I always think it’s a bit unfair  that sometimes there’s a comment in other places that readers of the blog only may not get to see. So I reprint here a series of exchanges on Twitter (cutting out all the Twitter technology so that you can see the comments more clearly and spelling out the Twittering abbreviations and missing words – indicated by [  ]). I was abroad for some of this time, so I don’t know I’ve seen all the points people made; in any case, unless you are continually on Twitter, you’re quite likely to miss some of what people say.

The debate here is about perceptions of a ‘local government social work’. Is it an over-generalisation to say that social work in local government is all bad? I didn’t say that, but I think an important issue is being raised. Should we be critical of the impact of the local government environment on social work practice? And is social work in a specialist environment, such as palliative care, always better?

The conversation on Twitter was about this post on April 25th, 2011: Palliative social work damaged by child protection controversy. You can read it in the archive.

Monstertalk retweeted one of my tweets drawing attention to the post.

Itsmotherswork saw this and commented to me and Monstertalk: [I’m] not at all comfortable with sideswipe at the end towards local government social work – as though it’s all bad.

Monstertalk re-read the post and could see the point that Itsmotherswork was making. I thought this was about a different post and tweet and, rather on the hoof, replied: Local government social services: [the] evidence (and my experience) is in general that many [people in local government social services] need to skill up on end-of-life care.

I made this point since it is a crucial element of the Social Care Framework document of the National End-of-life Care Programme; I was on the advisory group that contributed to this document, so I endorse its contents, although not uncritically. When I came back to a computer, I realised that Itsmotherswork was not tweeting about the social care framework, so I commented: [I] now realise you commented on a different post. No criticism of local government social work [intended]; all social work needs to get support from all specialisms.

Itsmotherswork then helpfully tweeted the part of the original post of concern and explained the critique of it:  It was this remark: ‘…and one could only wish that social workers in local government children and adult social care would look to the social work specialisms for evidence that social work can very easily be seen as a good thing, if you work at achieving a very high standard of practice in all that you do.’ …which seemed to imply that local government social workers of all types (it didn’t specify) don’t work hard at achieving good practice. That’s a bit sweeping!

There was then an exchange between Itsmotherswork and Memma_pie; I think I have not found all of this in my Twitter feed, but Memma_pie obviously asked about what Itsmotherswork was saying and there was this exchange between them:

Itsmotherswork said: That’s how I read it, but in fairness, it sounds as though it’s not how Malcolm meant it. I’ll retweet the original. Memma_pie then replied: It feels a little disparaging having read it in full, but I understand the gist and agree. Sadly.

I think this is a really important and worthwhile exchange of views; so, now I’m back at my computer, I’d like to extend the discussion a little to talk about the connections between local government and others locations for social work practice, with particular reference to palliative social work, which is what I’m supposed to deal with in this blog.

The most important point to make is that, in most European countries, local government is the main location of social care services and therefore of social work practice. Therefore, the responsibilities and organisation of local government has a significant impact on the form of social work in any particular country. In many countries, and this is certainly true in the UK, social work is very much defined by the kinds of social work practised in local government.

The peculiar characteristics of local government, as it is everywhere, therefore have a significant impact on how social work is practised everywhere. I work in a number of European countries, and wherever I go I find social workers complaining about stifling rule-bound requirements of practice in local government, compared with the freedom and flexibility of ideas about how social work should be practised. They also talk about how they are burdened by excessive workloads because their local government services are under-resourced to meet the requirements laid upon them by imaginative and forward-looking legislation. I was recently asked to give a lecture on ‘Social work: vision and reality’ the keynote topic of a conference in Slovakia. Talking about the topic to people at the conference, it is clear that the difference between vision and reality for them was just this distinction: between the vision of an empowering therapeutic social work and the reality of a constricting local government system.

In UK local authority adult social care the constriction is about workload and the highly tick-box oriented assessment part of the care management system and in children’s social care it’s about workload and the highly defensive practice promoted by media and political pressures around risk in child protection. I think everyone accepts that the focus on child protection has deviated much children’s social care from what used to be a child and family care service. You can exaggerate this, of course, because you can see a lot of very positive achievements in fostering and adoption work, in family support and work with children in family centres and in the community, in children’s residential care and in working with children in child and adolescent mental health services.

Equally, as I talk to people in any country, I come across practitioners who describe how they are doing imaginative and empowering social work with clients and community groups. Sometimes the way they have achieved that is by setting up a specialised agency that provides help for a restricted user group; sometimes it is by developing the skill and self-confidence to practise in an empowering way with their excessive caseload in a local government agency.

The same is true in the UK. I talked to a patient at the Hospice who told me that they had a wonderful care manager in the local authority, who really helped them to come to terms with the change of family lifestyle caused by dealing with their elderly mother’s increasing frailty. It quite changed their fantasy views, garnered from the gutter press, about what social work is and how it can help. That’s not the only example I have come across, I regularly meet people who sing the praises of their local authority social worker.

The problem is that I also come across a lot of care managers who tell me (just like all those other social workers across Europe) that their local authority is so controlling that all they can do is fill in the forms they have been given within the time limits required, and the extremely restrictive computer system that ties them to their desk.

By the way, this fantasy that social workers once went out and spent most of their time with their clients is just that: a fantasy. All the research that has ever been done on social workers’ workloads, going back to a study I remember but can’t now cite on child care officers in the 1960s, shows that most of the time always was taken up by meetings and paperwork (and, you hear less mention of this but it was always true, travelling to get to home visits). It’s self evident, if you think about it. An hour’s visit means at least the equivalent in travel, a further hour again in making notes and phone calls in following up, and if the agency has to be run, a further hour in meetings, coordination, cover for absent colleagues and training averaged out over the client contact you did that week. Twenty percent of your time in contact with clients is probably about average in any kind of people working.

I was involved in the introduction of care management and wrote a book about it and its possibilities (Social Work and Community Care, Macmillan, 1995) which to my astonishment is translated into other languages and still sells in the UK sixteen years later. Back in the late 1980s, care management was the personalisation of the age: it was going to lead to flexibility, imaginative creative practice and was going to be the foundation of a new adult social work (which was always the inferior branch compared with child care and family work). Just like personalisation now: forgive me for being a bit doubtful about fantasies that this will lead to a sea change in social work.

