avid the distractins and delays that ccur when structures are altered frequently a willingness t prvide financial supprt and flexibilities t enable the intrductin f new mdels f care. rganisatinal stability and leadership cntinuity are imprtant facilitatrs f integrated care. (Kings Fund June 2015) Similar pints had previusly been made by Institute f Public Care (2013) and als by SCIE, wh reprted the evidence base underpinning jint and integrated wrking remains less than cmpelling: It largely cnsists f small-scale evaluatins f lcal initiatives which are ften f pr quality and prly reprted. N evaluatin studied fr the purpse f this briefing included an analysis f cst-effectiveness. There is significant verlap between psitive and negative factrs, with many f the rganisatinal factrs identified in research as prmting jint wrking als being identified as hindering cllabratin when insufficient attentin is paid t their imprtance. (SCIE 2011) Skills fr Care (2013) reprted that: The evidence relating t integrated health and scial care mre generally, and wrkfrce issues mre specifically, has ften been described as prblematic, and this review fund it t be weak. The Barker Reprt s (2013) primary recmmendatin was that England mves t a single, ringfenced budget fr health and scial care, with a single cmmissiner. Current Gvernment Plicy n integratin is as fllws:..services ften dn t wrk tgether very well. Fr example, peple are sent t hspital, r they stay in hspital t lng, when it wuld have been better fr them t get care at hme. Smetimes peple get the same service twice - frm the NHS and scial care rganisatins - r an imprtant part f their care is missing. This means patients d nt get the jined-up services they need, leaving them at increased risk f harm. Health and care staff may miss pprtunities t make things better fr patients and service users, and taxpayers mney is nt being used as effectively as pssible. In the care and supprt white paper, we cmmitted t wrking with ther rganisatins t make evidence-based integrated care and supprt the nrm ver the next 5 years. Wrking with natinal partners, we are remving barriers by: c-prducing Integrated Care and Supprt: ur shared cmmitment - a dcument setting ut hw lcal areas can use existing structures fr integrating care 11

13 agreeing and publishing a definitin f integrated care inviting and supprting lcal areas t act as pineers and exemplars, t develp and demnstrate the use f innvative appraches t efficiently deliver integrated care.(department f Health May 2015). The Gvernment plicy has been supprted by The Better Care Fund, is being used t pilt integrated wrk between health and scial care, particularly arund hspital admissins and discharge. The ft quted pineer f this apprach is Trbay. Research by the King s Fund in 2012 int the utcmes fr peple in Trbay wh experienced the integrated service is smewhat tentative. There is sme evidence f reduced hspital admissins and shrter stays in hspital in areas where integrated care, althugh nt clear cut. (The Kings Fund 2012) The King s (June 2015) fund have mre recently reprted n integrated care pilts, supprted by The Better Care Fund. They cnclude that: There is n ne mdel f care c-rdinatin, but evidence suggests that jint cmmissining between health and scial care that results in a multi-cmpnent apprach is likely t achieve better results than thse that rely n a single r limited set f strategies. Hwever the cmpnents include: a mve t cmmunity-based multi-prfessinal teams based arund general practices that include generalists wrking alngside specialists a fcus n intermediate care, case management and supprt t hme-based care jint care planning and c-rdinated assessments f care needs persnalised health care plans and prgrammes named care c-rdinatrs wh act as navigatrs and wh retain respnsibility fr patient care and experiences thrughut the patient jurney. The reprt desn t supprt ne way r the ther structural integratin f rganisatins t achieve care c-rdinatin. Organisatins, including ADASS and the LGA have welcmed the Integrated Care Fund, hwever they and thers have made strng criticisms that the fund will nt be able t achieve its bjectives because f the reductins in budgets fr adult scial care that cuncils are having t deal with even if all f this is cunted as new resurces fr cuncils, lcal gvernment budgets are set t fall by 2.3% in real terms frm t , suggesting mre pain fr adults and children s scial care, bth f which are facing rising demand.(cmmunity Care June 2013). It is f nte that all the bjectives f the Better Care Fund are NHS bjectives, principally abut hspital discharge and preventin f hspital admissin. The Lcal Gvernment Assciatin als welcmed the integrated care funding but warned that the wider cuts wuld mean..sme cuncils will simply nt have enugh mney t meet their statutry respnsibilities, given the gravity f cuts already made t lcal gvernment since 2011 (Cmmunity Care June 2013). The reprted further 30% cuts in Lcal Gvernment frm as part f the Autumn Statement and Cmprehensive Spending 12

