Effective Social Work with Older People

CHAPTER FIVE ROLES, TASKS AND SKILLS FOR EFFECTIVE SOCIAL WORK WITH OLDER PEOPLE

Introduction

What is the social work role?

5.3 To provide a framework, this section takes a brief look at some standard texts, written for social workers and students, which address the role of the social worker with older people. Strikingly less has been written on this topic compared with the number of publications about social work with other service user groups, such as children and families. At the same time, there are arguments against categorising older people separately from other adults (as if older people were not 'adults') (Midwinter 1990), and, as we have seen in the previous chapter, older people do not form a homogenous group with a single set of needs. Nevertheless, there appear to be some distinctive, if overlapping, aspects to the social work role with older people, which are summarised below.

5.4 Marshall's text, Social work with old people (1990) is one of the few dedicated to this field. She suggests that the social work role lies in:

"It is possible that the complexity of some social work with older people is sometimes not fully understood. The work can require fine judgements regarding:

• effective communication
• core tasks of assessment, planning, intervention, and review
• understanding of individual experiences and the importance of biography
• empowering and anti-discriminatory practice
• identifying and working with vulnerability and abuse
• partnership working with older people, carers and agencies.

5.7 The importance of anti-ageist practice, and the need to promote the strengths and resilience of older people are also strongly emphasised by recent writers for a social work audience (Thompson 2002, Phillipson 2002).

5.8 It is worth looking at some of these 'core tasks' in more detail, as they are required in work with older people.

ASSESSING THE NEEDS OF OLDER PEOPLE

5.9 One of the most important features of the NHS and Community Care Act 1990 was the introduction of the right to community care assessment. The intention was to ensure that any services or assistance offered to someone in need were tailor-made to those needs, because they were based on a comprehensive assessment. Services were to be 'needs led', not 'service driven'. Anyone presenting themselves to a social services department appearing vulnerable or in need had a right to be offered an assessment, although not necessarily a right to whatever services the assessment recommended (Scottish Office, Circulars, 11/91 and 10/98).

5.10 As community care services developed and as skills and understanding of the need for, and importance of, eligibility criteria developed, assessment developed a secondary and perhaps implicit function of creating the basis for prioritisation of allocation of resources or services - in short, a rationing device. Assessments are carried out by social workers primarily to establish the individual needs of older people before creating a package of care services designed to meet those individual needs. However, the expectation that social workers would record unmet need, when decisions were made about what services could be arranged in response to the assessment, underlines the fact that assessment has a dual function.

5.11 Social work texts emphasise the importance of holistic assessment practice which takes account of a wide range of factors and steers away from routine matching of services to needs (e.g. Thompson 2001). Richards (2000), drawing on case materials in an ethnographic study of assessment of older people's needs, suggests that where older people's perceptions are not given due weight, the risks of unwelcome or inappropriate interventions increase. The researcher proposes a user-centred approach to ensure that information-gathering and service provision are meaningful to the older person and sensitive to their own efforts to analyse and manage their situation. It is suggested that these perspectives may emerge most clearly as older people tell their own story but this can be overlooked in more agency-centred assessment processes.

ASSESSMENT AND INTEGRATED WORKING

5.12 The introduction of single shared assessment was intended to 'broaden the range of assessors to include professionals from health and housing and where relevant, other agencies and groups' (Scottish Executive, 2001). More recent guidance has distinguished between care management and care co-ordination and states that care management is 'a complex activity that should be carried out by professionally qualified staff, suitably trained, who have appropriate skills, competencies, and experience' (Scottish Executive, 2004: 9). The majority of staff undertaking care management are professionally qualified social workers in local authorities and, whilst it is anticipated that there will be an increase in the participation of other key health and social care professionals, social workers are likely to continue to play the major care management role (Scottish Executive, 2004).

