Book review: Social Work Theory – A Straightforward Guide for Practice Educators and Placement Supervisors

Introduction

This book by Siobhan Maclean and Rob Harrison from Kirwan Maclean Associates Ltd (best ordered directly from the publisher) is a book written with a specific purpose to run through the different models and theories of social work to equip those teaching and learning in placement settings to have a broad understanding of their students’ needs.

Context

Kirwan Maclean have a reputation for producing social work textbooks and materials which are very much focussed on social work practice rather than the idea of social work which can exist in some text books which are written with a university market in mind. I have actively used this book as a practice educator and beyond that in broadening my understanding of social work models and theories as I try to link them in to the work which I undertake on a day to day basis.

I am a big fan of this publishing house and can honestly say I’ve never read anything from them that hasn’t immediately jumped to the top of my ‘most useful’ pile because the books are written to be understood and used rather than studies and the authors don’t care much for using academic language where it is not necessary. I’ve always believed that the best writers are the clearest writers and Maclean and Harrison certainly achieve this.

Summary

The book is set out into eight sections. Each section has a dedicated bibliography and includes some tasks to use with students relating to the topic covered, immediately helping the busy and maybe (I’m thinking of myself here) tired practice educator who needs new ideas.

The first section is background about practice education and the context of teaching social work in a practice setting. Teaching at work is a particular skill set and the teaching part is fundamental. Students are training in skills but they are also learning about practice. The book emphasises the importance of the education role as it includes theories of learning that were mostly familiar to me from my my practice education course. This was reassuring as it allows a refresh, especially after a few years.

The next sections look at different models, frameworks and theories, separated logically and allowing a ‘pick and mix’ approach when the student returns from university with a new theory. It starts with anti-oppressive practice (such as social and medical models, feminist and race perspectives) followed by human development and learning theories (including attachment theory with both children and adults, and models of grief and loss). Then the book covers a section on using theories in the assessment processes – this includes a section on risk assessment and models of assessment including how theories such as strength-based perspectives are used in practical contexts. The next sections are about models and theories which influence ways of intervening and they are split into ‘counselling models’ such as psychodynamic approaches. Then, those approaches and models based on social work frameworks such as systems theory, task-centred practice and crisis intervention. The models that will be very familiar to any social work student. Maclean and Harrison finish with consideration of organisational theories and leadership before covering the use of eclecticism.

Each theory or model has a roughly 4-6 pages with a brief explanation of the background, some examples of how it happens in social work settings and then some thoughts at the end of how you might ask a student to think of the theory.

The book is very accessible and easy to dip in and out of. It allows a quick refresh of concepts that may be a bit ‘rusty’ but also gives a useful bibliography where more can be explored if necessary.

There is a broad range of theories that should be a good start and cover most of what’s needed in practice but if it isn’t, it allows frameworks to talk about theories in practice settings.

There is a comprehensive presentation of a wide range of theories and models, explained clearly with pointers for further and deeper investigation.

Use in practice

The joy of this book, as with many from Kirwan and Maclean is its immediate practical value and use. From the moment I bought it, it proved its worth ensuring that I was able to catch up and refresh some of the theory and models that I had learnt years before but also allowed me to familiarise myself with the language of social work theories again. While we all know it shouldn’t, practice as a social worker can sometimes struggle, outside a student placement and practice education context, to call back to the theoretical contexts and the ‘why’ of what we do. While this book is very much aimed at practice educators, it has a use far beyond that for the practising social worker whose initial training may be a few years back and who wants to refresh understanding of the why and how we justify what we do within a professional framework.

I’m not teaching students anymore as I don’t take students on placement (I may, in the future but I’m fairly new to my job now). I was out of direct social work practice for a number of years. Picking up this book, which is genuinely a pleasure to read, allowed me to reconnect with the ‘why’. It is perfect for practice educators who like clear and concrete examples, written accessibly by knowledgeable authors who do not patronise their readers by over-complicating unnecessarily. But it also has a use far beyond that, for all who practice or who want to practice social work.