Well, adult services care management has led to a new adult social work; it has institutionalised social work assessment and service coordination skills as an integral part of the care system in this country. And well done, as it sometimes is, it can be life-enhancing to people in very difficult situations. I believe it has made a major difference particularly for people with learning disabilities, but also for other client groups. Even routinely done, as it often is, it enables a wide range of services to be provided and coordinated to a lot of people who really need and benefit from them. We all do the routine much of the time. For most of my practice career, I have done the job and provided the services as required. At any time, there have been a few families who have been at the point where I have something to offer them and you see a major shift in their lives.

When we comment on local government social work in any country, therefore, we have to be clear that the backbone of any service is doing the everyday job adequately. It is important also to be clear that there is always the chance if we can take time and space in the everyday job when there is a need, when there is a possibility, when people are ripe for it to make an extraordinary impact on people’s lives. I don’t think that is the difference between a ‘good’ local authority or practitioner or a ‘bad’ one. Whatever the setting there is always a chance to step up to doing a wow in a particular instance. The best practitioners are always looking for occasions when they can do this.

But we also have to accept that local government in general is over-burdened with responsibilities and under-resourced. It is also burdened with a management system that is primarily about rationing resources. Generally, throughout Europe, this is done by tight administrative controls that practitioners complain about. It also means that UK central and local government has chosen an administrative form of care management that international research has shown is not particularly effective at making a significant difference in the lives of vulnerable people, whereas there are other forms of care management that have a history of being much more successful at having an impact, but they are more expensive of money and staff resources. If you want that greater success, government, you have to pay for it. And if you want to connect with that research and my commentary on it, try my very well-reviewed book: Social Care Practice in Context (Palgrave Macmillan, 2009).

There are just such tight administrative controls on practice in specialist settings such a palliative care social work, or in forensic social work, another specialist area where I have been involved in the past. However, most of these services have fairly limited caseloads and an opportunity to use social work more fully, more broadly, more of the time as part of the everyday job. Many of these services are also part of healthcare, which is generally much better funded than social care in the UK (and elsewhere). So the expectations of professional colleagues in nursing and medicine are of a higher standard of everyday practice, because they have the resources to achieve it more often. High expectations tend to lead to stronger achievements. It ill behoves people working in these specialised services to complain about the everyday ‘good-enough’ standards of the more resource-constrained backbone local government social care, because it does provide the backbone, without which specialised services are likely to be flimsy in their achievements.

But what I was saying in my post was two things. First, specialist social work operates in settings that mean it has to develop credibility with colleagues in other professions. By meeting their expectations of good practice and using their generally better resources, social work can demonstrate to the world that social work can be and often is widely valued by other professions, service users and the managers and policy-makers who develop services. That demonstration of the value of social work in at least some settings should enable us as a profession to say in relation to local government social work: ‘Hey, this social work stuff can be a really good thing for people and as part of services generally’. We can say it to buoy ourselves up in our down moments and to show other people that social work does not have to be minimalist as under-resourced local government forces us to be. Second, it enables people in local government to point to valued social work and say: ‘Give us the resources and we can do more of that too.’

I come across palliative social workers who moan about what it was like when they were adult services or children’s social care social workers and say how pleased they were to work somewhere like a hospice and do ‘real social work’ or they complain about the bureaucratised attitudes of the care managers that they deal with who aren’t doing ‘real social work’.

Let’s be clear: ‘real social work’ is the local authority backbone of adult services care management and children’s social care. Because of the massive number of people that local government provides services to, the everyday backbone job makes a crucial difference to the generality of people’s lives in this country and elsewhere. And the times when there’s a chance to do a really good job in that setting means that a lot of people have really good experiences of social work in those settings too. Specialised social work settings, like palliative social work, provide the opportunity to add into that a social work that is relevant to the particular needs of people with very special needs. Because of the special needs, that kind of social work is different again.

I’ve stopped talking about social work, instead I talk about ‘social works’ of all different kinds, relevant to the setting and the role. That’s true when you talk about social works that we in the UK are not familiar with, like social development practice, or social pedagogy, or cultural social work; these are all well-established practices in some countries. It’s also true about the different social works practised in the UK. None is a ‘real social work’; all are a social work.

An interesting article by Jonathan Walters on an American children’s safeguarding case in which social workers have actually been threatened with prosecution for manslaughter for failure to protect children has taken my interest:

Read it here: http://www.governing.com/topics/health-human-services/punishing-social-workers.html?nlid=h110412

I’m intrigued by a certain amount of American social work anguish about this, because it so happens I’m writing a paper about the effect of thirty years of criticism of social work in child protection cases for a for a conference on parenting in Poland at the moment, and this post is based partly on a comment on American discussion on LinkedIn. You tend to think of palliative care social work as about social work with adults, but I think one of the things about palliative care is that you find yourself dealing with the issues that are facing a whole family, most of which are not about the fact that someone’s dying. So palliative social work is actually just as generic as social work used to be in generic social services departments were in the 1970s, when we were trying to deal with all sorts of social work issues.

High public concern on child protection  is of course justified (or as the jargon seeking a positive spin has it nowadays ‘safeguarding children’). Anyone ought to be concerned about abuse or neglect of children by adults and thinking through what we should do about it is an important concern of the public. Social workers have experienced opprobrium on child protection for thirty years, since the case of Maria Colwell in the early 1970s; Maria was killed by her stepfather in 1973 when being supervised at home by a social worker, and this has been damaging to the whole image of social work in the UK.

Since then, there have been many cases that have led to public scandals about child protection issues, including the Cleveland cases, when the public found out about the extent of child sexual abuse for the first time and the recent Victoria Climbie and Baby P cases. At least after Baby Peter, there has been a serious effort in government, maintained by the present coalition, to think carefully about what kind of social work we actually want rather than knee-jerk vituperation. Some thoughtful work is being done by the Munro Review, which alongside the Social Work Reform Board developments (a continuation of the Task Force) and perhaps the hopes for a College of Social Work might well help. Some links at the end to websites on this issue.

The main damaging result of justified public concern about child protection has been a naive proceduralisation of social work in the UK, to formalise and manage communication between agencies, to incentivise effective action by professionals and to share decision-making (and blame) among the agencies involved. It is as though if you tick boxes properly damaged human and social relationships can be This has led to a system in which child protection and the surveillance of parents is more important than providing good child care services and family support.

And public attitudes towards parental rights and responsibilities have also swung to and fro. The historical position was that parents had the right to bring up and discipline their children and nobody, least of all the state, should interfere with that. Over the last thirty years the law and public opinion has shifted towards a position that with that right goes responsibility for doing it well. But that hasn’t always meant that people feel that the state should interfere, and certainly there has been doubt about social workers doing that, not least because they have lost credibility because of child protection failings.