5.13 Although there is an increasing emphasis on the importance of effective joint working, we have uncovered surprisingly little research into the assessment approaches of different professions in community settings. However, a qualitative study carried out in Scotland in 1998 explored assessments of 18 frail older people, undertaken by social workers and district nurses (Worth, 2002). An ethnographic approach was taken to analysing the process, involving interviews with practitioners and observation of assessment practice. Similarities and differences of approach between district nurses and social workers were explored, with a view to identifying particular areas of expertise in this crucial area of practice. The study findings suggest that there are a number of similarities but that the focus of their assessment differed in important respects. It appeared that social workers and district nurses had different, but complementary, areas of expertise which brought together the components of a holistic needs assessment. The two groups covered similar areas of enquiry in their assessments apart from the financial assessments which only social workers were required to carry out. As might be expected, social workers tended to put greater emphasis on social, and nurses on health needs. Closer working relationships between district nurses and social workers within a care management team were found to support a more holistic assessment of service user need.

MONITORING AND REVIEWING CARE

5.14 The 21 ^st Century Social Work Review user and carer panel emphasised 'the need for regular reviews of support to determine whether the service offered is still working or if it needs to change.' It is interesting to note the priority it gives to the review process. The original guidance introducing community care assessment was also clear about the importance of reviews, and this is reinforced in recent guidance relating to care management: 'Monitoring and reviewing are essential parts of care management if services are to respond to changing needs and resources are to be used to best effect' (Scottish Executive, 2005:11). Assessing the impact of the 1993 community care reforms, Warburton and McCracken (1999) suggest that social service departments did not pay sufficient attention to monitoring and reviewing care of older people. Often social workers are unable to maintain an active involvement in individual care management once needs are assessed and services provided, with routine monitoring and review being undertaken by care providers such as care homes (Lymbery, 1998). Although monitoring and review is clearly an important role for social work, and one that has the potential for ensuring that older people receive quality care services responsive to their changing needs, there is little other formal research evidence of the effectiveness of reviewing and monitoring, or of the outcomes of different approaches to these processes.

5.15 For some older people who are at risk (or find themselves unable to cope in their own homes), a move to a care home can be part of the solution. In 2002, nearly 35, 000 older Scottish people were living in care homes (Scottish Executive, 2002). However, as the reports of the Care Commission show , good standards of care are not always achieved. The social worker is needed to empower the older person and their relatives to raise any concerns or to advocate on behalf of an older person where the standard of care is inadequate, where it is not centred on the individual and when there is concern about neglect or even abuse. The social worker needs to ensure that the initial contract made with the home accurately specifies the services required by each older person - in other words, translates the needs identified during assessment into a comprehensive and personalised care plan, setting out how those needs will be met. Then, along with the resident and family, the social worker should regularly review the implementation of the care plan, ensuring that it is updated to meet changing needs. This may involve challenge to the managers of the home, particularly around best value and resource constraints.

CARE MANAGEMENT FOR PEOPLE WITH COMPLEX NEEDS

5.16 The process of assessment, care planning and review is encompassed within the term 'care management'. While this term is most often associated with community care services, the concept is not markedly different from other models of social work, such as casework or the care programme approach in mental health. Social workers with older people will often have to commission services such as home care or day care from providers in the independent sector, involving contractual arrangements and costings, and this too is included within the term 'care management'.

5.17 A comprehensive evaluation of care management in Scotland, based on telephone interviews with staff in all Scottish local authorities and a number of case study visits, considered the definitions and models of care management in use (Stalker and Campbell, 2002). Although the question of effectiveness was not a major part of the research brief, the study found that in most instances social workers were most likely to carry out the care management role.

5.18 The research also reinforces the notion of complexity in a way which is helpful to this review. Care management, it suggested, was not a task required by all clients, or even all those who share the same condition - dementia, for example. Rather, where there was a variety of needs, and perhaps competing concerns of the service user and carer, where there was likely to be frequent change, unpredictability or vulnerability, then care management skills were needed. This leads to the conclusion that the skills required for care management are not only those relating to contracting and purchasing, but are more akin to those generally associated with social work, including assessment skills, based on an holistic approach to all the person's needs, and an ability to balance or mediate between competing interests. Given our earlier point about evaluative research which does not distinguish the effectiveness of social work from the social care/social service impact, this distinction around complexity is a valuable insight.

