The social services department and mental health

Puhf. t/lt& l.,,td. 11q72i 86, 57-63

T h e Social Services Department and Mental Health* R. ( , I , I N ( S I I / \ M

1),F,'~?" l)ir,'rn," o f .S',,<'i,d ti ',,/,-, ('i/.r q f Ah,'rdccn

1", I'.~l !'.ti~l~; lht', lv,tpcr il has hccn a.,sumcd thai ll,lCllll;crs c t t h e Gl',)tl.), f'accd ;;ts the>' el',2 ~tlli lhc ;n4n', Irlll',licitli~,l,ls ot' Secb(,hlltl rc-.ol'gaililati(~ll ill I]ngland and \Vales. wish to .' ctci ~.t- il ti , H II hnc o f hm~ I hlin!:.', h:,l\ c gnl,lt? i l,l Scotland "a hclic i'e-organizatiOtl a!oslg similar ]tp.c~ lo,,k I~klcc ztl:,l~;sl I ~ o ,.c';trs 4t,~,. -File l'nil<~ving col,l,llllcl-ts are d r a x l l I'io111 a detailed c t p c l t c n c c ,d lhc sittr,~ti,ql in N~,ith [:4sl Sct~lhlnd. especially ii,l relation to kherdeen. Ihe', \~ ill ?.llc.mpl I,, c,,n', c~ 4 in~ic general picltirc l\~r lhe resl d ' S c o l l a n d , based o7t frcquoll!. <',:i~(~tcis ',~lih c<,llc4.<2tic>, i~,l o l h c r alc4 <, :illlct ',~ilh pcrip;.~tclic advisers frolll M i n i s t r y cv<~t~tl~:;illn 5, 4rid , Pro!7'.l'Ck~, D h y 11~ l i l c a n s Llnil; ,I'tll ill all a:eas -.some hg,.vc ;t f!lc <,14II]n 7 p r , + l c m ~ h~qll in lerltl,, ~ f clualily and Cluanlit.v. some have local f u n d i n g ,lifii~ ti{llt-<,, l"lt{lll\ !'.in e ilt},lcl+ilcd l'c:.,otlrcch v. hlichl arc Ixisicallv \\cam, SOI11~t areas are faced ".x'th ~" .~l,~i ,,r,cmt p r o h l c m , \~hich \totltd rank as the worst i il n n r t h e r n [!tlrope. let a l o n e l}",c" fh~lhh I~lc~ <-~,,dal v~,~ik dt'l~4it 111011{,, ;trc ch{I I'{J0d tt lihl the rcspon.dhilily "'to pl-o111olo social wclf;.ire ! \ 1,4ctklll{,. ~.1'~;.i.!141~ic ;_tdx ice, ~.tlltlall,lt't.' {llld i t , s i q a n c e ~l~ s'lch n ~cale as It`iLl',,' t)e a p p r o p r i a t e !<,r It~t'~r a r c : ( ' -l"hcre :ire 52 dc-p:il'llllellth c m c r i n g pnptlkllinns ~!<~sniall as 20.000 or as large a~ I.(;()ti.llil. l h c ~ arc Ixi,dcallx coi!lp<~sc'd hi" lhrec pre-existing ~:gcncies, the Children's Dc'ixttl Illt.'11!,.. \Volt'are I)cpariillc'illh and Prol~alion l ) c p a r t i l l e n i s (iil [:l,lgla!,ld and Wales, ~q c,,llr~c, lhc l>roh41i,m 1)cp41~lil,lelllS rcnl;4ill sepal'ate). Thle social ~VOlk deparllllelllS are tar t.~c a{!.e~lt'ict,, cc'rtainl} larger Iha~l Ihe stln,l o1 their COllSlitUelll pal'L<,, and they present ;.i seelliingly i l l o ! w l i i h i c appearai'
*Based oft a paper read at the meeting of the Mental ]-lTealth Group o f the Brilish Medical Association, Septeinber 197 I.