Conclusion

This is one of those books with a purpose, which it states on its cover and it does exactly what it says on the cover. You want a straightforward guide to social work theory and you’ve got it. My only addition would be to say that it isn’t just for practice educators. Although there is a separate version which is adapted for student social workers (which I always recommended to my students on placement), this book suits more experienced practitioners who want to refresh and revise those connections with theories and it can start a journey, with helpful links and references, back to picking up the why as well as the what we do.

Paper Review: Emotional Intelligence, Emotion and Social Work : Context, Characteristics, Complications, and Contribution

This post is about this article:

‘Emotional Intelligence, Emotion and Social Work: Context, Characteristics, Complications and Contribution, The British Journal of Social Work, Volume 37, Issue 2, February 2007, Pages 245–263, https://doi.org/10.1093/bjsw/bcl016 by Tony Morrison

Introduction

This paper looks at the way ’emotional intelligence’ may link to social work practice by aligning it’s use with five core social work tasks ‘engagement of users, assessment and observation, decision-making, collaboration and cooperation and dealing with stress’

Context

The paper starts with a definition of emotional intelligence as

Being able to motivate oneself and persist in the face of frustrations: to control impulse and delay gratification; to regulate one’s moods and keep distress from swamping the ability to think; to emphasize and to hope’

p246 – quoting from Goleman 1996

The author sets up the links between emotional intelligence and social work (specifically social work with children) by explaining different models of emotional intelligence in different settings and applying them to social work. This is a discussion paper rather than describing research so the methodology is based on reflecting on literature relating to emotional intelligence and linking it to social work settings and environments.

Emotional intelligence literature emerged from management and business studies. The author as an academic teaching social work practice, found the literature useful in describing some of the skills and attributes necessary for competent social work. He draws links between literature about emotional intelligence and social work practice and drew this together with a study in the US about nursing practice (Benner 2001) and developing competencies in nursing which found that the emotional state of the nurse could impact on the quality of patient care. It was this ‘intuitive’ aspect of care which the author tries to link with good social work, beyond technical knowledge of practice.

He draws on literature reflecting the danger of social work becoming a series of skills to be learnt rather than a way of understanding to do undertake tasks skilfully. This is linked with the move towards managerialism in social work. Ironic, then, or perhaps not, that there has been the turn to the language and concepts of management.

By presenting emotional intelligence as learnable, it therefore becomes teachable which is key within a social work department in a university.

Learning and gaps

In looking at core social work skills identified by the author, he refers to them in the context of emotional intelligence. With engagement he refers to the lack of choice that people coming into social work services would have and why the initial contact may be filled with ambivalence or fear. Moving to assessment and observation, he relates to the importance on inter and intra-personal skills and the need for sensitive and responsive assessment as poor communication can lead to poor assessment. Part of this process is about understanding and interpreting emotions on both sides of the conversation that is an assessment.

Regarding decision-making, the author refers back to the challenge of objective (or ‘professional’) judgement as if there is a pretence that emotion does not play a role. I’d argue there is no such thing as objective judgement in social work because we have to bring ourselves into every decision we make but that’s more about the research work I am doing and why I chose it. Decisions cannot be made without understanding the place of emotion.

With collaboration and co-operation, he refers to emotion as a representation of the collective experience, including institutional experiences. Social work exists within the institutions in which we work and we need to understand organisational dynamics to work effectively. We also need to work with difference. This is where the author, somewhat tenuously, in my view, brings in the need to work with diverse groups and ensure we tackle and address discriminatory attitudes.

Values and knowledge about discriminatory forces have to be integrated with inter-personal skills, if practitioners are to be able not only to identify, but also challenge, such forces appropriately

p258

Finally, the author turns to the necessarily social work skill of dealing with skill and developing coping strategies. He relates the ability of social workers to seek help themselves when they might be approaching burnout as a key tenet of emotional intelligence. Practitioners who are able to create positive social and professional networks of support will more likely thrive and he links this to relevant research.