So social workers have continued to be the main target of criticism. This is partly because, in the UK system, children’s social care services are usually the agency with legal responsibility for taking action, so the police, doctors and nurses are inevitably less responsible.

But I believe it is also because of a political view among right-wing political parties, such as our Conservatives, US Republicans and German Christian Democrats, that people ought to be competent to manage their own lives and look after their children, and the state should not have to pay for a social work service to help them. So when people cannot look after their children, the political and media reaction is punitive to the parents and then also, when cases go wrong, to social workers for not intervening decisively enough and for being supportive and kindly to parents instead of representing a punitive public morality about parental responsibility.

So the criticism of social workers is also a frustration on the political right about the need for state intervention in family life. By setting themselves up as a profession that can help families deal with their problems, social workers have put themselves in the firing line.

The frustration for palliative social workers is that they have actually done a good job of convincing colleague professionals that they make a worthwhile contribution to multiprofessional practice in our field, but malking progress on this is held back by the continuing damage to the reputation of social workers by this semi-political issue about child protection. It;s important to keep plugging away about the positives, and one could only wish that social workers in local government children and adult social care would look to the social work specialisms for evidence that social work can very easily be seen as a good thing, if you work at achieving a very high standard of practice in all that you do.

The Munro Review website here: http://www.education.gov.uk/munroreview

The Reform Board website: http://www.education.gov.uk/swrb

The College of Social Work website: http://www.collegeofsocialwork.org

You’ll be aware perhaps from previous posts that BASW is, somewhat ludicrously, trying to claim the credibility to run the College of Social Work itself, rather than cooperating with everyone else; this is its website, but to get a balanced view of the issue, look at others as well: http://www.basw.co.uk

Another day, another book.

This is about some aspects of adult services in the EU; there are two articles specifically on palliative care, both from the UK. There’s also, among the general papers, a really good brief analysis of social policy affecting social services from a Czech perspective and a very nice paper with a private sector view on care home development in the UK – it’s gives a commercial perspective on decision-making you don’t often see.

More broadly, many of the authors (it’s a collection of conference papers) are from central Europe, so you get a picture of social services in a part of the world that most of us don’t know a lot about. There’s facinating paper in projects working with Roma communities and two comprehensive-looking papers on unemployment policy and disability policy all referring to Poland. There’s stuff on older people’s needs, on family problems and on community punishment in Slovakia (which gives a comparative perspective on their view of other countries’ developments), homelessness in Denmark and chronic drug addicts in Germany.

There are two facinating papers, with some interesting history on social work with families, on the problems with finding adults who will provide foster care and with transition to adulthood of young people in care in Poland. With a UK perspective, you tend to think of that as ‘child care’ rather than adult services, but actually these papers are about adult responsibility for young people and the transition to adulthood.

Another bit of a surprise is a comprehensive paper on university of the third age as a community development activity with populations of older people in Poland; it shows you an immense amount of social development you can do with older people.

Some practice skills papers give you a picture of how people in central Europe are thinking about skills issues.

I helped with the editing in English, and did a paper on where personalisation is at, but the book comes from Opole University in Poland.

It’s published by College Publications in London: http://www.collegepublications.co.uk/other/?00018

and you can find it on Amazon UK or US by searching for the title: Social Work in Adult Services in the European Union. Selected Issues and Experiences

Someone on LinkedIn asked about my new book, already out in the US, but coming out in the UK tomorrow (from Palgrave Macmillan: http://bit.ly/dTTf5M ). I thought readers of this blog might have an interest in the reply.

Perhaps the best thing to do to get a picture of the book is to read the excerpts on the American publisher’s website http://bit.ly/gEW2Hl. Here are some of the main points:

The book starts from the fact that we are human beings, working with human beings.

It tries to integrate four areas of knowledge about how human beings live in the world: humanism (in particular secular humanism), humanistic and transpersonal psychologies, human rights charters and the thinking that comes from them and microsociology.

From the importance it gives to human rights, it emphasises achieving social justice and responding in inequality as a major role of social work

It emphasises flexibility and dealing with complexity, whereas many systems of social work try to oversimplify human life into simple prescriptions.

It says we have an accountability for helping people use their personal skills and development in dealing with issues in their lives and also for helping people in their social context change to facilitate the personal movement that people are seeking.

Practice should incorporate artistic and creative understanding, and spirituality, as well as psychological and social knowledge.

We should be helping people to develop security and resilience in their lives.

This is the second of my posts looking at the whole situation in health and social care at the moment and its impact on end-of-life and palliative care.

It is clear that the government proposals on NHS and (to some degree) social care reform are in trouble. What will this mean and what will it mean for end-of-life care?

I did some detailed stuff on the proposals and what’s in the Bill in previous posts: search for ‘Health and Social Care Bill’; there are several posts in January 2011.

However, if you want a good summary of the characteristics and political impact of the proposals, look at the BBC news website, in its Q&A on the reforms:

http://www.bbc.co.uk/news/health-12177084 (this also has a nice diagram of the changes).

and its summary of views for and against them:

http://www.bbc.co.uk/news/health-12750695.

A more complex account of the issues may be found on the King’s Fund website:

http://www.kingsfund.org.uk/topics/governance_regulation_and_accountability/index.html#keypoints (start at the keypoints, then go on the background tab and the comment and analysis. Anna Dixon’s blog post on the ‘paradoxes’ in the reforms is worth a read, and so are some of the comments: the readers of the Fund’s blogs are better informed than a lot of comments in newspapers).

Are the reforms in trouble? Why?

The fact that the Health Secretary, Andrew Lansley has said that there is still room to amend the reforms suggests that they are: the Telegraph report on that here (I use the Telegraph to report on government views because it is a broadly government-supporting newspaper, so I can’t be accused of selecting press that might put a negative slant on things):

http://www.telegraph.co.uk/news/politics/conservative/8379284/Andrew-Lansley-signals-retreat-over-NHS-reforms.html

The reforms are in trouble for three main reasons.

It’s not privatisation

One of the reasons is not privatisation through marketisation (that is, reducing the public sector element of NHS provision, by strengthening that aspect of NHS care that is provided through a managed market). Of course, the usual suspects have said ‘Tories – get your thieving private sector friends’ mitts off our NHS’. The two main suspicions are (1) that American and other big healthcare companies hope to get in on running local commissioning and (2) that the ‘any willing provider’ policy integral to the reforms is likely to increase private sector participation.