5.19 This is given further weight by Statham et al. (2005). Considering situations where the social worker may be 'the professional of choice', these authors suggest that social workers have a particular role in complex and uncertain circumstances, thus:

• where no one knows what the right answer is - social workers are better than other professions at handling uncertainty and complexity
• where relationships are complex - for example, where there are tensions, disagreements or conflicts of interest within a family
• where there is a high degree of risk - social workers' approach to managing risk is at the core of their distinctiveness. Arguably, most other professions primarily focus on removing or minimising risk. Social workers frequently work with situations where there is a degree of risk, but where intervening could actually make situations worse.

The issue of risk in effective social work with older people is our next topic.

BALANCING RIGHTS, RISKS AND NEEDS

5.20 This aspect of social work is most often associated with child protection, following a number of enquiries, investigations and government reports over the last 30 years. Sadly, recent events in Scotland have also focused attention on adult groups. In April 2004, the Scottish Executive published a report of an inspection of services for people with learning disabilities in Scottish Borders (Mental Welfare Commission/ Social Work Services Inspectorate, 2004). This followed confirmation of the 'extreme' levels of abuse suffered by a woman who had been using social and health services for a number of years.

5.21 The MWC/ SWSI report made 28 recommendations for improvements, 6 of which are directed specifically at the future practice of social workers. Many of the recommendations echo similar proposals from child care enquiries, requiring improved communication and coordination, minimum standards for records, case conferences and reviews, and specific actions to be taken on home visits.

5.22 That report also argues that social work with vulnerable adults 'is a constant balance between promoting independence and self determination, and providing appropriate levels of protection.' This balance is articulated clearly in the Scottish Social Services Council Code of Practice for social service workers, which refers to: 'recognising that service users have the right to take risks, and helping them to identify and manage potential and actual risks to themselves and others' (Scottish Executive Social Work Inspectorate, 2004: 11). The emphasis here is on managing the delicate balance between independence and protection for all vulnerable adults, including some older people. This gives further weight to the complexity of successfully managing risk as a key issue in effective social work practice with older people.

5.23 The risk of abuse of older people is not a new phenomenon but it is only in the last twenty years that it has begun to be addressed in the U.K (Penhale, 2002). The major focus has been the abuse of elders by their carers in domestic settings but there is increasing awareness of abuse in institutional settings (Glendinning and Kingston, 1999). Abuse may include physical, emotional, sexual and material (both funds and property) abuse and shades into both active and passive forms of neglect. Pritchard's (2001) study of the abuse of older women in the north of England found that it is often perpetrated by partners in the domestic setting, and frequently continues a pattern begun in earlier life. Pritchard found that women often remained in abusive situations because they did not know how or where to access practical advice and information. They also needed supportive discussion and appropriate housing.

5.24 Older people may put themselves at risk of a different kind, knowingly or otherwise. People with dementia may not realize that they have left a pan on a stove, turned the gas on and not lit it, or be eating food that is unfit to eat. They may go out to look for parents or partners who are long dead. They may have lost awareness of the risk of crossing a busy road. Above all they may agree to various arrangements to protect them against these risks, and then forget completely what has been agreed. The prospect of moving, or being moved to a safer environment such as a care home will cause considerable anxiety and fear, and is likely to exacerbate confusion and forgetfulness, which in itself will be increased by an unfamiliar environment. Such issues are not limited to older people with dementia. Older people whose capacity to sustain an independent lifestyle is reducing may exaggerate their abilities and downplay the risks, so as to remain in their own home and avoid what they fear will be an enforced move to an unfamiliar, and perhaps institutional environment.