Use in practice

This paper is a literature-based study linking the work around emotional intelligence to the attributes needed for social work practice, particularly focusing on social work with children. It is an interesting approach and he has drawn some useful links identifying how the context of writing can be regarded from a different angle to have professional relevance. Personally, I’m not entirely convinced that pulling in management think is always helpful in understanding professional practice within social work. We need to ensure our language and how we describe what we do is not tied up with the latest zeitgeist management talk. However, where there are useful elements to glean it is important that we do not ignore them.

Regarding practical learning from this, there were two aspects that I thought I would take with me from Monday morning. One was about building supportive networks personally and professionally in order to ensure I am looking after my own support and development needs in order to thrive effectively as a social worker and secondly ensuring I have an awareness of the role my emotion plays in my report-writing and assessment as this has an enormous impact on the lives of those I am working with.

Conclusion

This was an accessible paper which drew together strands of literature to extract the core of good social work as separate from the ability to carry out social work tasks or have a good handle on social work skills. In some ways, I see the emotional intelligence as being linked to practice wisdom, as it is sometimes called, the sense of instinctiveness to make judgement quickly and remain open to challenge, learning and change.

The author expresses concern about the growth of managerialism but hope that by capturing the essence of social work in a concept which is basically teachable seeing ways forward for the profession. Personally, I think time and space is needed to develop the capacity for understanding the role emotion and individual subjectivity play in important social work tasks which is why reflection is necessary. Maybe less fast-track and more slow development will build the emotional intelligence necessary for good practice.

Book review: How to Write a Lot – A Practical Guide to Productive Academic Writing

I read ‘How to Write a Lot – A Practical Guide to Productive Academic Writing by Paul J Silva published by American Psychological Association – I have a copy of the 1st edition (2007) which is the one I am reviewing below but I have linked to a more recent 2nd edition (2018).

Introduction

To write well, you need to choose good words.

p61

This is a short and accessible book from the US Psychology Academic. The background of psychology becomes more important through the book and it is intended to be a ‘tap on the shoulder’ type book nudging reluctant academics and people who need to write in academic contexts, towards writing. I can’t remember how I came across it, if it was on a reading list or a recommendation (mostly how I decided what books to buy).

Context

As mentioned above, the author, Paul Silva is an academic psychologist based in the US. He has taken the approach of writing in a conversational manner and the book is intended to spur writers who may not see themselves as writers to ‘get on with it’. It would be of less use to experienced writers who have their own systems in place.

Of course, it also serves as a means to delay actually starting writing because you are writing it but fortunately, it is a short book which does not need a lot of time to cover.

The author covers a broad range of topics at a steady pace, including starting out and just writing as well as, more specifically, writing for publication including journals and books. The book itself is 132 pages.

Summary

Delete very, quite, basically, actually, virtually, extremely, remarkably, completely, at all and so forth. Basically, these quite useless words add virtually nothing at all ; like weeds, they’ll in fact actually smother your sentences completely

p64

The book is divided into chapters that cover the areas you would expect, including knocking down those barriers, including the excuses like ‘I don’t have enough time’ or ‘I need to read more about X before I start writing’ as well as ‘I don’t have any space/working PC etc’. They’ll be all the usual ones you can think of. Silva comes back at the reader with responses, some more helpful than others.

Ultimately, the reason is often related to time or alternative priorities with work or life, to which the answer is, unsurprisingly, just write and allocate protected time to write. This isn’t a wonderful relevation but it is a message which can keep being knocked on the head to make sure it has a difference.

Silva may claim to not always have been a planner but a planner and a scheduler you need to be if you are going to write effectively and productively. Planning your writing, counts in the writing time and setting achieveable goals is important as well and give yourself deadlines if noone else is going to. He also talks about prioritising projects and how those priorities can differ and that needs to be fluid.

He likes monitoring progress by word counts or meeting specific daily goals which might work if reading is writing.

To Silva, ‘writers block’ is not something that happens to academic (as opposed to creative) writers. It is just ‘not writing’ and by ‘not writing’ you have ‘writer’s block’. The way to cure it is to write. This is about approaches, attitudes and excuses. It might be that some writing needs more editing than other writing because of the flow that develops but it can be progress and it can be measured all the same.

