While I was away in November, the Social Work Task Force produced its Report. Rather than comment on all aspects of it, I have chosen to look at the implications for end-of-life and palliative care and the implications of end-of-life and palliative care for how the government should respond to the Task Force.

You can find the Task Force Final report and various government documents at:

http://publications.dcsf.gov.uk/default.aspx?PageFunction=productdetails&PageMode=publications&ProductId=DCSF-01114-2009

The Social Work Task Force’s 15 recommendations, together with a comment from me, are as follows:

1. Calibre of Entrants: that criteria governing the calibre of entrants to social work education and training be strengthened.

This sounds sensible and easy, but only when you don’t think about the practical implications, because I think there might not be a lot of agreement about what calibre means. I was once on a panel which did not accept a clearly inadequate, long-in-the-tooth, but salt-of-the-earth-type locally-committed social care worker onto a social work course. Later, we found out that she had been seconded by her local government employers onto another course. I asked the assistant director about it, and his view was that they were probably going to be employing this person for the next twenty years and they hoped that something would rub off in training that might lead to some improvement, although he accepted that I was probably right that it wouldn’t. There are two issues here. One is that employers have to make the best of what they can get and training ought to be able to help even not-very-good social workers do the job better.

Another thing is that some people, including some politicians I think, would probably think that a lot of salt-of-the-earth-type locally-committed recruits would be just the calibre that they needed. For all sorts of practical professions, there is a section of the population that thinks that nice caring maternal people would be better than these educated young things. This is true in palliative care, where there is a lot of prejudice against young people. When I was responsible for volunteers, we got a regular flow of applications from young people, often applying to go on medical courses who brought their fresh air into the hospice with their lively minds and their wide range of activities. But many people were doubtful about whether they should have contact with patients…too emotionally fraught…too difficult for such a young person…they don’t have the maturity…Ageism works both ways; against the older person and the younger. Examine yourself, o mature and experienced middle-aged social worker! I have met some young recruits to social work who were emotionally very competent, and some older ones who weren’t.

The other problem with calibre is competition with other professions. I wonder if reports that David Cameron’s Conservatives are going to be ‘unashamedly elitist’ in recruiting teachers will have an impact if they get in. Since social work competes mainly with teaching and nursing for recruits it’s likely to. Being elitist for teachers means being less elitist for social workers and others – just leave the rubbish to the lesser professions. Do these people think about what they’re saying? Do they really think everyone is rubbish who hasn’t accelerated through the academic educational route to a ‘good university’ (ie one of the old-fashioned kind that doesn’t bother to give opportunities to people whose families have struggled in life). I worked in one of those, and some of the hotshot graduates were lackadaisical about their commitment; their bit of paper was just owed to them. Some of them were fantastic too.  But I have also worked for one of the universities that the Conservatives are talking about downgrading again. Some of those people were fantastic too; not so many, but some. And the reason why they were there is that their life had not got them through to the Russell Group (the posh universities) fast-track in time; they were usually late starters because of the social factors that stop people making rapid progress as a child. But they had made up for it by hard work. Also, most social work is taught in such universities and not a lot is taught in those universities that are mainly worried about their research assessment grading. So if you’re going to fill those posts, you’ll have to support what the theoretically inferior universities are offering to our education system.

2. Curriculum and Delivery: an overhaul of the content and delivery of social work degree courses.

This is the usual load of whinges from employers who sometimes don’t have the inclination, but more often don’t have the resources, to contribute effectively to participating in professional education for their workforces wanting to have control over something without giving, or usually being able to give, the staff resources to understand what they want to have control over.

One of the problems is that the employers we’re talking about here are really the big local government agencies with their interest in a compliant and bureaucratically included workforce. What they don’t want is social workers, and what we want in palliative care is very much social workers. Palliative care agencies and social workers should be stickng up for the range and quality of the roles that we want practitioners to undertake. I know it’s a struggle to have effective involvement in a social work course, that’s why local government finds it so difficult to have influence, but unless we do get involved, we are going to get what the government wants, not what we and our patients and service users want.

3. Practice Placements: that new arrangements be put in place to provide sufficient high quality practice placements, which are properly supervised and assessed, for all social work students.

As I’ve said before in the blog the only way to do this is to pay the fee in two slices. Not to the agency, because that’s a recipe for excuses for not bothering, but to the actual practice assessor (you may not know that that’s what practice teachers are called nowadays, presumably to emphasise that their job is not teaching but judging people – fortunately not a lot of people who are doing it have actually taken any notice of that) who is doing the work and the manager of their team who provides the placement.

