As we adjust to a world pandemic and the impact this has had on our society many are starting to look to the future and consider what next. What have we done in a few months that can be normal practice and business as usual in the future? What doesn’t work and how can we fix it quickly? All understandable thinking but thinking that runs the risk of setting the future direction on the experience of 3 months. Nowhere is this more obvious than the debates around social care, its future and more fundamentally what is it.
That later question is one that as social workers we have a duty to help define and shape alongside those that use and rely on social care. The narrative must not solely start at the point of resolving self-funders fears and the ideology that social care is all about care homes and ‘some’ home care.
Social care is much bigger than that. Social care happens throughout society and communities, in living rooms, on street corners, at work, in colleges and even in the pubs and night clubs across the land.
50 years ago, this week the Local Authority Social Services Act received royal assent and with it the creation of a new approach to social services. The act was the culmination of over two years work by Fredric Seebohm and his committee and the publication of the pivotal Seebohm Report. This report set out the recommendations and aspiration for the foundations of a modern forward thinking independent and responsive social services system.
It is important to consider why Seebohm was commissioned in the first place and what this report can tell us about how we should approach our thinking of the new social care post Covid 19 and concepts of integration.
In reality the Seebohm report and its recommendations led to the disintegration of any elements of combined integrated social care, education and health systems that existed in the 1960s. There were some precursors to the modern integrated mental health trust in existence from the mid-50s throughout the 60s. These services contained Mental health officers and the early state employed social workers, imbedded in what was an NHS in its teenage years.
But Seebohm challenged and changed all this.
Throughout the late 50s and 60s the NHS was rocked by a number of scandals.
The abuse and degrading treatment of people with mental health problems, learning disabilities and the elderly were appearing in the public eye. These scandals began to challenge society’s concepts of how they viewed the worth of all members of our communities and more importantly how society should care for them.
The early commissioning documents that defined the remit of the Seebohm committee clearly cites such concerns as a driver for the review:
‘Given concerns raised in both houses and by her majesty’s subjects over the ill-treatment of persons in the care of the national health service, the Committee should consider the government’s function and that of local government in the oversight of the national health service and how independent oversight could be applied to the stated service’
Obviously Seebohm had a much wider remit but this key element led to the development of some of the core concepts of modern social care and social work. It enshrined the idea that social work and social care was so much more important than the treatment and diagnosis of illness and or conditions, it was about embracing humanity and equality for all, it was about people.
People, their families and their communities in all their complicated, messy, wonderful, aspirational, sad and inspirational ways. It was people who counted, as a whole, not just one part of their care.
One of Seebohm’s key recommendations in the final report was:
‘We recommend a new local authority department, providing a community based and family oriented service, which will be available to all. This new department will, we believe, reach far beyond the discovery and rescue of social casualties, it will enable the greatest possible number of individuals to act reciprocally, giving and receiving service for the wellbeing of the community’.
You wouldn’t be surprised if you found that paragraph in the Care Act now.
Seebohm understood that the value in social services were their ability to work with people, understanding the implications of a society that was far from equal and how this shaped communities. The understanding that working with social disadvantage could come long before any intervention needs from health services.
The report showed that the enablement of the disabled, families, and the elderly was as preventative as it was just.
The report also noted the specific role and value of having a social service that provided independent oversight and challenge to a hospital central model of the NHS which dominated at that time. That challenge bought some criticism and anger from the purveyors of medical models and hierarchy at the time.
In a fantastic letter to a medical Journal one doctor wrote
I have no shame in declaring my ignorance of the Seebohm report. I do wonder perhaps that these sociologists are too preoccupied with their own paradigms to concern themselves with the fact that they are fundamentally no more than coffee shop blaggards. The idea that such inferior ‘arts’ can in any way challenge our long founded and proven approaches to dealing with societies flaws is ridiculous’
In a letter to the British Medical Journal in 1971 another argued:
‘The Seebohm Committee can be charged with a number of defects in their deliberations and their report. An eminent sociologist has listed some. My own experience as psychiatric adviser to a children’s department convinced me that the basic weakness is that young devoted but inexperienced workers often fall into the trap of making the better the enemy of the good. The problems with which they are often faced however would tax the ingenuity and resources of a Solomon. Some social work theory derived from psychodynamic theory often seems irrelevant in such situations. Given the crash courses that many directors (designate) are given, it is my opinion that quite a few doctors could adequately cope with the burdens. The need for a sprinkling of mature, experienced medical personnel in the infrastructure is even more obvious. Finally, the Seebohm Committee should have known that the involvement and contribution of those concerned in effecting change is a sine qua non’
And this from the then Royal Medico-Psychological Association published in the British Journal of Psychology in 1969:
‘This Association wishes to state clearly that it cannot foresee any chance that psychiatrists will be able to enter into proper collaboration with the proposed Social Service Department organized on the lines the Seebohm Committee proposes. We absolutely oppose the proposals for the transfer of the mental welfare officers and the child guidance services, and consider that to implement them on the grounds put forword by the Seebohm Committee would be irresponsible.’
Despite the objections, the Seebohm report recommendations were adopted and as made clear in 1969 Parliamentary debate by Baroness Brooke of Ystradfellte the role of social worker was imagined with a clear focus on welfare, and rightly positioned within the heart of Local Authorities:
“Take an extreme example, of a not very bright mother with a mentally subnormal child who has to be with her all the time, another child at a primary school who has to be taken and fetched, and a baby needing diphtheria or polio immunisation at the child welfare clinic, as well as an elderly, blind, sick father, who is also living with her, requiring the help of the district nurse and the chiropody service, and the whole household is calling out for the services of a home help. There is no telephone in the house, and several different welfare departments need to be notified. How does she cope? The answer is that often she does not; she gives up. In Seebohm’s Utopia, we are led to believe that one social welfare worker member of an area team might be the answer…At present, the waiting lists for residential care of the mentally ill and subnormal, the handicapped and the old, are lamentably long in many parts of the country. …I hope everyone will agree it is right that, if we are to have a family social service of this sort, it should be the responsibility of the local authorities.”