There is a chapter specifically about style and the importance of clarity in writing. This includes a good reminder to write for audiences that may not have English as a first language. The best writing is accessible and readable. Use jargon when it is necessary but don’t import it in if it does not add to the understanding of the reader. This may be a good discipline in all writing exercises and tasks. He reminds us, as writers to think of the meaning of the words you use, each one having a function to increase clarity. This is a lesson which stuck to my heart as I often write with excess verbosity.

Strengths and Gaps

Silva writes unapologetically as a psychologist and the book is published by the American Psychological Association (APA) so examples about journals and book are based on psychology. I don’t think this is a weakness or a gap so much as a ‘thing to be aware of’.

As he goes through the different parts of a paper and how to construct them, he includes a section on the importance of references and what the reference section means. I have not seen this in a book of academic writing previously but that might say more about my reading than about what is out there but I found this helpful.

It was useful to see a differentiation in the way writing would be approached when considering papers with empirical research and ‘review’ articles, both of which he covers.

This is, though a small book. It probably won’t teach you information you have not come across before regarding how to start writing and get writing but it is concise, clearly written and accessible. It is quite pricey though so might be worth tracking down in a library or getting a second hand copy (as I did).

Use in practice

This is an eminently practical book which has immediately led to some changes in behaviours and ways I think about writing. While it isn’t about innovative new methods, the point about writing is you just have to do it and the way to get better at it is doing more of it, so the book serves to grant permission to believe in yourself and your ability to improve by doing.

For myself, I tend to schedule writing time anyway. I write and study at weekends because I work during the week but it has made me consider how much time I may be able to add to weekdays before work and how to quantify the writing I do. For example, I am now editing this post at 5.45am when I usually get up for work at 6am. I’m also writing a blogpost instead of academic writing though, so swings and roundabouts. Writing is writing!

Silva makes writing – including articles and books, accessible. It seems like the ‘I can do it and so can you’ attitude prevails to the extent that I almost begin to believe it. More importantly, it is a fun book to read. It wasn’t difficult to sail through it quickly. It wasn’t an effort to read which some texts can be.

Conclusion

This is a useful addition to the toolkit for someone who is new to academic writing. It can also serve as a cheerleader in the resources to give more confidence to do what you do regarding writing and to feel better about writing than not-writing. Style is essential but practice embeds style. I would recommend this if you come across it, particularly in a library.

The link to buy it is at the top of the page – this is not an affiliate link. I bought this book for myself.

Paper Review: Human Rights : Its Meaning and Practice in Social Work Field Settings

This post refers to the following paper :

Julie A. Steen, Mary Mann, Nichole Restivo, Shellene Mazany, Reshawna Chapple, Human Rights: Its Meaning and Practice in Social Work Field Settings, Social Work, Volume 62, Issue 1, 1 January 2017, Pages 9–17, https://doi.org/10.1093/sw/sww075

Introduction

As I have covered Australian and British social work papers, I thought I’d turn to the United States with this one and while I have read and learned about human rights in the context of English mental health and mental capacity legislation, the ability to see where the global human rights debate is, was appealing. It has been useful to look at where research is focused in the US where the role of social work has some distinct differences and the cultural context may not be as similar as we sometimes assume.

Context

The research study which was carried out involved interviews with social work students and and ‘field supervisors’ who are experienced social workers as might be obvious, who are supervising students in their initial training placements.

The paper starts with a literature review which covers social work and the role of human rights in social work settings. This has the UN Universal Declaration of Human Rights in 1948 as the starting point but diverges by looking at some of the additional principles to cover, what they describe as ‘population-specific’ conventions including the Convention on the Rights of the Child and Principles for the Older Person which grew up subsequently. There is also reference to some of the work which has linked human rights with social work in a broader context and where human rights practice crosses with social work. This includes the role of advocacy in social work and an interesting distinction between case-based advocacy and cause-based advocacy. There is also reflection on the role of community based social work as human rights in practice.