Palliative care could and should be offering lots of placements and be prepared to offer parts of placements that are mainly somewhere else, so that more adult social workers get an element of understanding of loss and bereavement in their course and some experience of non-local government social work. Be very aware that the local authority employers’ whinges are not about bad social workers, they are about social workers who have not been drilled in doing what local authority employers want, as opposed to all the other possible and often better ways of doing social work in the wider world.

4. Assessed Year in Employment: the creation of an assessed and supported year in employment as the final stage in becoming a social worker.

Yes, and when it’s being assessed in local government, as it usually will be because that’s where most beginning social workers have their beginning, we should insist that they also have some experience in some of the other settings that connect up with their services; like palliative care. that means of course that we have to be prepared to offer it

5. Regulation of Social Work Education: more transparent and effective regulation of social work education to give greater assurance of consistency and quality.

More employers’ whinges to try and get social workers who are nice little local government bureaucrats. We have got to give people wider experience than that; experience that would be recognised in the rest of the world as good social work.

6. Standard for Employers: the development of a clear national standard for the support social workers should expect from their employers in order to do their jobs effectively.

I don’t believe this will happen in my lifetime, because nobody will be prepared to spend the money.

7. Supervision: the new standard for employers should be supported by clear national requirements for the supervision of social workers.

I don’t believe this will happen in my lifetime, because nobody will be prepared to spend the money.

8. Front Line Management: the creation of dedicated programmes of training and support for front line social work managers.

I don’t believe this will happen in my lifetime, because nobody will be prepared to spend the money.

9. Continuing Professional Development: the creation of a more coherent and effective national framework for the continuing professional development of social workers, along with mechanisms to encourage a shift in culture which raises expectations of an entitlement to ongoing learning and development.

I don’t believe this will happen in my lifetime, because nobody will be prepared to spend the money. But if we are going to get some sort of cpd framework, it’s got to include the many and rapidly expanding specialisms in social work, including palliative care, instead of giving advanced training in being a local government bureaucrat,

And, if we are going to be equivalent to many other professions, the cpd framework has got to mean, as it does in nursing and medicine and increasingly in teaching, competence and experience in doing research, so that people can evaluate their work and contribute to building a knowledge base.

And, finally, it’s got to allow people to do higher degrees and get qualifications that match up to other professions, not as local government often wants, to stop people getting any more than will absolutely fit them to be good little bureaucrats.

10. National Career Structure: the creation of a single, nationally recognised career structure for social work.

The reason for this is to make employers provide for advanced professionals, like nurse and medical consultants, as well as managers. This is doomed. I well remember the incomprehension of a local authority social services director I knew the last time someone tried to introduce career grades in his department (several decades ago). ‘How can you have someone doing the job who is paid more than his manager?’ he said. So say all of government. Until local authority treasurers and central government ministers will give up minute control of minute sums of money, any idea that a professional will be allowed to use their judgement about what is needed to allocate resources of government time and money without an immense multilayered bureaucracy is in fantasyland.

11. National College of Social Work: the creation of an independent national college of social work, developed and led by social workers.

Nice, but I have yet to be convinced a) that the government will ever be able to avoid interfering b) that the basic prerequisite will come to pass of government not interfering that social workers are prepared to pay for it themselves through some really chunky subscriptions and c) that it will find something useful to do.

12. Public Understanding: a new programme of action on public understanding of social work.

Doing a good job is the main thing here, so we can all make a contribution. For a start, palliative care social workers should make sure they admit to what they are, and not conceal it through some nom de travail like ‘family support worker’ because they’re sick of having to explain that they don’t just do some bureaucratic job. One of my palliative care colleagues has taken to christening herself a ‘specialist social worker’. She finds that it means ‘different from local authority bureaucrat’ in the public mind.

One of the most important things is the routine inclusion of social work among the positives of life. It wasn’t nice to see the obituary of Kay Carmichael in the Guardian the other day; she was a securing and thoughtful presence in social work for the last part of the 20^th century and I am sad to hear of her death. While the obituary focused on her political and public service, it was clear that she also contributed to social work a lot and that her social work contributed to her other life. And on the same day, Mies Giep was also obituarised – the woman who risked her life to keep Anne Frank’s diary during the German occupation of the Netherlands. She was married, it said in passing, to a social worker and they jointly did a lot of socially positive things. And there was a recent telly documentary about a girl who had decided not to have treatment for her life-threatening disease. Some doctor had tried to get her taken into care so that her wishes could be overturned – you may remember the fuss in the papers at the time. But, the documentary said: ‘…a social worker ruled…’ (say that again ‘ruled’, just think, a social worker) that the girl had the capacity to make up her own mind. No comment on this, just the social worker doing her job, taken for granted. The more social workers doing a good job is a routine part of the media coverage of all sorts of things the more members of the public will come across the positives of social work – there are bound to be negatives, but they ought to be balanced routinely in people’s minds.