58

PUBLIC ttF.~.LTH VOl... 86 NO. 2

The management system is democratic and group orientated. Its management aim, arc to p r o m o t e free and efficient communication, to provide a comprehensive system of" suppor~ to alt workers, to maintain continuous evaluation of casexvork methods and to p~-~ym~c development by utilising the initiative and experience o f all members of staff. Social workers are expected to cover any problem which occurs in the families ~br ~ hich they are responsible, and to,i~tke a share of all the referrals received by the dcp:~rtmcnl This demands of them a wide range of skills and knowledge and the} h a \ c access Io the expertise or opinion of any member o f staff who can assist. This degree of gencricism. whilst being lhe essence of the working system, has attracted more criticism than an~ othc; aspect o f our operation. Having a wide range of statutory responsibilities il xv:ts ncces.~ar~ in the |~rst 5'ear to concentrate on training and educating the stalT. This absorbed ~ital manhours at a time when the Departmenl, like many others, was 25",. under ,q[cngth. Some o f t h e agencies which had prc~ iOtlS]y worked wi~h social workers in specmtized roic,,. particularly the hospitals, found that these changes placed strains on their o ~ rc,,,~urcc., Where such pressures could be foreseen tile managemcm ~talt" consulted wi~h the agct~c? concerned and in many cases they were able to reach a firm ~orking agreement m,l al~,~ just a compromise. In some cases they arranged tk~r a limited number of generic social workers to ~ o r k in liaison with individual agencies. }tt;wc\er, in the calsc of .social \~orl, Jr~ who were already, attached to consultant teams in n~cnIa] hospil:aly, il \xas ii~md e ascnl~:~] to preserve the special relationships since they were fundamcntall~ necessar,, ~tut. iH recent months it has been found that these attached workers have moved tox~ard.,, gcncricism and that their colleagues in the community are being d r a u n increasing[3 into the I~.<~>piml >cc~c. Specialist social workers atIached to the hospitals have found that thex arc calling.,_ ot~ the wider resources o f the Social Work Department in order to cover the need, of thei~ ~ clic~/~ and his family: generic social workers have followed-up Fami~ memb~,rs xW~o~ced p..,ychi-. attic treatment or admission to hospital, The staff have all been acutely aware that the total ihmil\ approach of., generic .,,oc~a! workers brings a danger that individual clients needs arc overlooked t~r ~>bsct~rcd. lhci~ + own self-criticism and the criticism of others has kept this danger to the fore in thinking and practice. A relentless increase in the number and complexity of re!errals has added to the danger that social workers might provide a purel.v symptom relieving crisis serx~cc. too severely under pressure to allow involvement, or too general in scope to r, ermit intensive casework, The 5' have. however, become attuned to u o r k i n g with families rather lhan with the individual members Mac> show stress, and are tinding that a more conaprehensi\c l\~cus in casework is reducing the risk e l repeated breakdown by individuals. As the department moves towards the end of its second year a more stable service is emerging, The administrative staff have a clearer view of our organization, its strengths and weaknesses, its demands and initiatives. The social workers are certainly more secure in their role. Their anxieties a b o u t individual effectiveness and ftmction are diminishing as they absorb a working knowledge o f all the department's resources, as they experience the supportive structure which underpins our organization, and as tt~ey see the effectiveness of family tbcussed, community oriented working. Staff at all levels need less and less to cling to tile residual security o f their previous roles, having found tile security and strength of their new roles. In case this statement appears sell-satisfied or over self-suMcient, it must be made clear that throughout the two years there has been considerable difticulty concerning tile need to keep a balance o f forces. The D e p a m n e n t is laced with enormous tasks of maintaining existing services and developing new techniques, all o f wiiich present competing demands which have to be appraised and met through relatively static resources. Those responsible