It was interesting reading through a UK lens where obviously the European Convention of Human Rights doesn’t figure but also where the UK-based literature on human rights and social work would not have been as relevant to the article. This is very much my ‘little England’ view and a literature review is never going to be comprehensive. However, it also introduced me to a broader understanding of human rights, encouraging me to read further and put my focus on UK human rights into a better global perspective.

Methodology

One thing I noticed in this study which was helpful (to me, as a novice researcher) was that the authors explicitly stated their research questions which were

“What means do social work students and their field supervisors attribute to the concept of human rights as it relates to their work in field settings?” and “How do social work students and their field supervisors describe human rights practice in their own agency meetings?”

Having the research questions clearly established helps with appraising the research which takes place and helps understand decisions made regarding research design.

In this case, the authors took a phenomenological approach. These terms can sound like a different language intended to detach academic world but it only means that it is looking at the experiences of people who have them from their viewpoint. It is not an ‘objective’ study but that would not have been unsuitable for the research questions which are asking about how the participants experience and understand human rights in their practice and so phenomenology fits well.

The study was carried out through online questionnaires. Online surveys were sent out to students and supervisors and they were open for responses for two months. There were, in the end, 35 student participants and 48 supervisors. There was a mix of students on different programmes (Batchelors and Masters) and mix of gender and race which was established in the results. The average age of students was 20 and the average age of supervisors was 45. I noted this only because I can’t imagine the average age of UK students would be so low. So another notable difference.

The survey contained a mix of open-ended and structured questions.

Results

The researchers divide the outcomes into seven themes in terms of identification of human rights issues relevant to practice and five themes under which they described their own practice or observation of practice.

In terms of the human rights overlap with social work, the most common theme identified was poverty, in addition to this was discrimination, participation, self-determination, autonomy, violence (right to live free from violence where violence is expanded to mean abuse), dignity, respect, privacy (including confidentiality) and ‘freedom and liberty’.

Poverty identified reflected the resources that link to access to housing and healthcare. This obviously has a different context where healthcare is mostly on an insurance basis but presented another layer of the economic and social human rights which occupy the social justice element of social work and embed social work as a human rights profession.

The interesting point the researchers made about discrimination was that students primarily focussed on discrimination faced by LGBTQ+ groups whereas the supervisors more often referred to cultural competencies and gender based discrimination.

The themes of participation, self-determination and autonomy emphasised the right to have the means to determine ones’ own destiny, including refusing or discounting professional advice.

The group of supervisors who referred to ‘freedom and liberty’ were non-descriptive. It is an interesting expression of a more abstract concept as a right.

In terms of practice and how they saw human rights expressed within the agency there were five themes determined. These were advocacy, service provision, assessment and relationships.

Advocacy was reflected in both individual practice with clients and in terms of challenges within organisations. The researchers distinguish themes of case advocacy versus cause advocacy. Cause advocacy was more heavily emphasised by students. Service provision included areas like psychoeduction and providing direct support to groups of people that had specific needs. I’m not sure of case management as human rights but that might be about my prejudices and understanding of the term rather than the way it is meant by the participants.

Assessment was seen as a human rights engaged activity as a process in order for ‘needs and wishes’ to be met. I think this may be a bit tenuous at best because I prefer ‘conversations about needs’ to ‘assessments’ but that might be my issue with the language. Sometimes, assessments need to be assessments. Do they always lead to resources that are necessary? Perhaps not.

The relationship was interesting as it was presented as being key to human rights in practice including the honesty and transparency of the connection. For the purposes of the paper, treating people with dignity, care and in a way that is free from discrimination were part of the relationship.

Key learning for practice

There were a couple of interesting elements that I took from this paper. It was fascinating to read about human rights from a non-European perspective. It made me itch for more exposure to international research. Struggling to match human rights in principle to work that social workers apply on a day to day level can be a challenge and this research addresses this by asking about both conceptual and practical visions of human rights.

The language of human rights was measured in the research and it can make us think about the language we use in practice. Do we talk about assessments meeting wants and needs or about assessments as processes to be completed? Do we distinguish and action both case and cause advocacy? We might not be able to to both but do we recognise it when we do it.