And palliative care can help with this because generally people’s experience of palliative care and social work within it, when they get it, is positive. It’s one of the social work jobs where you get a lot of positive feedback. So we need to make sure that the positives get out there and that they know they’ve had a hood deal from their social worker. Similarly, our colleague professionals.

The other point is that politicians have got to stop trashing the profession every time they want to redirect responsibility from themselves.

13. Licence to Practise: the development of a licence to practise system for social workers.

This is vague and there’s not much of a case made in the document, but it’s really about tightening up the requirements for regular re-registration, so that social workers really do pursue cpd in a coherent and developing way throughout their careers and this is checked up on. Well, it’s never really worked in most other professions either, but there certainly is a need to tighten up the requirements for re-registration.

14. Social Worker Supply: a new system for forecasting levels of supply and demand for social workers.

I am extremely doubtful about this. The bane of the NHS has been workforce planning which always goes wrong because of the wishful thinking of the planners. I say train as many social workers as you can. A few students that I tutored or supervised years ago seem to have made it to the upper reaches of social work, others are doubtless doing sterling jobs somewhere. But it we’d trained lots more social workers over the years our products would be contributing those interpersonal skills and competence in getting the business done for people in difficulties in all sorts of places that would benefit from social work skills. One of my students fairly rapidly became a member of the county great and good, and contributed her skills and education to all sorts of charities and the magistracy. You can use social work in many ways other than being employed in jobs that the government imagines it might want doing in ten years time, when it’s changed the law twice and reorganised once.

For example, I’ve no doubt they’re not thinking and will never bother to think, about palliative care, where the research shows they are useful members of teams and they’re appreciated by patients  and their families. Or training members of the public about death and dying, or developing community bereavement services for all the families of wall theodler people who are going to die over the next thirty years.

Our society might be a lot better if there were a lot more social workers around than the bare minimum needed to fill government jobs.

15. National Reform Programme: the creation of a single national reform programme for social work.

No; let a thousand flowers bloom, especially if you’re going to work the voluntary and community sectors. Because they’ll have loads of imaginative ideas that some single national reform (a typing error produced re4m, which I liked but thought might confuse you)(ie government) programme will never be able to think of, let alone make work.

This post is about some follow-up on the NICE guidance in palliative and supportive care. Non-British readers perhaps need to know that NICE (the National Institute for Health and Clinical Excellence) is the government body that collects research and views about what is effective in various healthcare services, advising government bodies that purchase them. Social workers have been concerned about its discussion of psychological support. In most hospices, social workers do a lot of this. Of course doctors and nurses also do it and probably do most of it, but they tend to pass on the complicated and time-consuming bits. NICE did not really deal much with social work. This was partly because it is a healthcare biased body that gives priority to healththink. Most people involved would have thought that it was fine to neglect the fact that most palliative care patients have been receiving social care services for years before they end up connecting with a hospice. It is also because a similar body (SCIE, the Social Care Institute for Excellence) should do this, but wasn’t commissioned at the same time to do the same thing for social work in end of life care. They don’t do joined up thinking at the Department of Health on social care because they have a healthcare mindset.

The National Cancer Action Team has been pegging away for ages at operationalising the NICE Guidance. It has finally got around to psychological support, which it issued a consultation paper about, and of course it continues to pursue the NICE line. This has hyped social work concern although the consultation is about the measures that peer review teams will apply to cancer networks. These are the multiprofessional committees that coordinate palliative care services in each area, so they’re hardly at the frontline or organising services and the measures actually offer quite a fair bit of flexibility. They are the sort of guidelines that say ‘You’ve got to have this, that or the other plan’, but don’t really tell you what the plan should be.

Whatever, to work out the guidance on psychological support the NCAT has picked up the NICE approach which, not unreasonably, was to ask psychologists what they thought and of course they came out with the idea that anything called psychological should be be done by psychologists. So NICE set up four levels of psychological care, in which, rather sniffily, people such as nurses and social workers can do the two lowest levels of, although they need to be trained and guided by the wise, and the upper levels can only be done by psychologists, or, in the case of level 3 those who have been made a bit wise by being given extra tuition by the specially wise.