14 Assessment further cmpund the ptential fr meltdwn in the prvisin f adult scial care services. Anther Gvernment plicy is t delegate all health spending t lcal areas. Manchester Dev Manc is an example f ne f thse areas. The plan is t delegate all health expenditure t Greater Manchester s that health and scial care expenditure can be pled. Devlutin t Greater Manchester shuld enable decisins t be taken much clser t the ppulatin being served, with cuncillrs having a bigger influence n future decisins. This raises the prspect f a health care system similar t thse in the Nrdic cuntries where reginal and lcal pliticians ften have a mre significant rle than their natinal cunterparts in the running f health and care services. The unanswered questin is hw much freedm public sectr leaders will have t depart frm natinal plicies in taking greater cntrl f NHS resurces. This is ne f many imprtant issues that will need t be wrked thrugh in 2015/16, which will be the build-up year. We have n knwledge at the mment abut whether devlutin t Greater Manchester r ther regins wuld affect hw health and scial care services are cmmissined and delivered n the grund. The main risks f the plans are that they will take time and effrt away frm wrk t address the grwing financial challenges facing lcal gvernment and the NHS, and that they will result in cnfused accuntabilities. The wrst f all utcmes wuld be further structural changes t the health service that distract public sectr leaders frm their cre task f imprving utcmes fr the ppulatins they serve. It will be just as imprtant t ensure that gvernance arrangements help t clarify where respnsibility fr prviding leadership f public services rests, especially as the calitin gvernment s refrms have left a vacuum in the NHS that needs t be filled. (Kings Fund March 2015) The Independent Cmmissin n Lcal Gvernment Finance endrsed the Barker Cmmissin s recmmendatin fr a single spending settlement. It has gne further by recmmending the intrductin f place-based budgets cvering a wide range f lcal budgets fr places that are willing and able t take n this refrm (Chartered Institute f Public Finance and Accuntancy 2015, cited in Humphries, R Wenzel, L June 2015). This reflects a grwing interest in the devlutin f respnsibilities and resurces frm Whitehall t lcal areas, perhaps best exemplified in Greater Manchester s prpsals fr a cmbined health and scial care budget. A recent review f primary care health services endrsed the recmmendatin fr a single pint f access t cmmunity services and scial services fr urgent assessments. T facilitate effective multi-disciplinary assessment (fr example, acutely ill lder peple, discharge planning), staff frm the necessary range f healthcare disciplines and frm scial services shuld be c-lcated and develp a team-based apprach (Primary Care Wrkfrce Cmmissin (July 2015) (BASW England cmmented n the review at pre-publicatin stage). In the reprt Optins fr integrated cmmissining Beynd Barker (Humphries, R Wenzel, L June 2015) the authrs reprt the testing and discussin f the Barker Cmmissin s findings and recmmendatins with stakehlders frm charities and patient/service user rganisatins, natinal bdies representing prfessins and rganisatins in the NHS and lcal gvernment, as well as academic and technical experts. These discussins indicate a 13

15 substantial.grundswell f supprt fr the central prpsitin f a new settlement based n a single ring-fenced budget and a single lcal cmmissiner. But the biggest cncern expressed by stakehlders especially frm within the NHS and lcal gvernment was hw a new settlement culd be achieved withut majr rganisatinal change, t which there is almst universal aversin. The reprt ges nt say that the evidence fr the need fr integratin is strng and they ech the findings f the DH (2013) reprt that that fragmented and disjinted care have a negative impact n patient experience, result in missed pprtunities t intervene early, and cnsequently can lead t prer utcmes. Pr alignment f different types f care als risks duplicatin and increasing inefficiency within the system (Department f Health 2013). Prblems with cmmunicatin and jint wrking ccur bth within primary health care and lcal authrity care services and between secndary health services and the cmmunity (bth health and scial care). A study published in February 2016 f issues relating t integratin cncerning mental health scial wrk fund a varied picture abut the directin f integratin. The implementatin f the Care Act and cntinued pressure n resurces demnstrates that fr sme scial wrkers and scial wrk teams wrking in mental health that there have been particular pressures including examples f relcating scial wrkers frm mental health t mre generic adult teams. (Mersey Care NHS Feb 2016) The abve details nly plicy in relatin t England. A quick lk at internatinal cmparisns indicates that in sme cuntries scial wrkers are fully integrated int primary care and that their rle is nt cnfined t a narrw case management apprach, but includes a cmmunity apprach and public well-being apprach. An example