The main concern there is cherry-picking. Private sector providers like nice cheap easy, repeatable procedures to carry out (hip and knee replacements, cataract operations like the two I have just had, and so on). If you take these out of the NHS, you leave the more difficult stuff for the NHS to do. As a consequence, they have to deal with the more complicated and expensive stuff and over time can be made to look even more unrealistically expensive than they are now. Also, they cannot train up their surgeons on the easy stuff, so they are going to be less skilled on the difficult stuff. Faced with these criticisms, the government has introduced some concessions to meet these concerns. Lansley says in an interview (link below) that this means any willing qualified provider, so the local commissioners will decide; they can choose to avoid excessive private sector provision if they want to maintain their local hospitals.

Also, patients can say they want their local hospital and I expect a lot of them will. After all, we all know that if there is any problem in a private hospital, they can’t cope and the patient is blue-lighted to the nearest NHS hospital. It’s only really naive believers in the private sector that are unaware of this. Also, things like palliative care just don’t happen in the private sector and since the main increases in service demands are going to be among older people with long-term problems, they’re not going to find really good care in the private sector of healthcare. Private sector domiciliary and community care is far more likely to stay directly commissioned from the public sector, even if providers are increasingly private or social enterprise organisations.

Is there any evidence that private sector companies are trying use the reforms to get into the NHS? Yes, of course; any private sector organisation is going to look for expansion opportunities, just like any energetic public sector manager. Try having a look at the website of the private sector consultants, Binley’s: they’re charging a lot of money for people who want to get up-to-date news on changes, NHS changes are the top of their list of ‘products’ enabling private sector organisations to ‘track’ the NHS reforms; they say they have 30 researchers doing nothing else. Yes, there is big money in prospect for the private sector:

http://www.binleys.com/Products.asp?CatID=13

It is a broad spectrum of important opposition

Not including, it has to be said, the official opposition, Labour. As with the cuts campaigning that I covered yesterday, they are somewhat stymied by the reality that many of the reforms explicitly build on their own policies, and they might well have wanted to do something similar.

No, the three main reasons why the reforms are in trouble are mainly other professional and political opposition.

The first is that the people who are intended to be major players in the reforms, the GPs, have turned out to be mostly opposed to it. There are supporters in the GP camp, mainly people who have been making GP involvement in commissioning work in, mainly rural, areas where the Conservative MPs come from. A few of these people can be (and have been) characterised as venal doctors keen on supporting a privatised NHS so that they can get rich(er); possibly because some of them really are like that. Consultants have also called for the Bill to be withdrawn, it seems because it may endanger the importance of the major local hospitals through fragmentation and privatisation, and therefore their influence. They have been trying to whip up concern about local hospital closures. See the Telegraph report of their concerns, for example. This presents a mish-mash of claimed concern for the NHS and their patients and complaints that they are not respected by politicians, who promised to leave the NHS alone: http://www.telegraph.co.uk/health/healthnews/8400872/Doctors-call-for-industrial-action-over-devastating-NHS-reforms.html

However, they are still negotiating on pay and conditions (like other public sector employees, their pay has been frozen, fancy the consultants being treated like the lower orders), so perhaps the government will be able to buy them off. Governments have been doing that since Aneurin Bevan, the Labour health minister in the 1940s.

Also, lots of people concerned about the management of the NHS are doubtful that GP consortia being responsible for commissioning the majority of services can be made to work. This is partly because GPs are considered to be mainly interested in treating their patients (although GPs I know are also scathing about the management of commissioning on behalf of their patients and it’s important to recognise that being able to refer your patients to the right treatment is an really important aspect of the role of GPs), but also because this will lead to further fragmentation in planning and management. Some others are concerned that it will let private sector healthcare companies in to help them manage it. If you think pct bureaucrats are the worst kind of management to have, wait until you see a management consultant: incompetence is miles better than financially motivated rapacity.

The second major reason for the trouble that the reforms are in is that the LibDem party, in coalition with the Conservatives who have dreamed up the plans, have now come out opposed to them. There will have to be concessions. The Telegraph report contains a video of Nick Clegg, the LibDem leader, distancing himself from the reforms:

http://www.telegraph.co.uk/health/8378143/Nick-Clegg-faces-crisis-over-NHS-reforms.html

Another account of the LibDem debate here:

http://www.telegraph.co.uk/news/politics/nick-clegg/8378236/Nick-Clegg-in-climb-down-on-NHS-reforms.html

An important influence in this has been the intervention by Lady Williams, Shirley Williams an ageing national political treasure on the left: interviewed by Simon Hattenstone in the Guardian, she said:

“I’m very worried about health. I’m a passionate believer in the health service, I’ve never used private medicine in my whole life.” She believes the NHS is “by and large wonderful” and the proposed restructuring is as unnecessary as it is dangerous. “We looked at [Andrew] Lansley’s white paper, and it’s got a lot of holes in it. For example, what happens if a foundation hospital has a deficit or a surplus, where does the money go, to whom is it accountable? There’s no system of accountability of a democratic kind, except for the bit the Liberal Democrats have put in, which is not very strong, but all credit to our guy for doing it.”

Williams is aware that critics argue this is a preliminary step towards privatisation of the NHS. And yes, she is fearful. “What I do know is that if there was any sign we were moving towards privatisation of the NHS, a lot of Liberal Democrats would not put up with that.” Would Nick Clegg? After all, power is pretty intoxicating, isn’t it? “Oh to be fair to the man, I think he would feel this was a red line.”

The full interview at: http://www.guardian.co.uk/theguardian/2010/aug/14/shirely-williams-saturday-interview

The third major reason, also political, is that while the reforms are likely to get through the House of Commons, they will be under much more pressure in the House of Lords. Lady Williams and her friends are clearly calling up a storm. Again, probably some more concessions.

There’s a good LibDem document which is perhaps the best available political statement in favour of the reforms – it’s significant that Appleby, providing a critique in the British Medical Journal, cites this, rather than the white paper or any Conservative statement; it’s just such a good explanation of the political case:

http://www.libdems.org.uk/latest_news_detail.aspx?title=Modernising_the_NHS%3a_the_Health_and_Social_Care_Bill&pPK=e73493ce-b0f0-46f8-b83f-c94ffac3ed63

This is worth reading to get an idea of the arguments against the ‘Tories red in tooth and claw’ critique you get from left-leaning sources.