5.25 The social work role is complex in these potential risk situations, raising difficult questions about how to balance empowerment with protection. Preston-Shoot (2001) argues that the value of self-determination is highly influential in social work practice but should not absolve practitioners from finding ways to protect vulnerable users. He finds that the literature on elder abuse emphasizes the importance of social workers:

• using communication skills e.g. building trust and support
• assessing, especially the vulnerability of the service user and circumstances of the abuse
• providing information about services and consideration of different options
• protection planning, monitoring and review
• understanding the legal mandate relating to welfare provision, incapacity, common law and criminal justice. (Preston-Shoot, 2001:12)

5.26 We look in detail below at the 'legal mandate' for social workers in Scotland working with older people at risk. The common themes of communication, assessment, planning, monitoring and review again emerge, although this time from a different starting point.

The duty to protect

5.28 Social workers have a statutory responsibility to intervene when action is required to protect older adults from dangerous situations, including abuse. It was noted in chapter four that older people can experience difficulties created by the onset or continuation of mental health problems. A number of specific duties are imposed on local authorities by the Mental Health (Scotland) Act 1984, including the appointment of Mental Health Officers ( MHOs) (s.25(1)). Guidance states that MHOs should have a professional qualification in social work and have completed an approved training course (Scottish Office, 1996). The main functions of MHOs under the Act relate to their involvement in considering consent to compulsory detention, and the provision of social circumstance reports ( SCRs) for the Responsible Medical Officer and the Mental Welfare Commission. The number of older people subject to detention under current legislation is broadly in the same proportion as for all adults (Grant, 2004).

5.29 In October 2005, the existing Mental Health Act will be replaced by the Mental Health (Care and Treatment) (Scotland) Act 2003. The Millan Review of the Mental Health (Scotland) Act 1984 took the view that social work was the only profession to combine independence from the health service with training and experience in working within a statutory framework. Accordingly, MHOs 'play a significant role' in many parts of the new Act:

"similar to the role they play under the 1984 Act, but greatly extended. Local authorities will be able to appoint as MHOs only those individuals who are officers of the local authority and who meet certain requirements on qualifications, training and experience." (Scottish Executive, 2003)

Whilst the Act does not specifically refer to older people, its principles include a respect for diversity, including age, and non-discriminatory practice.

5.30 The Adults with Incapacity (Scotland) Act (2000) introduced measures to safeguard the interests of adults who are unable to make all or some decisions or to communicate those decisions about their welfare and/ or finances. This includes adults with dementia and learning disabilities as well as people who have lost communication skills, for example, as a result of a stroke. Local authorities also have a duty to investigate any circumstances made known to them in which the personal welfare of an adult appears to be at risk.

5.31 Part 6 of the Act introduces welfare and financial intervention and guardianship orders. Local authorities are under a duty to apply for intervention/guardianship orders where it appears that such an order is necessary. Local authorities discharge these responsibilities through their social work departments or equivalents; such is the complexity of issues likely to arise that qualified social workers (although not necessarily MHOs) are most likely to be required. Whilst the Act does not specifically refer to the needs of older people, figures from the Office of the Public Guardian show most applications for guardianship and intervention orders are for people over 60 (70 to 80%) and female (Grant 2004).

5.32 Research into the first two years of operation of the Adults with Incapacity (Scotland) Act 2000 suggested a dynamic situation with patterns of usage changing over time (Killeen et al., 2004). The research into the operation of Part 6 of the Act (Grant 2004) found that MHOs were most knowledgeable about the Act and had a key role in promoting awareness of it to service users, carers and other professionals. MHOs also played an important role in seeking alternatives to statutory intervention.