<.laqu.ulu .I!atll lnq"so,',tl,~t,.ld dnoa,~ c)l pmp,',lie attlo.'~aq lqg!tu "s.lol!%x ttl[t,,at [ a~! I "sd,~.lO><~ le!,~O,~ l~;tIl pos!a~7~n,a uaaq st;t I i I 'sa;)l.~.las .~!.itl;!t[:7.(sd Otll .,~t.|t,it~.-.~llJt,,d "saaL'da~; t[lleaq aql ill; 1o aut~vl>[,'~l~q art1 ap} ~o.ld ..~!potu {t!.iotltill? l!:2Ol p, "'if, -t~lotla.(sd [t~tiolltLTil iT,a ui; 'Ut:l:~l.{Wlpot;d.. I; "'4.Ia't.Io ~ [t? .~t)4 0pll[.~u! !tta.l.~Ui p tUO.l.l -~.',lltt.> t[li ~ tlOl<~li.~Stp i)l.l~; ttaap.iaq\, tl! ,,.iaXt.lc~ ~t ll~!.~c) ,~ jo dttO.l~7;~7.ip t U.t~I:!tf'LLi Oi/Ttilcltac 1 i t] (""~tlOi-l"~tika "'7tl1°4 ('-I O'~t:~},ill4 Dill i.tO Ll\'~t>tlS aq "~l.~ttl ti', t [;ttt: ,lt!TS at I, ~Uip.if;77a.14ip ,iO t ['~tli; DtI~IU ii ~Idtc);{ .~O1 tlOIlP, ttttJ,t.t 17 I)1,'.tt11; <)I ltlaO'~ 4.lO"[.tt)kt IITt.~t~ ' 1 t ! , ,;!ol,,c,s 1t~: ,>! IO~\qlll: uou e .,o.Ut, ol <-.~!,Lld ,.Ul~\ 1l!1~ .~ v]llt~.l~ I ~, ,;tuappn, lt~t!| p)U.tak', 4i;!I 11 i't.tc, i {- tl"l" l [ )ill: plO{i, lt17~ ,~OtflK '[ll'qlptll LtI,\\O,;~ ISO~.71~, i Ottl ~,M pay t ,LTk,7~li) tlOO~. I ,;l:t i xt.it,\~, il>.,~t,S -L~i,7,.1.~,77f: .IOq10 i.]ltxx J~t.I' 40.~l\.',a~..'iii.~ad< slt Lqt!lpJt)~,~..i laUi cll~c).l~7 "tll.lic I "- !ttOllil,it;c]ap ',i,lO,
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60

PUBLIC HEALTH VOL, 86 NO. 2

make this somewhat difficult. For example, the group practices in Aberdeen could be covered only on an unworkably diluted basis. Social workers are, however, encouraged Io make strong links with family doctors, and often find this is best accomplished through practice-attached health visitors. The health visitors have correspondingly direct access to the social work department, and in fact provide basic screening services for many aged. physically handicapped and sub-nol'mal clients. The Social Work Deparlment reciprocates such co-operation by providing social work consultation services to other agencies--t\~r example, on drug abuse co-ordinating commiltees, prison parole boards, special school review and assessment groups, Ministry of Seeial Security special committees, councils of social service, etc. This interchange of professional opinion and skills clearly benefits shared clients by resisting the tendency to compartmcTatalize the treatment of families problems and reducing the risk of pursuing conflicting aims. It has to lake place at both grass roots and policy-making levels, must be continuous and not limited to crisis situations when differences in aims are reconciled through hastily convened case conferences. Case conferences may relieve specific stress but carry the risk of over-structuring comm~mication and are inordinately time consuming. In Aberdeen the staff have been advised that they m tim establish and maintain an 6n-going relationship wilh key agencies, and not just seek hclp when a rapid mopping up operation is required. tn the field of day care all social work depe~rtments have had to analyse thoroughly Hae range of local needs ar:d present provision. Scotland has, in ~he past, so lagged behind England that departments ~ow have to accelerate their rate of provision al a lime when the increasing rate of unemployment is throwing a heavy strain on existing facilities for the marginally employable. Centres are being built or in the final planning stage in many local authorities. In Aberdeen, the department is currently starting to build a new centre for the physically handicapped, finalizing arrangements for the extension of its day centre f,)r severely sub-nom~al children, and commencing the planning process for a third training centre for the adult sub-normal. Departmet:ts are trying in varied ways to bring day centres more actively into general community life, for example by offering lines ofaUraclive, useful goods with local sales potential, or by promoting the deve[oi~ment of community supo-)rt groups with membership open to youth groups and other interested people as well as trainees' relatives. Several departments have encouraged ~eaching hospitals and universities to undertake evaluation and research projects. In Aberdeen this has given social workers access to detailed research findings on the sub-normal, and the department is co-operating in the establishment of research into the needs and facilities for the physically handicapped. Social work departments are, of course, deeply involved in residential care, particularly for children and the aged. D e m a n d for placements has tong since outstripped supply, so that it has proved essential to explore possible alternative types of provision. There were hopes of using foster care for the ~ged, the sub-normal and mentally ill, but despite intensive recruitment campaigns the basic ~tock of placements is tending to diminish, even in areas of rural Scotland which have traditionally provided homes for these clients, as borne out by a recent survey conducted by ~he Mental Welfare Commission for Scotland. Whatever the reasons for this decline, and these are under scrutiny, social work departments have a heavy responsibility Io develop other methods of care. Large homes are institutional, expensive to build and to run, and sometimes almost impossible to staff adequately. Group homes are socially beneficial, foster a normalizing atmosphere, can be economically more efficient and are more readily absorbed into the general run of community life. Many departments are therefore expanding this type of provision and took with interest to the methods employed in Sweden on a large scale and in this country by Kushlik and others.