Is there a real concern?

The government makes two main points. It argues, first, that reform is needed because UK health outcomes are not as good as in Europe. This point has been subjected to a statistical analysis in the British Medical Journal by Professor John Appleby of the authoritative King’s Fund: http://www.bmj.com/content/342/bmj.d566.full

He argues that UK outcomes on cancer and heart deaths are worse than some countries in Europe, but are coming down faster, so we’ll be better soon, that in other illnesses the UK does better and that much of the difference is down to how the data are collected and analysed, rather than actual differences.

In a later article, Appleby points to the British Social Attitudes survey results, which show increasing public support for the NHS, and evidence that the public thinks it’s improving. A link to Appleby’s article: http://www.bmj.com/content/342/bmj.d1836.full

And to a summary of the British Attitudes survey (actually co-authored by Appleby, so it appears his BMJ article is in the nature of an advert for his work – what an academic would call effective dissemination):

http://www.natcen.ac.uk/media/606952/nat%20british%20social%20attitudes%20survey%20summary%204.pdf

This report says:

The largest increases [in positive views of the NHS] have been among those with traditionally low levels of satisfaction. These include 18-34 year olds (up 32 percentage points since 1996, compared with an increase of 24 points among those aged 65 and over) and better-off households in the top two income quartiles (up 31 and 36 percentage points respectively since 1996, compared with an increase of 25 points among the lowest income quartile).

While satisfaction with the NHS among Conservative supporters fell initially when Labour came to power, it rose 12 percentage points between 1996 and 2009, reaching a high of 61% in 2009.

So actually it seems that people mainly like the NHS as it is. We know this, of course, because satisfaction surveys are not the most sophisticated way of measuring effective healthcare outcomes and most people could not imagine how it might be better if they’ve had (or they’ve heard that other people they know had) a broadly good experience. But all this does not add up to an overwhelming case for a very disruptive reform in most people’s eyes.

The second, and more important, point the government makes is that the NHS will have to cope with escalating demand and need and these reforms empower people in the NHS to transform the way they work to meet that demand.

You can of course go back to the horse’s mouth. Andrew Lansley gives an extended 42-minute interview on a doctor’s website at:

http://healthandcare.dh.gov.uk/andrew-lansley-talks-to-doctors-net-about-modernisation

(unfortunately, you have to sign up for other things – make sure you set your preferences); if you think 42 minutes is too long, set it going and do other things on your computer while it’s running; don’t do this at night, it’s very soporific. For example, he argues that cherry-picking will not be possible because if GPs set up an integrated care pathway, private sector companies can’t pick off individual procedures. The journo who interviews him puts serious criticisms (from doctors) to him, for example from specialist doctors who say they have studied to acquire the knowledge about what is effective, so how can GPs make these decisions, and, for example again, if things don’t work out, what are they going to do? He, of course, sounds eminently reasonable, and the interview doesn’t really put him under Paxman-like pressure, but it does give you a picture of what he thinks.

Overall, the picture is that it’s future population and medical cost pressures on the NHS that he has to reorganise to cope with, and if there’s not going to be much money, it’s clear that doing things better is the major way of dealing with those problems. The critics would say, of course, stop spending the money on silly things like maintaining an unrealistically significant place on the international scene,  settle for being a little country with not much international power but a really good lifestyle for citizens. Then you might have more money again, and you might give priority to citizens’ healthcare.

Will GP commissioning work?

The Department of Health is keen to say that GP involvement in commissioning has been very effective. If so, there’s not a lot of evidence on its website. One case study is trumpeted as showing how it will work, but is about a group of GPs who decided they wanted to get more counselling for their patients with personality and eating disorders and worked with a local voluntary organisation to provide it, which eventually got the contract. Here is the link:

http://healthandcare.dh.gov.uk/case-study-integrated-care-commissioning

There’s another case study based in my home town, Sutton, where Care Minister Paul Burstow has his base. This is about local authority and GP commissioning. In this case, the GPs and local councils worked together to keep patients at home rather than admitting them to hospital for three conditions. ‘A six-month pilot, based on just three medical conditions and a trial area of only 25,000 patients, reduced PCT admissions by 29 patients with long-term, high risk conditions and saved approximately £322,000.’ It is now being extended to two more conditions. Again, this is a small-scale project, rather than mass commissioning.

On the web: http://healthandcare.dh.gov.uk/case-study-sutton-integrated-health-and-social-care-pilot-shows-benefits-for-patients

Better integration with social care and local government

GP commissioning is not the only aspect of the reforms. A much greater welcome, across the political spectrum, has been extended to the arrangements for better integration with local authorities. And of course, if you are going to make things work better for an ageing population and a country that can’t afford medical developments, this is one important route to achieving it. One of the pluses is that better integration with local authorities will connect up health and social care services much better, and it builds on long-term attempts to improve relationships and joint work and planning. The minus is that this has been going on for forty years, and conflict and competition is still rife on the ground. One simple reason for this is lack of resources; both sides try to pass the buck as much as they can.

A more high-flown point about the failure to integrate, is that all integration efforts assume that NHS illness care is the most important thing. However, we are not talking about illness, we are talking about long-term care for people with complex social and health care needs as they age. And the NHS has withdrawn from all that, but still demands all the resources for its acute services, starving the much more important long-term care needs of resources.

As a result, healthcare (and DH generally) twists social care into being the mere servant of healthcare priorities. Remember that social work is about promoting social solidarity, resilience and cohesion so that a population can cope with the social pressure on it more effectively. Public health sits well with those priorities, but the NHS is about illness care, not wellbeing. Attempts to merge NHS concerns with public health and wellbeing are prone to disaster because the imperative to treat sick people twists all other social objectives out of kilter. This runs a serious risk of prioritising massive treatment problems instead of equally massive but rather more distant problems of health inequality and social cohesion.

I think of it as rather like the Japanese and their nuclear power industry. The Japanese don’t have reserves of fossil fuel, so if they want to run an advanced industrial society, they have to have lots of nuclear power. However, they also occupy a mountainous set of islands, with minimal coastal plains in which people can live, be industrious and build their nuclear power station, alongside a major geological fault on the earth’s surface which creates large earthquakes and tsunamis. So they keep quiet about the problems, and minimise the difficulties. The recent earthquake and tsunami has found them out.