5.33 Interpretation and use of Part 6 has not been straightforward. The Mental Welfare Commission reported:

"Early in the implementation of Part 6 of the Adults with Incapacity Act, it became obvious that there was considerable uncertainty about the appropriate circumstances in which to use Part 6 applications for welfare interventions. It was not clear whether a significant intervention (such as a change of residence) should always require the authority of a guardianship or intervention order." (Mental Welfare Commission, 2004)

5.34 As a result, the Commission commissioned Hilary Patrick, from the School of Law at Edinburgh University, to prepare a discussion paper on the use of Part 6 (Mental Welfare Commission 2004). She concluded that, whenever a local authority deals with a person lacking capacity, it should do so within the framework of the Act. This does not, however, mean applying for a Part 6 order for every case in which a significant intervention is proposed. An assessment for an order should be carried out, in accordance with the principles of the Act. (The implication is that such an assessment, which will include the needs of the client, as well as their capacity to understand and agree to what is proposed for them, will be carried out by a social worker).

5.35 In such circumstances, and faced with these needs, the effective social worker must be able to evaluate the risks, balance the individual's rights (as a citizen and under the European Convention of Human Rights) with the need to protect and promote the welfare of people in need, and to mediate between the concerns of relatives and carers and the wishes of the older person, much as described in the extracts from the SSSC code of practice and discussed by Statham (quoted above).

5.36 A vivid practice example of the potential for effective use of Part 6 of the Act also makes clear the complexity of issues that face social work staff in work with older people:

"An older man with long-standing mental health problems, and subject to a section 18 detention at the time, was determined to return to his house despite growing concern for his safety. The chronic delusional beliefs he held led to his conviction that he could not leave the property. He had become increasingly isolated, had refused to accept the support package arranged for him, and had become increasingly vulnerable to the unpredictable behaviour of a relative. Powers were sought to decide where he should live, and ensure that a range of services/professionals were able to enter his new home to provide the care he was assessed as needing. Although initially reluctant to move, he accepted that he was required to do so as part of the guardianship order. With the benefit of an improved environment, very supportive staff, and a confidently designed support package, he quickly became more confident and independent in all his activities for daily living. Staff (health and social work) who had known him for years felt that the change in the quality of his life was dramatic. The situation became so settled that it was decided that the welfare powers were no longer required." (Scottish Executive, 2004:3)

Loss, change and transition

5.36 One potential outcome of the introduction of the current community care model is that health and social care practitioners' role could be limited to a technical and administrative one of assessing need and arranging services provided by others (Hughes, 1995). Indeed, it has been suggested that an administrative model holds sway, so that 'paradoxically, community care, as defined, evidences a migration away from direct contact between elders and practitioners' (Biggs, 1993). Hughes instead argues for a 'professional' model of community care which is 'exploratory, holistic, integrative, and therapeutic and is based on an understanding of the complex interconnected nature of needs for many older people' (1995: 144).

5.37 Later life is a time when many people will experience multiple losses - of health, status, close friends, relations and spouses. Phillipson (2002) suggests that social work with older people in these circumstances is often inseparable from supporting older people with bereavement, helping individuals to rebuild confidence, self-esteem and social networks to manage loss. Whilst this work is clearly not exclusive to working with older people, experience of death tends to be 'clustered towards the end of the life course' (Phillipson, 2002:59). The notion of 'the life course' for work with both children and adults is significant in social work education. The life course involves a series of transitions, including the 'developmental crises' associated with the work of Erikson (1977). Thompson (2002: 297) suggests that 'an understanding of the significance and impact of such transitions should be a basic part of the social worker's repertoire of competence'.

5.38 A life course approach emphasises the importance of seeing older people in the context of their life history. Biographical approaches to work with older people stress the importance of individual life stories and include activities such as reminiscence, storytelling and life review work. This approach also takes account of people's environment and the impact of wider social issues including gender, class and race (Crawford and Walker 2004). Two studies, neither directly about social work practice, provide evidence of the effectiveness of biographical activities. McKee et al. (2002) looked at the impact of reminiscence activities on the quality of life of 142 older people living in care settings. Residents who participated in activities over a period of a month appeared to have an improved quality of life compared to those who did not take part. Reminiscing seemed to help older people convey their identities and life events to care staff and appeared to enhance inter-generational family relationships. However, care staff expressed concern that social care (talking, listening, sharing) with older people is not recognised as 'real work' within care organisations. Another study, exploring use of biographical approaches in a nursing home and NHS Hospital Unit, found that life story work helped practitioners understand the needs of service users better and form closer relationships with them and their families (Clarke et al., 2003).