The world has changed greatly in the 50 years since the passing of the Act, not least we had a decade or two ‘blip’ with the rise of care management following the NHS and Community Care act 1990. The act albeit ambitious did little more but damage our roles as social workers and give rise to the industrialisation of models of social care and prescriptive approaches to who was worthy of support.
But the inherent values that Seebohm set in motion are as valuable today as they were 50 years ago. It is these key values and the unique role that social work has that we need to fully understand and uphold as future discussions are commenced.
There is a lot of emphasis being placed on the merging of the system, more centralised control, an NHS lead and more provider power. Whilst these are key conversations for the future delivery of social care and health, we must look much wider and understand what social care truly is or should be. It would be too easy to get wrapped up in the commissioning of models and the funding of private providers and fundamentally miss the point and the opportunity of public sector integration. It has to be about people.
So, what is the role of social work and what can it bring to integration?
As Seebohm set out all those years ago social work brings a unique approach to working with people, communities and society as a whole. The concepts of equality and personal growth through enabling and strengths-based practice and the belief that personal independence however small and in whatever area of life is something so very precious. That the championing of individual and community aspiration is key to not just fulfilling lives but healthy and happy lives.
If we do not allow Social Workers to practice as they trained to do and embrace the opportunity that social care can and should achieve for people, then any future models will fail.
Connecting people, systemic understanding and relationship-based approaches, risk positive thinking and resistance to industrialised responses to systems pressures are not only set out in the Care Act they are the right thing to do.
Social work over recent years has found itself being moved to the front and back doors of hospitals at the behest of bed pressure, itself a policy construct. In reality social work should be five miles down the road working with people to prevent social or health issues and maintain or regain control of their lives in the face of adversity. Social work in our communities should understand the key causes of distress and health determinants, addressing them proactively to prevent.
It is the removal and restriction of such thinking and practice that will damage any success of a transformed social care system and more importantly the ability to integrate around the person, an expectation of policy that seemed to vanish as quickly as it was pronounced
4 years ago, we asked social workers across the country what the opportunity was for integration with health services and future aligned social care transformation. The overwhelming response was not the who and how we work but the need to recognise that Social care is based fully and rightly in human rights and the concept of relational practice. Enabling and protecting participation in true communities and relationships through prevention, wellbeing and personalisation.
That despite 50 years of social services there remained greater risk via integrations in the restricting of people’s lives, choices and rights through irresponsible and subjective care control. The prescribing of disabling and risk averse care that in reality only makes people more dependent on the system not free of it was an increased likely outcome.
Unknowingly echoing the Lords debate in 1969 on Seebohn, one responder also pointed out that if we don’t think differently about organisational integration with health then it would risk two things 1) fill up all the care homes and 2) fill up the court of protection:
‘they fear—and I think their fears are quite justified—that if they are going to be partly appointed by the local authority and partly appointed by the National Health Service a considerable amount of local pressure will be brought upon them to admit people out of their turn into residential homes or to hospitals.’
4 years on and we may be seeing the most horrendous price for not listening
The key point is that all professionals bring something unique and valuable to the health and social care world. The idea that we will have a single NHS and Social Care system or one that is provider led with no clear thought around local accountability to the people health and social care serves risks furthering existing health and social inequalities.
Social care embraces the ideals of self-determination, even when such self-determination promotes the right to fail. A right to fail that in the eyes of social work could be another step towards personal growth. Social workers legal literacy and ability to lead careful consideration on the use of law, power and control are a vital protection of individuals rights. They are also a promotion of their strengths. The ability to resist pathways to inappropriate care and control defined as a duty of care, will allow for shared and inclusive discussions placing people at the heart of decision-making.
We must also remember that social care has many key partnerships many of which were recognised and enhanced by Seebohm. Housing, education, children’s services, neighbourhoods, probation and the police are all natural partners of social work. Enabling supportive responses to difficult situations.
We have to ensure any future model or design is wholly inclusive of these key elements and partnerships. The role of social work in areas of poverty, crime, domestic abuse, community cohesion and social justice to name but a few can only be continued if social work remains at the heart of communities.
The thinking, analysis and outcomes of social work done in partnership with people is worth so much more than any bricks and mortar or beds and sheets that a commissioner can commission. We should see the post Covid discussions as the opportunity to re-embed the values of social practice,
Hold on to the ambitions of Seebohm positive independent challenge and ethical scrutiny of partners and health. Also ensuring that local authorities and social workers also take a long hard look at themselves and start to work alongside people understanding that human rights underpins all of the health and social care laws that we apply.
The right to be an included citizen is a right that must be upheld. If you aim for citizenship you will deliver good care to make it happen. If you only aim for good care then you may just get good care, not citizenship.
Let’s not forget our IFSW global definition of social work and get ready to shape the future, a future that must be locally focused and led by the citizens that live there, not providers, not organisations alone but as people. The rush to design on the basis of 3 months enforced action is not a design that recognises people it just recognises transactions that have taken place and we may be quickly seeing have made things worst.
‘Social work is a practice-based profession and an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people. Principles of social justice, human rights, collective responsibility and respect for diversities are central to social work. Underpinned by theories of social work, social sciences, humanities and indigenous knowledge, social work engages people and structures to address life challenges and enhance wellbeing’.