Effective Social Work with Older People

CHAPTER THREE THE SOCIAL AND POLICY CONTEXT FOR EFFECTIVE SOCIAL WORK WITH OLDER PEOPLE

Introduction

3.1 This chapter summarises the context within which effective social work must be achieved. We consider the literature describing the environment in which effective social work takes place and the cultural background within which older people's expectations of good outcomes are formed.

3.2 In doing so, we are reflecting the comments in the Interim Report of the review, highlighting the IFSW Code of Ethics (2004) statement that

" Social workers should be concerned with the whole person, within the family, community, and societal and natural environments, and should seek to recognise all aspects of a person's life."

3.3 The Interim Report summarises the context for all social work in Scotland, noting recent social, political and demographic shifts, legislative change, policy developments and the 'modernising agenda' as it applies to the workforce and to services. We look therefore more closely at three contextual elements

• Poverty in old age
• Ageism
• The integration of services

Poverty in old age

3.4 "Poverty and social exclusion are seen to be increasing and this is seen by some commentators to make the continued provision of social work especially important." (Clarke et al, 2003).

3.5 The weekly basic state pension (from April 2004) is £79.60 for a single person and £127.25 for a married couple (claiming on the husband's contribution record).

3.6 To qualify for the full basic pension, an older person needs to have paid national insurance contributions for most of their working life (usually 44 years for a man). The period since the war has seen a sharp increase in the number of workers paying into occupational pension schemes. In 1999, 59% of newly retired people had occupational pensions. Nevertheless, a limited number of pensioner households at present enjoy substantial occupational pensions; most still receive the largest proportion of their income from state benefits, particularly the basic pension. Certain groups, such as single older women, are less likely to have an occupational pension and, if they do, the average amount is less.

3.7 For many older people, income is so low that they have to claim additional means tested benefits. In June 2004, the DSS reported that 259,000 Scottish pensioners claimed Pension Credit. Many thousands more who do not get Pension Credit receive some help towards their rent and/or council tax. The government also estimates that between a quarter and a third of pensioners eligible for means tested benefits do not claim them (National Audit Office 2002).

3.8 Poverty is not limited to cash income. Older people, particularly if they have a disability, are likely to spend more time at home. Therefore warmth will be very important. Age Concern Scotland (2004) believes that people over 60 account for over half of the fuel poor, although they account for less that one quarter of the population. Twenty-one per cent of older, smaller households (66,000 households) and 37% of single pensioner households (128,000 households) are classed as fuel poor. The Scottish Executive, which has committed itself to abolishing fuel poverty by 2015, is implementing a programme to install free central heating in all older people's households. Meantime, an additional fuel payment (£200 for those between 60 and 80 years old and £300 for those over 80) is being paid each year.

3.9 Poverty will also affect the condition of the home. Communities Scotland reported in 2002 that 58% of pensioners are owner-occupiers, 28% rent from the public sector, 6% from housing associations and 5% from a private landlord (Scottish Household Condition Survey 2002). Older homeowners can find it difficult to maintain their houses, and the need for more expensive repairs increases, the older they become (Age Concern 2004).

Free personal care

3.10 In 2002, The Scottish Executive introduced free personal care for women over 60 and men over 65. The state pays the cost of personal and nursing care for anyone of pensionable age who is assessed as needing it. The benefit is payable irrespective of where the older person lives (at home or in a care home). Payment is dependent on a needs assessment, generally carried out by a social worker.

3.11 Personal care for those at home is tightly defined. By no means all the services needed by older people at home are eligible. Practical care services - such as cleaning, meal preparation and shopping - are not covered. Ironically, these 'preventive' services may be most valued by older people. For provision of 'non-personal' services, all local authorities will make a charge, the level of which will depend on a means test.

3.12 Although a non-means tested universal benefit, free personal care has mainly benefited better off older people in care homes. A government regulated means test meant that care in care homes was already free to those who had less than £10,000 in capital before its introduction.

3.13 The benefit consists of a fixed rate (£210 per week) intended to meet the care costs of a resident. The resident must meet the full cost of their accommodation and subsistence (subject to a government regulated means test). These charges are set by the care home provider. Charges (in all sectors) have risen sharply since the introduction of free personal care, thus reducing the value of the benefit to those eligible to receive it.