THE SOCIAl. SERVICES D E P A R T M E N T A N D MENTAl., I-IEALTII

61

Several departments arc planning group homes for the sub-normal, often using a larger hostcl as the nucleus unit to provide training, socialization and subsequent support. It is generally though! preferable to establish group homes in existing council houses, some of which will be stalled, others will be supervised only. Such schemes are actively supported both by the advisory and planning stall" from the social work Services Group, and, perhaps more important, b} Ihe Scottish Association for Mental Health and the Scottish Society for .Mcn~ally Handicapped Children-- the latter organization bas offered interest-fi'ee loans to social work departments and voluntary bodies for the purpc'se. The potential in this field is enormous; the need l\3r ahernative provision for clients both fi'om the comnaunity and from hospitals is clearly demonslrated bv recent researches. McKeown and Leck's survey in England. and the Iktchclor Report on Stalling ot' Mental Deficiency Hospitals in Scotland, agreed that t,p to 50",, of sub-normal patients are not in need of hospital medical and nursing care. It should be slated, however, that tier some of us who have attempted to evaluale lhc exlent of need to provide group homes and hostel care, our experience has led us to question either the findings of these surveys, o1" the hospitals view of their patient's potential. Some departments have been advised by the hospitals that the number of patients suitable for community life is quite minimal. I:aced as they are with a ltood of demands fl'om other groups of clients, the social work departments are tile last to encourage a new torrent of referrals from the hospitals, but it is dillicult to plan the present and future demand for care which is their slalutorv responsibility when. contrary to supposedly informed research lindings, it is found that tile anticipated torrent is a mere trickle. This seeming anomaly relates to both the sub-normal and the mentally ill. One social work department has been advised .by its area psychiatric hospital that there are insufficient patients lit liar discharge to warrant building a local hostel which could act as the nucleus of a group living scheme, and in several areas tile exisling hostels are severely under-used. In Aberdeen there is a halfway house l\~r men, and a group home for women, run by voluntary bodies with social work department support, neither of which has been fully occupied. This situalion is being discussed by the hospitals and social work departments in joint meetings convened by each Regional Hospital Board. and in at Icast one region the hospital services have agreed to take a head-count o1" their palients who may be fit for discharge into community residential care. The needs of the aged population are receiving special scrutiny. Departments have been helped by the tindings of recent surveys such as the Scottish Home and Health Department's report, compiled by a team under the chairmanship o[" Professor Malcolm Millar. This report points to the need to provide commt, nity homes for psycho-geriatric patients and several social work departments arc engaged in pilot planning of such provision. These specialized homes must, however, operate in conjunction with a comprehensive scheme of residential care including not only existing large homes but wide scale groups of sheltered housing which provide support, supervision and social life whilst maintaining maximum independence and self-sutticiency for the resident. This type of housing is already well developed in north-east Scotland, and Aberdeen is currently planning two model proiects with support from the Central Department. One will provide a large group of sheltered housing clustered around a day centre; the oHmr is a multi-storey block, entirely equipped for aged and physically handicapped residents, situated within a multi-storey housing scheme. Social work departments are attempting to participate in the development of-services for groups who have distinctly special needs, such as disturbed adolescents, alcohol and drug abusers, socially outcast derelicts and criminal recidivists. Services for disturbed adolescents are woefully insufficient in Scotland, and departments t