Because people’s free health care is so important to them, what the DH does, like the Japanese on nucelar power, is run everything they do as subservient to the NHS, and just ignore or keep quiet about any other priorities that might interfere with it. That is why the DH is so bad for social work and social care. It also runs everything as though important care services such as end-of-life care is the same as but less important that acute care in hospitals, so that acute care always seems more important. That is why the DH is so bad for end-of-life care (but seems alright for palliative care, which is really only what the doctors and nurses want to do, and the less important doctors and nurses too, because they’re not concentrating on curing people). It is important not to forget these eternal verities about health care in the UK. Actually, what is more important is mutual social support, prevention and quality care in the long-term that affect everyone as they age. As I said yesterday, we should be aiming to love quality care, but theNHS is set up to love expensive acute care; they love money for treatment rather than less money for quality of life. The whole NHS healthcare system is set up to twist everything so that it fits the fantasy medicine of high-level surgery and heroic medical care.

In some ways, these are points made by the experienced civil servant, social services director and former Labour health minister Lord Warner, in a book: http://www.guardian.co.uk/society/2011/mar/22/nhs-reforms-essential-lord-warner

He argues, according to the Guardian, that Labour failed to ‘…achieve effective commissioning of healthcare, allowing an excessive expansion of the workforce, thus worsening productivity, and ducking the challenge of replacing seriously underperforming and unsustainable hospitals and other care providers.’ He is focused here on the way in which local campaigning often emphasises acute hospital care and the closure of acute hospitals rather than boosting the far more important provision of long-term care in the community.

The reforms aim to use enforced collaboration with local authorities to achieve this. I’m not hopeful, because as I’ve said, it never has achieved any change in the ‘acute-is-best’ NHS scenario yet. The DH trumpets ‘early adopters’ of health and wellbeing boards; these are 132 areas where they have set up shadow boards: http://healthandcare.dh.gov.uk/early-implementers-of-health-and-wellbeing-boards-announced

But if you look carefully, they haven’t actually done much. The DH general statement says:

Many local authorities already have projects in place to integrate services, including:

• combining health and social care support for dementia suffers (sic) to reduce hospital readmissions

• improved communication between health and social care professionals to enhanced the support package offered to vulnerable members of the community
• fast-tracking learning by integrated public health teams in local authorities.

Notice that this is not a brave new world; it talks about local authority projects. I wonder how genuinely collaborative they have been and whether they have been directed to social objectives and health prevention aims, instead of NHS treatment priorities. Notice that the leading achievement is to reduce hospital admissions for dementia sufferers (as I think they meant in their website); this is, it means hospitals don’t have their acute care priorities twisted by actually having to care for people with long-term problems.

This overall impression is supported by another entry on the DH website, the example of effective health and wellbeing board shadowing in Leicestershire: http://healthandcare.dh.gov.uk/leicestershire Again, this is in special project territory, with the aim of getting more health checks for people with learning disabilities. Nice, for example ‘supporting people with learning disabilities to interview Trust Board members about progress’ but not exactly mass commissioning of the full range of NHS services. It’s an important aspect of service, which you would hope to see developing, but a small development project involving a local voluntary organisation for a limited range of patients who are unserved at present is a million miles from commissioning the whole range NHS services. When the big boys of private health want a slice of the action over something that’s important to them, it’s unlikely that a little local group will get a look in, and the GPs would find it hard to resist the pressures of the big professionals.

The website also has a filmed interview with someone described as an early implementer. This is an accolade I’ve often been tempted to seek, and always discretion proved the better part of ambition. You really wonder why the DH decided this innocuous film of someone saying they’ve got an shadow health and wellbeing board was worth putting on their website. The interview is apparently conducted against the background of a conference, no doubt to make it stunningly as of the moment, in that artistic way that only Channel 4 news can really achieve. It features a pink-bespectacled NHS bureaucrat, now working for a County Council. I thought of not bothering to give you the link, since it’s one of the most pointless uses of internet technology I’ve ever seen, but I’ve decided to offer it as a good example of how to say absolutely nothing in 38 seconds – it was edited too, so she was obviously irrelevant to anything important for even longer. Don’t show it to any Tories: this is exactly the sort of unnecessary bureaucracy that they’re keen on killing off and she seems quite nice really: http://healthandcare.dh.gov.uk/early-implementer-cheryl-davenport-nhs-leicestershire-county-and-rutland.

This has a lesson for palliative care. Existing palliative care organisations which are providing services on the ground are quite likely to get their provision supported under the new system. But if extensive developments in palliative care are required in local hospitals, is this going to get priority when they’re fighting tooth and nail with big private providers for more major areas of acute care? Will it fall by the wayside because the big health providers will not be interested? This is likely, because exemplary care for amorphous things like the end of life is not what the big private providers are about. It works in America, I hear you say? Yes, but only because everything is private in the US, so there are financial mechanisms for all sorts of values-based bits of healthcare, and of course, unlike the NHS, they do not have to be responsible for a substantial slice of the population that presents social problems and does not have any personal, family or community resources.

Finding out what’s being said

To add to the more neutral stuff mentioned above (good old BBC), the Guardian’s page on the reforms covers the main points on the reforms well as they were published in January:

http://www.guardian.co.uk/society/2011/jan/19/nhs-health-reforms-unveiled

(with a nice Steve Bell cartoon in which surgeon Lansley bloodily extracts the innards of the NHS:

http://www.guardian.co.uk/commentisfree/cartoon/2011/jan/20/steve-bell-andrew-lansley-nhs-reforms?INTCMP=ILCNETTXT3487)

Why are they in trouble, then? The Guardian account of the BMA meeting which rejected the reforms of behalf of GPs, who are the main protagonists in the new system, is instructive:

http://www.guardian.co.uk/society/2011/mar/15/bma-meeting-rejects-nhs-reforms?INTCMP=ILCNETTXT3487

However, there has been something of a media war and the government tried to put the  positive side. The Guardian also reported on GP supporters of the scheme who turned up at a reception at No 10:

http://www.guardian.co.uk/society/2011/mar/15/nhs-reforms-doctors-accountants

and there was a subsequent exchange of letters, mainly representing opponents of marketisation, in which ‘fantasy economics’ had a part to play:

http://www.guardian.co.uk/society/2011/mar/18/doctors-fantasy-economics-nhs-marketisation?INTCMP=ILCNETTXT3487

What about comment other than in the left-leaning Guardian. I turn to the Telegraph.