3.14 This brief summary of the financial disadvantage - and in many cases, poverty - faced by older people is relevant to this essay for two reasons. First, to reiterate the conclusion of other work done for the 21st Century Review Group, social work has a distinctive role amongst the poor and socially excluded sections of our society. Secondly, it highlights another conclusion in the interim report- ' the important area of income maximisation, often triggered by social work assessment'. Effective social work with older people will ensure that income is maximised through assistance with benefit claims and other financial advice. Indeed, the introduction of free personal care relies on a needs assessment by a social worker; it is social workers who apply the eligibility test for this cash benefit. In many authorities social workers will also apply the means test for any charge for other services, immediately after a needs assessment, and as part of the process of arranging a care package. For the older person, the different aspects of the process will not be experienced as separate. Apart from the administrative efficiency required, the social worker's sensitivity in approaching the subject of financial assessment will be important, particularly if the older person prefers not to disclose, or refuses to accept the services they need because of fears about being able to meet the charge.

3.15 The introduction of single shared assessment was an important initiative designed to streamline needs assessment, reducing duplication by enabling health and housing staff to play a much greater role in the process. For health staff (district nurses, community based CPNs and so on), working within a culture where health care is always 'free at the point of delivery', the expectation that this will include discussions about charging and involvement in financial assessments, has been a real difficulty and may have slowed the implementation significantly.

AGEISM

"the social process through which negative images of and attitudes towards older people, based solely on the characteristics of old age itself, result in discrimination".

3.18 Taking a similar approach as to gender and race, Thompson identifies personal, structural and cultural dimensions to ageism, and develops Phillipson's (1989) 'political economy' approach. He identifies one manifestation of institutional ageism as the 'tendency for social work with older people to be seen as routine and uninteresting, more suited to unqualified workers and social work assistants than to qualified social workers'.

3.19 Thompson (2001:12) goes on to identify a number of implications for social work assessment. Quoting Marshall (1989) and Fennel (1988), he first argues that assessment should address not only simple notions of need and service availability, but also wider issues which form part of a comprehensive assessment. The second relates directly to ageism and can be divided into two parts. Assessment should include consideration of the impact of ageism on older people's lives, including low self esteem, feelings of being a nuisance and so on. On the other hand, care must be taken to ensure that ageist assumptions are not influencing assessment. As with racism and sexism, if we are not actively 'swimming against the tide of cultural and institutional ageism we shall be carried along with it, such is the strength of ageist ideology'.

3.20 Dominelli (2004) also notes the complexity of the impact of social dimensions such as gender, race, disability, mental health and sexual orientation, in work with older people. She writes:

"the negative image of the older person as dependant and in need of care portrays an ageist construction that treats every older person the same by ignoring the specific needs of older individuals and the contribution that older people as a group have made and continue to make to society" (Dominelli, 2004:137)

3.21 Thompson (2001:107-110) goes on to identify no less than ten aspects of anti-ageist practice for effective social work, including:

3.22 He concludes by arguing that anti-ageism is not a separate area of practice:

"It needs to be seen in relation to sexism (as the vast majority of older people are women) and racism (as the number of older black people is increasing significantly). These are fundamental aspects of human experience and need to be understood in relation to each other. Anti-ageism needs to be part of the wider enterprise and challenge of anti-discriminatory practice. The lessons learned from anti-racism and anti-sexism must also be applied to anti-ageism. They are not in conflict or competition but rather, part of the wider movement towards an emancipatory social work." (Thompson, 2001:110)

3.23 Thompson's book was first published in 1993 and it may be argued that effective social work practice has, or should by now have incorporated these ideas and concepts. However, a Joseph Rowntree Foundation publication (2004), summarising a four year research programme about the priorities which older people themselves defined as important for 'living well in later life', gives pause for thought. The older people involved in these projects did not commonly refer specifically to 'ageism' but the projects reported 'strong' evidence of its existence 'in a number of spheres'. These included poverty and a denial of opportunities:

"Much policy and practice still frames older people in terms of being a burden, a problem to be solved, denied rights to the ordinary things in life because of the process of ageing'.