62

PUBL1C HEALTH VOL. 86 NO. 2

are increasingly becoming involved with young adults for whom casework is ineffectual. conventional psychiatric care is insufficient and penal care is inappropriate. It seems ~herc is a need for social work departments, hospitals and educational services to seck a new initiative, perhaps to provide special care units. Such lreatmenl centres as the Northgalc Clinic at Edgware have achieved good results and whilst it may not provide an exact modcl. places of its kind are sorely needed in Scotland. Comprehensive services for addicts must also be provided, particularly for alcoholics who, in Scotland, are four times more numerous in proportion to population ~h~n in England and Wales. Treatment is, of course, not sufficient--the social work departments and health services must also co-operate in providing an effective screening and preventive service. Drug addiction has not yet made a great impact in Scotland which obviously has its own culturally determined agent of escape, but the problem is increasing. ~dthough ctt~scl~ observed and to some extent countered by co-operation between social work deparlnacnts, the health services and the police. Social derelicts are, perhaps, a natural product of any culture which is heavily dependent on alcohol and which has tended to favour restrictive penal praclices. In Aberdeen it h~s been found that an overnight shelter, staffed by a student group and pr(~viding a ha~ic 'doss' plus a little solid nourishment, h~ls reduced the incidence of calls on cmcrgenc> hospital services; cut down on social workers' hours spent searching (k~r temporary z~cc,~. modation; and reduced the number of police convictions for loilering, puhlic drunkcnnes~ and creating public nuisance. This paper has inevitably been restricted in scope and depth, but it has attempted to gixc an overall impression of those activities in social work departments which may be ot" inlcrcst to the B.M.A. Mental Health Group. it has touched on basic aspects of departmc~tzH structure and attempted to elaborate on some of the detail regarding specilic development,~ and their related issues. In conclusion it should be acknowledged thzlt social work dcp~rtmerits are mindful of their responsibility to provide a pattern of serviccs to meet b~tsic community needs and not just to offer palliatives. They are attempting to meet d~esc needs with the co-operation, understanding and support both of the community and of t)lhcr agencies. They realize that their techniques of care require detailed sc,'utiny and improvement; indeed they have attempted to organize and support their staff in such a way that they all constantly examine their professional ability and effect on the clients in their ca,c. II would be all too easy to accept compromise and half standards in the lhce of incessant demands, but they are trying to provide a service which is sufficiently secure in its beliells and open minded in its practice that any client may feel able to express his opinion F~OI only of his own needs but of the adequacy of what is done for him. There is a great need to improve the quality of professional functioning in social work .... one only has to think of residential child care practices, adoption procedures, fostering services, aftercare of the mentally disordered, tO find great areas of work which require revision and improvement. Social work departments cannot and should not tackle these tasks alone; they must resist any tendency to allow their new stature and independence to create an omnipotence which would isolate them from the support, advice, experience and criticism of other professions. Social service and social work departments represent the second stage of a total restructuring within the welfa,re state. The first stage; involving the re-organization of the Department of Social Security and that of Employment and Productivity is complete and functioning, Social service and social work departments a~e in the process of consolidating their aims, objectives and methods. The revision will be cbmpleted by the health service re-organization which many of us consider crucial in the process of achieving a creative,

T i l l : S O C I A l . Sf: RVfCI.S I ) t I ' A R T M [ : N T

A N [ ) M I : N ' I ' A L tlI:AICI"It

63

c o m p r e h c n ~ , i x c x~ctliu-e state. ( ' o - o p c r a t i o n in p l a n n i n g , m u t u a l r e s p e c t a n d s i m p l e g o o d w i l l mu.~t bc fk~,~lcred, l ! x p c r i c n c c in S c o t l a n d s h o w s this not o n l y to be p o s s i b l e bill a c t u a l . A d \ i~;tmic p;~rtl~cr~llip c a n gr~)\~. Sources soci;fi \ v o r k ( S c o l l a n d ) A u t .

19~8.

l,~,~Pi ,~x, (i. I19~,1 I. An .,\Pl=roach to ('~3n1133Ll13ily~Cllta] llcalth. S~dal \~,'~>~k Scr', k'c~ (,;:oup, Scotland (1971)..,\s~cs.~mcm of Childrml. M e n t a l ~,\ctlar~' (',mm~r,,don I'or Scotland (1969.), N o Folks o f T h d " O w n . ( h ~ ,,~ w ~ l t~. K. ( 19(¢)t l h c ~'lt:nlaily R c i a r d c d in Sweden. (;, ,l~i,, ,\. \ \ . \t~ K t, ~\~ ",. "I, & I i( i,:. 1, (1967}. Medic41 and ~(~cial nccds of pal ients ilt hospitals liar fi~.c m c H t a l l ) sub-n,~rmal, lb#, l-: prc~. ~(~(..llu, l. 21, 115. I~ ~ t~, ~~,i~, t. R. ( '. (( "huirman)( 19701. ,S'tat!)'n~,, o f ~fel~tal D,'!rci~'m'y H~.q~itats. F-dinburgh : t I . M . S . O . \ I H I ,q,L ',l. \~, {( h 4 i r m ; l n l 1197111. ~'cJ-~-n~'~ li,r tl~' l:.'ldcHr w#h ,~h'ntal D£s~rdc~'. E d i n b u r g h : It \1 S ()