A Tory MP and GP says that the reforms will change the NHS ‘beyond recognition’:

http://www.telegraph.co.uk/health/healthnews/8392556/David-Camerons-health-reforms-risk-destroying-the-NHS-says-Tory-doctor.html

Her criticism is that it’s good to get rid of a middle tier of NHS bureaucrats, but NHS planning should not be done by an unelected regulator (Monitor, the much-expanded financial regulator in the plans) and local GPs have too much to do treating their patients. Also, stripping out two tiers of management is really top down, and the Tories are not supposed to be being top down.

If you want to see Conservative official policy on health, this is the link to the election manifesto, which says ‘where we stand’:

http://www.conservatives.com/Policy/Where_we_stand/Health.aspx

But I searched for ‘NHS Reforms’ on the Conservative Party website and in the total returns found only one passing mention by George Osbourne in a party speech in 2011; most of the entries are much earlier. The Party obviously does not keep its website up to date, or else it’s keeping quiet on NHS reforms.

You can’t search the Labour website, I’ve said before that they don’t like you to find out anything they don’t want to tell you (although it is easier to read than when I last assessed it – but I suppose that may be because the NHS has renewed my eyes). They don’t really talk about policy there, but there are one or two items telling you how David Cameron has broken his promises to protect the NHS, but not a lot of detail. I worked hard to find these by ploughing through the site map, so here they are:

http://www.campaignengineroom.org.uk/frontline-nhs

I’ve already mentioned the very good LibDem statement explaining the case for the reforms, but here’s the link again:

http://www.libdems.org.uk/latest_news_detail.aspx?title=Modernising_the_NHS%3a_the_Health_and_Social_Care_Bill&pPK=e73493ce-b0f0-46f8-b83f-c94ffac3ed63

These are the positives that the critics have to argue against.

The Social Enterprise Coalition, whose sector is one of the intended beneficiaries of the reforms enabling non-public providers a chance of getting involved, focused on a concern that NHS staff would find it easiest to go for privatisation because they didn’t know enough about social enterprise to use it properly.

http://www.charitytimes.com/ct/NHS_reforms_must_shield_against_privatisation.php

This is a thoughtful point, and the palliative care sector, along with many voluntary organisations, could draw on their own experience to support this. Most NHS commissioning is done from the perspective of people who mainly only know about the NHS and do not have the time or knowledge to build alliances with small local organisations, or to support them to develop. Privatisation may come about by default.

A good realistic website, which usually contains links to the latest news, is the Royal College of General Practitioners’ commissioning website. They are trying to improve GPs’ skills in commissioning and getting feedback from their members about what’s happening on the ground, so this is a really good site for understanding how GP commissioning is going to work:

http://www.rcgp.org.uk/centre_for_commissioning.aspx?gclid=CJrznKuW9KcCFY0hfAodphr3bQ

This is the daily news update for today:

General practice must embrace change to improve quality of patient care

GP reforms’ leaders on boards of private firms

Why the NHS needs to be reformed

Private firms set to join NHS Board

Consortia must save £4bn by 2014

There could be no better evidence of the likelihood of serious privatisation and reductions of funding than these headlines from just one day.

And here is a broadly supportive comment from a blog, and some of the supportive or critical comments received:

http://bellagerens.com/2011/03/13/those-nhs-reforms

Among the points made are comments that many people involved in health and social care would agree with, that neither central government nor PCT commissioning has been particularly effective, and improvements in effectiveness are certainly needed. There are also some ways in which these reforms might help; whether they do will depend on how they are implemented.

Conclusion

Writing a conclusion sounds a bit like finishing off a student essay, but I feel I should get to some sort of summary of what I think, having looked at this stuff. In a few sentences, it’s this.

It’s clear that reforms of NHS provision are needed, to cope with demographic and medical developments.
I have probably also made it clear over the years of this blog that I yield to nobody in doubting NHS commissioning, which I think is very distant from the priorities of patients and the communities they live in; I have never seen any genuine engagement in the community from NHS commissioners, but I’ve seen a lot of worries about the budget and relationships with big providers; hence I am also doubtful about the value of PCTs as at present constituted. So I’m up for reform, but I want to make sure it improves things and I think the general opinion is that this might not be the right way to go.

Evidence of successful local collaboration is of small-scale projects with limited service user groups, rather than extensive broad service commissioning. This is likely to continue. It’s good to see, but it’s no evidence that GP commsisioning will work for everything.
It looks as though proposals for universal GP commissioning are over-optimistic, but greater bottom-up professional engagement, and not only from GPs but other professionals and from social care and local government, would probably deliver a better system.

Campaigning by critics of privatisation have already achieved some concessions, but it is clear that marketisation will go ahead, because the Conservatives have a majority and believe in it and most people (like me) are not convinced by NHS bureaucracy and are happy to see some change. In this way, I think NHS bureaucrats are a bit like child protection social workers – they have the kind of job where something is bound to go wrong and they’re bound to be blamed for it.

While there are many opportunities for private sector input, there is everything to play for in defending local services against excessive cherry-picking and disruption by private sector companies.

There is broad support for collaboration with local health and wellbeing boards, and some good joint projects: there will have to be a better focus on long-term care, prevention and care policy and away from over-emphasis on local acute hospital provision.

To achieve better end-of-life care, we need to put effort into supporting better integrated long-term care, especially for older people and in dementia services, because that is where most end-of-life care happens, and therefore we need to support the shift from acute hospital care to better community care, more effectively integrated with good palliative care in hospitals so that people’s end-of-life care needs are better met wherever they are.

Being at recent roadshow about the National End of Life Care Programme’s Social Care Framework means that I’ve picked up some of their other publications. I may be old-fashioned, because I could quite easily see them on the website, but actually I don’t look at things that are not directly relevant to me, so until I see them in physical form, I don’t really give them a going over.

If you need to link to the Social Care Framework, here it is:

http://www.endoflifecareforadults.nhs.uk/assets/downloads/Social_Care_Framework.pdf

If you need to find the website listing of the NEOLCP’s documents, here it is:

http://www.endoflifecareforadults.nhs.uk/publications

Bizarrely, the NEOLCP seems to use pictures of trees and flowers a lot: it seems to be symbolic of the way through the woods; either that or it’s the very cheapest stock pics. The Learning Resource Pack for staff in housing, particularly care and support staff in extra care housing, is one of these. You would expect a few pics of housing. In view of the fact that they major on pics of healthy and happy looking older people (nobody can ever look depressed or grotty in a government publication) you would think they could come up with pics of healthy and happy looking housing – actually there’s only one of these in the 40 pages. I presume their public relations people tell that that people sell things better than buildings. The weakness of this is that we are not looking to be sold something in these documents; what they should be doing is using the illustrations to show us what to do.