Social work with people who are dying

5.39 Social workers have made a significant contribution to the development and delivery of palliative care (Clausen 2005). In a review of the literature, Small (2001) suggests four main contributions

5.40 These contributions resonate with four key elements of the social work role in palliative care as identified by Sheldon (2000)

5.41 Lloyd, in a study of hospital social workers working with bereaved and dying people, found that 'social workers have the integrated approach and necessary skills to incorporate both the individual and social meanings of death'. Picking up an earlier theme in this review, Worth (1998) found that social workers are currently concerned that current care management arrangements limit their opportunities for counselling and case work, echoing Clausen et al's argument that resources and structures do not enable social workers to meet the needs of people who are dying. He speaks of the 'disadvantaging' of members of the community who most need 'the compassion, knowledge and unique intervention of a skilled social worker':

" The patients in our study had clearly expressed needs which could potentially be met by social workers, yet few if any had social work involvement. Sheldon (2000) stresses the need for a whole person approach, looking at the individual in the social context, linking past, present and future. Social workers may best be able to conduct holistic needs assessments and be case managers, with medical support, providing continuity of care, journeying with the patient and acting as a guide into the unknown." (Clausen et al., 2005: 283-4)

THE SOCIAL WORK ROLE IN HEALTH CARE SETTINGS

5.42 Thus far, most of this review has focused on social work in community care settings or integrated specialist teams for older people. We now review briefly effective social work in other settings, beginning with health care.

5.43 Social workers in hospitals and other health care settings are often particularly well placed to identify the needs of older people and carers for support and intervention at times of crisis and change. Marshall (1990) emphasises the application of crisis intervention theory to these situations in which people may, for a short period, be more receptive than usual to support and assistance. This area of social work practice seems to have generated more research than some others. Three examples of research into social work's role in health settings are described below.

5.44 The policy of diverting older people from admission to acute hospital care on social grounds has, in some areas, resulted in the placement of social workers in Accident and Emergency teams. McLeod et al. (2003) undertook research into the outcomes for 28 people using one such scheme in a Midlands hospital. The findings suggest that Accident and Emergency based social work can be of great benefit to service users, including assistance in negotiating the hospital environment, information about issues crucial to managing their health and help with the complexities of planning future care. Social workers in this study had the role of identifying social care needs, reducing inappropriate hospital admission and minimizing hospital stays on social grounds. They also had fast track access to social care services and had their own budget for incidental services. However, these services were not always sustained in the longer term due to service user/ service provider power imbalances and lack of resources.

5.45 A study of post-discharge needs among 456 older patients (over 75) stressed the particular importance of effective assessment for older people, because a stay in hospital often represented a 'turning point' (Healy et al., 1999). They found that multi-disciplinary assessment was associated with superior care assessment and that formalising assessment procedures improved communication between different professional groups. The authors concluded that teams led by social workers tended to produce more fine-tuning in matching patient needs to available services, including a wider range of services. The study has implications for health and social care professionals, since it demonstrates that the post discharge services received by older patients are influenced by the kind of professionals who assess them.

GROUP CARE SETTINGS

5.47 Social workers also work alongside social care staff within a range of group care settings, including day care facilities and care homes. Most of the research in this area relates to the perceived quality of these services rather than the social work role within the setting. Some recent research with relevance to the role of social work in residential settings is summarised below.

5.48 The Office of Fair Trading (2005) has conducted a study of how well the care homes market serves people over 65 in the UK. It notes that the process of moving into a care home can be very distressing for the older person and sometimes their families. The findings of the study emphasise the need for good information for service users about the rights of older people and the obligations of local authorities, fair and clear contract terms, and accessible complaints procedures. These are all areas in which social workers are centrally involved.