f that is given regarding the Irish Republic (Fleming T. et.al 2011, supprted by persnal crrespndence with ne f the authrs).anther example is Canada where Scial wrkers are key members f inter prfessinal primary care teams in Cmmunity Health Centres, Health Service Organizatins, Academic Family Practice Units and Shared Care Teams. (Ontari Assciatin f Scial Wrkers (2005). Masn et.al (2015) in a recent review f internatinal integrated health and care funding arrangements nted the widespread use f jint budgets as a means f prmting integrated care. The review explred sme f the challenges assciated with the implementatin f these arrangements and in particular stressed the imprtance f their being underpinned by effective wrking relatinships and leadership acrss the system. The Scttish Gvernment has created a cmpletely new legislative framewrk fr integratin between health and scial care cmmissining and delivery the Public Bdies (Jint Wrking) (Sctland) Act This has the aim f prviding high-quality care and jined-up services that supprt peple t stay in their hmes, and f ensuring resurces are used effectively t prvide services fr the grwing ppulatin f peple with lng-term and cmplex cnditins, many f whm are lder. Health bards and lcal authrities are required t enter int integrated partnership arrangements by April 2016 that will: have an integrated budget as a minimum this will cver adult scial care, adult cmmunity health care, and aspects f adult hspital care. (Cited in Humphries 2015). 14

16 Appendix 2 details: A The Scial Care Perspective, B) The impact f integratin n scial wrk identity, C) Resurces and D) Inherent cntradictins in the system 15 A) The scial care perspective and the risk t it f integratin Scial factrs cntribute t many f the prblems that peple experience. This includes islatin, pverty, lack f persnal and cmmunity resurces, stigma, prejudice, discriminatin. Scial wrk and scial care have a bdy f knwledge and research that demnstrate that the scial wrk perspective hlds valuable lessns fr plicy. The perspective n the wrld that is recrded in the BASW Cde f Ethics is rted in the scilgical and psychlgical traditin. This is the traditin that we are nw glad that the health prfessin is embracing, at least in sme f its statements f plicy persn centred, well-being nt just being abut an illness. There has been supprt frm a number f rganisatins fr a hlistic rle fr scial wrkers wrking in adult services. This includes wrk by the BASW Scial Wrk With Adults Reference Grup (BASW SWARG 2012). ADASS. The Cllege f Scial Wrk (2013, 2014) and The DH Knwledge and Skills Statements Scial Wrk with Adults (DH 2015). The cmplexities f this hlistic apprach t understanding human behaviur and systems des nt lend itself easily t traditinal ratinalistic scientific research, because f the multi factrial influences n peple. Hwever there are examples f a ratinalistic evidence base fr the scial perspective. One example frm mental health is wrk by Jerry Tew and thers. Tew, (2012) gives an example f evidence in the field f mental health where he says the mst imprtant factr in recvery wuld seem t be scial pprtunities e.g. reclaiming valued scial rles / identities; persnal relatinships f giving and receiving (Tew et al, 2012). Martin Webber (2015) argues that the scial perspective cntributin t mental health scial wrk: We need t restate ur interventin ptential as champins f scial perspectives in mental health services. This requires the adptin f epistemlgical paradigms beynd scial wrk t influence NICE guidelines and t challenge the dminance f psychiatry and psychlgy. Similar issues apply t the area f wrk f wrking with peple with a learning disability. Scial wrk has pineered cmmunity alternatives t hspitalisatin, yet the pwer f funding has remained ften with health, as seen in the fall ut f the Winterburne View scandal (DH 2012). Really gd integrated cmmissining can vercme these tendencies as Salfrd have demnstrated, (Prfessinal Scial Wrk July August 2014). Integratin can wrk, but the principles funded in scial wrk values such as human rights have had t dminate. Mental health services were ne f the first t cmbine scial services and health functins, with mental health trusts taking the lead n the prvisin f mental health services. This led frm the 1990s t scial wrkers and scial care staff taking their lead frm, and frequently being directly emplyed by health trusts. BASW fund that in sme areas this was very effective, with gd utcmes fr patients and the scial care perspective being well integrated int the eths f health. (BASW 2010). Hwever the last few years has seen an appraisal f the effectiveness f such arrangements, with sme scial service departments pulling ut f pled arrangements. (BASW (2013). Evidence frm this survey fund that