3.24 MacDonald (2004) summarises a range of research findings about the experience of older people from ethnic minority communities in Scotland in relation to community health and social care services. In her conclusion she notes the 'scale' of inequality indicated by one comparative study (Bowes and MacDonald 2000), highlighting the low uptake of home care and aids and equipment amongst older South Asian people. She concludes:

"For professional practice, the research referred to in the review can be helpful in promoting a more person-centred approach generally. It is not necessary to commission research on the specific needs of every national and ethnic group resident in Scotland to find out that people with distinct languages and cultures require sensitive treatment involving people with knowledge and understanding of the language and culture." (MacDonald 2004).

Integrated Services - A Joint Future

3.25 For at least the last ten years, government policy throughout the UK has urged social services, social work, health and housing staff to work together more effectively, as a major strategy for improving community care services. In Scotland, the theme was articulated as part of the 'modernising government' agenda in Modernising Community Care - An Action Plan (Scottish Office 1998). Its vision was for 'agencies working in partnership in localities, through better operational and strategic planning, joint budgets, joint services, and joint systems.'

3.26 A Joint Future Group was set up to explore these aims further, leading to 'A Joint Future - The Report of the Joint Future Group' published in December 2000. The Scottish Executive accepted, in its formal response, the group's recommendations for:

• single shared assessments
• shared information (across health, housing, and social service agencies)
• financial and service management frameworks; and
• joint resourcing and management of services.

Initial implementation of 'A Joint Future' was targeted at services for older people, and thereafter rolled out to other community care services.

3.27 The same themes were picked up in a later consultative document from the Scottish Executive, Better Outcomes for Older People (2004), and a related Action Plan which provides a number of examples of joint developments across Scotland said to have improved services for older people. The Action Plan requires partnerships to review their joint services by December 2005 and to assess opportunities to extend them.

3.28 The enthusiasm for 'joined up' services is not universally shared, however. Dalley (2000), for example, writes

"The theory-free nature of such policy changes has been evident down the years. Little attention has been paid to research which has suggested that this may not be a problem free road, and even less to examining the fundamental reasons why this should be so."

3.29 She goes onto identify three sets of factors affecting the attitudes of all the professionals involved, which severely inhibit the improvements hoped for. These include:

These points will be very familiar to those who have struggled to introduce single shared assessment to health and social care services for older people.

3.30 For social workers, the introduction of what can be presented as a 'common sense' and eminently practical change has been a real challenge. Dalley's analysis goes some way to helping us understand why. Of particular relevance to this essay is a suspicion, harboured by some social workers with older people, that single shared assessment and related integrated service delivery arrangements represent at best an indifference to, and at worst a severe dilution of, their particular skills and competence. Having had exclusive responsibility for comprehensive assessments since the introduction of community care, suddenly other professional groups-including housing staff - were expected to share this responsibility, after the briefest of induction and training.

Joint Teams and Specialisms

3.31 These policy initiatives coincided with and informed the development and publication of initiatives designed to improve services for other 'client groups', for example:

3.32 As well as articulating the 'joint working' ethos as applied to particular service user groups, these initiatives led agencies to consider the desirability and viability of joint teams, or joint 'specialist services', within which social workers, community psychiatric nurses, occupational therapists and other 'specialist' health staff work together to meet the needs of discrete client groups. While no equivalent framework specific to older people has been produced, similar integrated teams or services have developed in many areas, bringing together services for older people. These developments themselves required consideration of such questions as 'what is distinctive about the social work task with (for example) people with learning disabilities?' and 'what is the difference between the skills and knowledge of a community psychiatric nurse and those of a social worker, in meeting the needs of older people recovering from mental illness?'

3.33 The Interim Report of the 21 ^st Century Review (Scottish Executive 2005) states:

"It is apparent that social workers working in integrated services have varied experiences of their effectiveness. Integrated services need to be clear about their goals. They need to be properly supported and developed, and in particular social workers need clarity about their roles, and the scope to actually practice their profession. In teams where a clear and valued place for social workers has been negotiated, a greater sense of partnership is discernible than in joint teams that have been set up with little explicit discussion of the social worker's particular contribution and those of other team members."

Conclusions

3.34 Social workers have long had a distinctive role in working with people facing poverty and social exclusion - this includes many older people. Effective social work involves a sensitive approach to carrying out financial assessments and, where appropriate, a focus on income maximisation.