5.49 Bland (1999) also explores the transition into residential care and examines one of the main problems for older people facing admission - fear of losing their independence. Drawing on a wide range of literature relating to the development of institutional care, Bland compares two approaches to residential care provision. A case study of one private home illustrates the 'service' approach in which residents were treated as though they were hotel guests, their movements were not restricted and the normal conventions of privacy were observed by staff and residents alike. Staff treated residents, including those with dementia, as competent adults rather than as dependents in need of protection, and residents' needs and preferences were respected. Based on her research and observations of care homes, Bland characterises the dominant 'social care' approach as more akin to the hospital than the hotel. Most care homes attach overriding importance to minimising risk, leading to residents being kept under surveillance. Bland argues that the ideology of care implicit in this approach impedes the changes necessary to allow older people to retain their dignity and independence in a care home setting.

5.50 The Accounts Commission's (1999) evaluation of residential and nursing homes involved a self-selected sample of 39 establishments. This survey included interviews with 318 residents and 47 relatives. The report concludes that quality could be improved in some homes without incurring extra cost by measures such as paying more attention to individual needs and requirements, developing better links with local communities, and integrated team working, giving residents a smaller staff group to relate to. The report also includes many illustrations of good practice in involving residents and taking account of their individual needs.

5.51 The quality of life of older people during and after transition into institutional care was explored in an ethnographic study of 52 frail older people through observation and focus groups (Tester et al., 2003). The authors concluded that in order to promote quality of life, practitioners (as well as policy makers and providers) needed to disregard their own assumptions and focus on the priorities of the older people. The role of practitioners in enabling residents to maintain their sense of self, to communicate verbally and non-verbally, to exercise rights and control, to maintain and develop relationships and to participate in meaningful activity and interaction within the care setting was stressed.

WORKING WITH FAMILIES AND CARERS

5.52 The Community Care and Health (Scotland) Act 2002 (s.8-11) introduced the entitlement for 'substantial and regular' adult carers to have an assessment of their ability to care ('carer's assessment'), independent of any assessment of the person they support. Given the numbers of older people who are also acting as carers, already noted, this development is very relevant to this essay. In this instance, there is no restriction on who can carry out such assessments, and no systematic evaluation has yet been conducted.

5.53 Pickard (2004) has undertaken a comprehensive review of the effectiveness of services for carers in the U.K., focusing particularly on studies undertaken since the implementation of community care policies in the early nineties. Positive outcomes for carers, in terms of reduction of the negative psychological effects of caring, were found to result from the use of day care, home care, institutional respite care and social work/ counselling services. She supports her evidence of the efficacy of social work intervention with data from a study of community care for 419 older people and 238 care givers in 10 local authorities in England and Wales (Davies and Fernandez 2000). This research suggested that counselling and therapeutic social work activity was effective in reducing stress on carers. The study also found that social work and counselling were highly cost-effective in reducing subjective carer 'burden' compared to other interventions. However, social work intervention was not effective in delaying moves to long term residential care and only a small proportion of carers (18%) were found to have access to a qualified social worker.

Conclusions

5.54 Social workers bring a unique mix of skills and expertise to situations of complexity, uncertainty, conflict and risk - all of which arise in their work with older people.

5.55 Effective social work with older people requires both practical skills, such as securing and co-ordinating resources, and 'people' skills, such as sensitive communication and listening skills, taking time, moving at the individual's pace, supporting families and collaborating with colleagues in a multi disciplinary setting.

5.56 It is vital for effective social work with older people that the demands of care management are not allowed to prevent social workers from engaging meaningfully with older people and developing a good understanding of their lives, needs and wishes. There is a risk of assessment becoming bureaucratic, being used primarily to ration services rather taking a holistic, user-centred approach. Care management should not be seen as an alternative to counselling and casework, where these are needed.