17 scial wrkers had very mixed experiences f wrking in multi-disciplinary teams, varying frm great satisfactin, with pride that their views and perspectives were listened t, t strng cncerns that the vice f scial wrk and scial wrkers was marginalised. There are sme interesting pilts taking place t lk at the impact f integratin frm a wrkfrce perspective, which is welcmed. Fr example Health Educatin Nrth West (HENW) has established a dedicated wrkfrce transfrmatin functin in January (Health Educatin Nrth West). We d nt have gd evidence f the perspective f scial wrkers in the new integrated primary care teams. Anecdtal evidence hwever shws that scial wrkers are supprtive in thery, but that hw this apprach will wrk in practice will depend n the srt f factrs that have been identified by SCIE, The King s Fund and the Institute fr Public Care. Anecdtal infrmatin frm members indicates that sme f the integrated teams are nt integrated in any legal sense, but are lcal practice arrangements. Fr example basing scial wrkers in GP practices, r c-lcating primary care health and scial care wrkers in health centres (fr example in Leeds and Staffrdshire) but the scial wrkers still being emplyed by lcal authrities. This srt f mdel wuld appear t have the advantages f rganisatins wrking c-peratively, withut all the structural changes that full integratin wuld entail. One f the biggest challenges t integratin (hwever defined) is cultural. As Bamfrd (April 2015) states: The greatest difficulties lie in the different cultures and values f health and scial care. Scial care s value base is derived frm scial wrk. It emphasises the empwerment f service users; it stresses the rights f users t self-determinatin and has a cmmitment t scial justice. Medicine, histrically, has been mre paternalistic and fcused n meeting individual and specific health needs. Pririties in healthcare are changing, but preventin and health prmtin are lw-status activities. Genuine integratin has t lk at the wellbeing f individuals and cmmunities. This shift f fcus requires a whle-system apprach. Anecdtal evidence frm sme scial wrkers wrking in integrated adult trusts reprt that there are strng differences f apprach fr example between scial wrkers and cmmunity nurses ver individual service users / patients and decisins as t whether residential care is needed r nt. B) The impact f integratin plicies n scial wrk identity. Identity is imprtant t prfessinalism. If wrkers in any prfessin feel that they are part f a wider traditin, rted in practice, research and values then they will feel mre valued and will perfrm better. Cnversely rle cnfusin, lack f identity r attacks n prfessinal identity will lead t issues f pr mrale and pssibly pr perfrmance. These issues were reprted n in a BASW (2010 BASW) and were further evidenced in BASW (2013). The issues explred thse papers demnstrated sme f the challenges f partnership wrking in mental health. The reprts gave details f sme lcal authrities pulling ut f partnership agreements with health services. This was als reprted in Cmmunity Care (2013). Chatzirufas, (2012) explred the views f practitiners wrking in multi-disciplinary mental health teams and fund mixed satisfactin. Feedback frm BASW members has been that the issues and lessns frm the BASW studies equally apply in ther multi-disciplinary settings and cntinue t apply in sme mental health settings. (Als see Bailey D and Liyanage, L (2012). Carey argues that there are risks t scial wrk identity frm the mve t integratin. He states: Scial wrk practitiners are nw increasingly integrated within 16

18 multiagency health and scial care settings which mean that wnership f their casewrk may be lst in favur f sharing with health care, educatin, unqualified r ther welfare staff, at times drawn frm different discursive and pedaggical terrains. Whilst such multidisciplinary practices may prvide new insights r the pssibility f effective cllabratin, it is als as likely t muddle interpretatins r generate cnflict r cultural and paradigm-related cnfusin r lead perhaps t idelgical clnisatin f seemingly mre legitimate bimedical paradigms and mdels f practice. (Carey, M. 2015) The reasns fr lcal authrities pulling ut f partnership agreements with mental health trusts are varied, but ne f the reasns given by sme scial wrkers was that they felt that their identity and prfessinalism was marginalised in multi-disciplinary teams. Nt nly is that prblematic fr the prfessinals invlved, but the independence f thught that scial wrkers can shw in the face f a dminant medical mdel is lst at a significant price fr users f services. Integratin dne well is psitive fr wrkers and service users, dne badly it is bad fr bth. This includes the rganisatinal and cultural issues identified by the Kings Fund and thers and in ur view the requirements t recgnise the value f scial wrk by supprting scial wrkers as detailed in BASW Charter belw. C) Adequacy f resurcing. It is nticeable that the plicy drive twards integrated health and scial care in relatin t lder peple s services has ccurred at a time f huge pressure n the NHS and austerity impacting n lcal gvernment. These pressures are recgnised and reprted n by the Gvernment in their plicy n integratin between health and scial care in relatin t lder peple s care where it is reprted that services ften dn t