In case you haven’t worked it out, in the previous paragraph wise = qualified in psychology or psychiatry. You’ll have gathered that I’m not all that sure that a qualification on psychology gives you that much more competence in responding to people’s life problems or the problems of the world than rather similar qualifications in other related fields (or possibly just developing yourself as a competent human being, but that’s another story). There’s a whole range of knowledge out there and different qualifications give you a purchase on different bits of it.

This kind of specialisation produces sillinesses among all professions. As an example of a psychological silliness I am inclined to quote the British Psychological Society’s publication on psychology in palliative care. This is a classic example of professional imperialism, claiming that the whole world is to be understood as a psychological problem that only psychologists know how to do something about. One role of psychologists in palliative care for example is said to be: ‘Dependency issues, such as fear of leaving the hospice/hospital, etc.;’ (BPS, 2008: 17). They’re welcome to dependency issues, a term which I regard as an offensive way of labelling people as psychologically inadequate for being dependent on others, which we all are. On the substantive point, though, most people who fear leaving hospital or hospice quite legitimately worry about how they’re going to cope with a major illness in their own homes, and they also fear losing their own home and having to go into some ghastly nursing home (they’re not all ghastly, but people fear this move). It just brings psychology into disrepute to call these widely-experienced and legitimate fears ‘dependency issues’. Then seeking to justify psychotherapy to resolve them takes the biscuit. The much more sensible social work approach is to sit down with patients and their relatives, find out what their problems are and organise the services or help them make decisions that remove the problems that raise the fears on the first place. Psychologists don’t do that because they only work with the patient, or their family, they don’t go on to sort out practical problems, or they do that by opassing it on to social workers. I say ‘get a social worker in the first place’. See BPS (2008) The Role of Psychology in End of Life Care. Leicester: British Psychological Society.

One of the problems with the NICE approach is that in reality there are very few psychologists around in palliative care and most of this work is done by social workers.Consequently, it tends to be closely intertwined with social care responses to issues, as you see with the ‘fears on leaving hospital and hospices’ example. It is senseless to set up a whole series of practices that rely on a limited set of ideas associated with one small and not very important profession, that seek to exclude other small and not very important professions.

Another problem is that, because palliative care is not a mental health or psychotherapy service, the main focus is not on psychological problems. Some people (I’m thinking here of Randall and Downie, 2006) have argued that patients and certainly their relatives, who are not anyone’s patients, have not given informed consent for psychological, social and spiritual interventions and all people really need is a nice kindly doctor to assuage their worries. This is a medical silliness similar to the psychological kind. However, it does make the legitimate point that we should be cautious of psychologising or sociologising common humanity. And, says he, delinquently, medicalising it too. See Randall, F., & Downie, R. S. (2006). The philosophy of palliative care: Critique and reconstruction. Oxford University Press.

The NCAT measures, and the NICE guidance, contains a really expert piece of professional imperialism by the psychologists, which says if it’s psychological call a psychologist. NCAT should have applied their minds to it and realised it’s not just psychological, it’s  also a lot of other things. It’s all to play for, of course, because even if NCAT falls for this, the measures are only about how cancer networks organise themselves, not about services. So what social workers have got to do is stick up for themselves, get themselves on the committees and fight for reality as they understand it, just as the psychologists have done for reality as they understand it. Playing the game means joining the team.

Consequently, for the St Christopher’s response to the consultation I have drafted a comment that starts off by saying this:

St Christopher’s Hospice has a strong commitment to providing effective psychosocial support in palliative care, and has recently been involved in research, including random controlled trials, to explore effective psychological care. It views the formulation of this guideline with concern, and considers it contrary to the basic objectives of palliative care, public policy, to the possibility of achieving effective management of psychosocial care in palliative care services and contrary to the available research evidence. The main issues are as follows: 1        Psychological and social support are closely intertwined in palliative care and measures for psychological support should not be seen in a way that prioritises one or the other. 2        Public and professional policy seeks to break down divisions between professional groups and emphasise flexibility in multiprofessional working. However, these measures are written in such a way as to create professional division. 3        The effective management of a multiprofessional service requires the utmost flexibility in the deployment of, often scarce, staff. 4         Palliative care, and cancer services more generally, are not settings for psychotherapy or psychiatry; their objective is integrated multiprofessional care. Most patients and their carers do not require psychotherapy to respond to personal and social issues that affect them. They prefer their main team to help, rather than being referred to specialists. The Hospice has found that a liaison psychiatry service with clinical psychology available on referral for psychotherapy is the most effective model.