This document is also unusually text-heavy for the NEOLCP, and there’s only one flow-chart – can this be a first for the Department of Health?

It is clearly aimed at housing staff who don’t have a lot of knowledge of the care system. Chapter 3, for example, lists professionals who can help in end-of-life care. I, of course, turned to what it says about social workers. Here it is:

Social workers can provide emotional and psychological support especially at difficult times in people’s lives. They aim to see the individual as the “expert” and, using a person centred approach, offer support with no judgement value. They can act in a care management role as well.

How can they help?

• Assessments.

• Liaise with other professionals.

They can facilitate:

• Social inclusion.

• The person’s rights.

• The person’s choice.

• The individual’s views.

• All done with respect for the individual.

• Help the individual complete a person centred plan.

• Support the individual and their families and/or carers. (p 12)

This is probably a realistic view about what most local authority social workers do, but it doesn’t help housing workers to understand what a social worker in general might offer, if they’re a palliative social worker. And is all this respectful ‘expert service user’ and person-centred approach not also done by other people? If I were a housing worker, I might think I could do that naturally – what do I need a social worker to do it for? And don’t any of the numerous varieties of nurses not do that too (I’ll answer my question, yes they mostly do). Many of the other pen pictures of professionals are similar in their partial description, but the social worker description is particularly limited. For example, occupational therapists are acknowledged to work in a number of different settings and apparently ‘…help an individual who has a physical, psychological or social problem that interferes with their ability to carry out normal everyday activities…their aim is to enable people to achieve as much as they can for themselves.’ (p 13). Well yes, but I would think most people working in end-of-life have similar objectives and concerns.

This section illustrates the way in which many accounts of multiprofessional practice in health and social care are over-simplified, with the aim of making generalised distinctions which do not stand up – who does what in each locality tends to vary according to the settlement between professions in that area.

But the rest of the document contains good information about medication, common symptoms, mobility and the last days and hours which would benefit a lot of care workers whatever their role.

This document is produced in cooperation with Housing21, a well-experienced housing association.

National End of Life Care Programme/Housing 21 (2009) End of Life Care: Learning Resource Pack: Information and Resources for housing, care and support staff in extra care housing. London: Department of Health.

On the web: http://www.endoflifecareforadults.nhs.uk/assets/downloads/pubs_EoLC_learning_res_pack_housing.pdf

If you read nothing else this year, read this. And tell everyone about it: it speaks directly to everything that palliative care and social work tries to do.

Kate Bell and Matthew Smerdon (2011) Deep Value: A literature review of the role of effective relationships in public services. London: Community Links.

On the internet:http://www.community-links.org/uploads/editor/Deep%20Value%20-%20final%20web.pdf

This report, funded by the Esmee Fairbairn Charitable Trust, says and shows the evidence in detail for saying: the literature shows that effective relationships are not just a ‘nice to have’ but increase the likelihood of achieving a positive outcome across all of the sectors examined in this review. this includes health and social care.

More detailed points:

Deep Value is a term that captures the value created when the human relationships between people delivering and people using public services are effective. In these relationships, it is the practical transfer of knowledge that creates the conditions for progress, but it is the deeper qualities of the human bond that nourish confidence, inspire self esteem, unlock potential, erode inequality and so have the power to transform.

The evidence shows:

People using public services put great importance on the human relationship with the
person providing the service.

The elements of what make for effective relationships are strikingly similar across all areas studied in this review. Understanding, Collaboration, Commitment, Communication, Empowerment, Time. The effectiveness of relationships is therefore dependent on both parties taking responsibility. Delivering and securing good public services is something of a mutual endeavour and one…where the citizens’ relationship with the state is established.

Where relationships are effective, they contribute to achieving a range of valuable benefits: the failure to realise these benefits can be damaging.

There was a clear consensus in the literature about the types of working conditions and practices which were more conducive to building effective relationships:

Front line autonomy – excessive focus on a set process, and on ‘output’ targets (as opposed to outcomes) restrict the ability of advisors to treat the client as an individual.
Continuity and time
Training and skills
Attitudes of the provider – professionals need to have an attitude towards their clients of trust and respect, and to be proactive in pursuing their case.
Separation between ‘policing’ and ‘supporting’.

The Social Care Framework is having some impact and social workers are beginning to think about the reality, especially in adult services,  that the people they serve die.  Community Care has published a comment on a report; the link simply takes you to the NEOLC website, so presumably this is the end of year report. It emphasizes how valuable it can be for social workers in all settings to have some understanding ofhelping people cope with death, dying and bereavement. A social worker makes thoughtful comments.

See it here:

http://www.communitycare.co.uk/Articles/2011/01/27/116170/Social-workers-need-more-training-in-talking-about-death.htm

And one of the most impressive social work practice blogs http://fightingmonsters.wordpress.com/2011/01/27/death-2/

has an interesting reflection on an experience of meeting a client from way back. She had devotedly cared for her husband who had died, and this leads to a review of other experiences about death in a social worker’s career.

As Margaret Reith and I have argued in our recent book Social Work in End-of-life and Palliative Care, every social worker comes across death and bereavement as part of their work: this is not a specialist area, and it is sadly neglected in agencies and social work education.

You can see details of Margaret’s and my book here:

(UK, Commonwealth and Europe) http://www.policypress.co.uk/display.asp?K=9781847424143&sf1=contributor&st1=Malcolm%20w/2%20Payne&m=4&dc=4

(US, N and S America and Far East)  http://lyceumbooks.com/swEndofLifePalliativeC.htm

One of the failings of British social work (and possibly elsewhere, too) is that we mainly think of ourselves as caring for and supporting people during their lives. So we do, but they will die, and in adult services they will probably die while they are on our caseload. We don’t think of caring and supporting them to prepare for and live successfully through their own death and the deaths of other people who are important to them.

And a Community Care article with links to current activity:

http://www.communitycare.co.uk/blogs/mental-health/2011/01/the-social-work-civil-war-begi.html

Jackie Rafferty also gives links to press articles on the BASW/College of Social Work spat:

Community Care:
http://www.communitycare.co.uk/Articles/2011/01/21/116155/basw-confirms-launch-of-own-college-of-social-work.htm

The Guardian:
http://www.guardian.co.uk/society/2011/jan/21/social-workers-professional-organisation