wrk well tgether. i The Better Care Fund, r Integrated Care Fund has seen significant sums f mney transferred frm health t scial care. This is t supprt the plicy bjectives described abve. Hwever there are significant cncerns in the scial care sectr that althugh the mney transfer frm health is needed and is desirable, that it des nt make up fr the verall reductin in scial care services caused by cuts in lcal gvernment funds. A lt f the integrated care fund mney is being spent n prpping up scial care services. It is reprted by ADASS that much NHS mney prvided t cuncils is being used t stave ff tighter threshlds n access t adult care services rather than invest in integrated care. The finding raises dubt abut the ptential f the Better Care Fund a 3.8bn pled budget between cuncils and the NHS frm , largely made up f health service resurces t deliver mre integrated services, (Cmmunity Care May 2014) D) Inherent cntradictins in the system. One f the big stumbling blcks t integratin f health and scial care is the issue f scial care being a charged fr service and being means tested, a pint made by the Barker reprt (Barker 2014). This has been an unreslved issue ever since the creatin f the NHS and scial care services. Anther issue is that it has prved very difficult t integrate systems at a practical level. Sme f the integrated services that have been running fr twenty years still have prblems with integrating their IT systems, their HR systems, their training and develpment systems and general plicy and prcedures. Put simply scial wrkers and thers still reprt that in spite f wrking in a s called integrated system they may nt be able t access the health IT systems, if they d that they might have t dual recrd events n bth scial care and health systems. 17

19 The evidence base fr particular integrated systems appears t be weak as the reprts by the IPC and SCIE shw. What cmes acrss is that a fcus n the needs f service users and carers and their invlvement in develping integrated services is imprtant. It wuld appear frm this evidence that structural changes are nt necessarily the answer t c-rdinated and integrated care. The IPC reprt (2013) and SCIE (2011) bth have sme accrd f the factrs that prmte and hinder integrated wrking between health and scial care services. The IPC reprt says that there was insufficient evidence t supprt r reject the hypthesis that: Particular rganisatinal structures supprt integrated appraches. Hwever the Gvernment appear t be pushing the integratin agenda very hard, regardless f evidence fr r against. Gvernment are pushing fr integratin via the use f such mechanisms (unsuccessfully as it happens) as the Integratin Fund and with s called Dev Max t regins. T many scial wrkers knw frm bitter experience that s ften partnerships have been set up withut the infrastructure t supprt integratin. In sme services, such as mental health integratin can be f benefit t the service user and retain the scial wrk identity: Being part f an integrated team is great. I nw wrk alngside district nurses, GPs, cmmunity OTs and thers. We have a much better understanding and appreciatin f each ther s rles and als respect fr each ther s rles. I am sure the service user gets a better service. Scial wrker, (BASW 2013) E) Opprtunities fr scial wrkers and benefits f having scial wrkers in integrated teams. Scial wrkers have develped expertise ver many years in c-prductin f persnal care plans and persnalised services, including wrking with service users t manage direct payments and persnal budgets. Persn centred care is intrinsic t scial wrk training and values. Scial wrk als has a histry f cmmunity engagement and where supprted there are gd examples f scial wrkers develping innvative cmmunity engagement appraches. Fr example the Chief Scial Wrker fr Adults has recently reprted n why the NHS needs scial wrkers, with a number f examples given t the benefits f a cmmunity based apprach. (Guardian December 8th 2015). Scial wrkers are ften the key prfessinal in c-rdinating diverse grups f prfessinals and prviders, using their skills f facilitating cmmunicatin in cmplex situatins and their knwledge f hw systems wrk. Summary f the BASW psitin in integratin Overall BASW is fully supprtive f c-perative wrking and breaking dwn barriers between rganisatins. We can see the benefits fr service users f wrking c-peratively between rganisatins. Hwever we have severe reservatins abut a headlng dash t create fully integrated health and scial care structures. The cultural and knwledge basis f health and scial care are different and in BASW we fear the scial perspective, which is crucial fr the future f health care as well as scial care, culd be lst. The independence f the scial wrk perspective in health settings is invaluable. The ability t challenge, withut fear f rganisatinal censure is an excellent fil t the pwer f health rganisatins. This independence applies nt nly t independence relating t statutry functins such as the AMHP rle r Best Interest Assessr, but als as an advcate in a nn-statutry cntext fr 18