One of the things I thought I could do as a result of this, was self-audit some of the small actions and conversations I have and records I write in each week, meetings I attend and consider how human rights legislation and principles are enacted in practice.

Reflections and gaps

I enjoyed reading this paper and enjoyed particularly seeing the process of a research project including research questions being described. Of course, the study was based on students and practice supervisors. It would have been interesting to see the outcomes if it had been practitioners at various stages of their careers. The different areas of practice were not also clearly differentiated so it wasn’t clear how many worked with adults or children and in what settings, for example. This might have produced further interesting results. It was a relatively large sample (I thought) and the survey was an interesting way of collecting data, particularly large tracts of data but I wondered about how useful (or different) interviews might have been.

Conclusion

One of the things that struck me (and possibly the authors as well) was the lack of reference to race and discrimination on the basis of race and culture particularly by the students who were interviewed. This was something I wondered about in terms of teaching within social work settings as well. The authors speculate that this might align with gaps in the teaching curriculum although discrimination in the LGBTQI+ community was more heavily referenced by students.

Poverty came up as a strong theme in discussion but in practice it wasn’t always clear how this was challenged and addressed. This is more about where some of the cause advocacy might focus, perhaps.

Book review: Developing Research Questions

This review refers to

White, P. (2017). Developing research questions : a guide for social scientists. 2nd ed. Basingstoke England ; New York: Palgrave Macmillan which is available to buy on Amazon here (non-affiliate link). I was not paid to write this and bought the book myself.

Introduction

This is a book which I picked up quite early in my ‘research journey’ and I picked it up because it was one of a number on a reading list. It was written by Patrick White who is a lecturer in the Department of Sociology at the University of Leicester.

Content

This is a book that is best suited to the beginning of a research project as you start out. It’s focus is entirely the start of the process and how to build both effective research questions but while doing that, identify the key areas to focus on when starting with a topic and trying to narrow it down. As well as focussing on the process of defining a clearly focussed topic with an answerable research question, which is the starting point in terms of the aims of the book, it also covers aspects of this including what a good research question looks and sounds like.

For experienced researchers this is probably more than they need but it helps to clarify some of the confusion which can start at the beginning of a project when you have an idea but want to make from it, questions that are not just interesting but answerable.

When I bought the book, I read through it start to finish, which probably isn’t necessary, but I also tried the suggested exercises as I went, saving my initial thought processes into my research diary to return to and to help me understand and then reflect on my thinking early on in the process.

White gives frequent examples, which are taken from a range of disciplines, about what might make a good research question and the different types of questions one can ‘ask’ or at least, identify in research. It is written very much from a social science perspective and as that is where I am coming from, I’m not sure how translatable it is but it makes sense.

Summary

This is a book very much aimed at novice researchers but it highlights the importance of clarity of purpose in research from the very start in the building of research questions that might well be dipped into from people at different stages of their careers. As well as an explainer of types of questions in the context of research questions specifically, and how ‘answerable’ they need to be, the book covers broader areas around research design and levels of evidence, information required to answer them.

Starting from a premise that literature reviews, lead to identification of areas in need of research in order to justify the research questions being asked, White writes, taking a logical order to offer clarity in the face of what can be an surplus of information and studies and cleverly helps the reader find a path through the jungle of information to read the end goal.

While the focus is clear in the title of the book, there are some excursions into later stages of the project including whether and how one manages to answer the given research questions and use of hypotheses and what ‘counts’ as evidence and linking evidence to claims which can help to answer these questions.

This is a practical text which refers to the answerability of a question which can depend on time, resources and level of research projects. Each chapter ends with exercises and has chapter bibliographies for further reading. Personally, I found the earlier exercises in particularly, helpful in narrowing down some of my initial thoughts.

Key strengths and gaps

I enjoyed this book. The strength was in the narrowness of it’s aim, in a way. I have other books which talk about research processes from start to finish but this was focussed solely on identifying research questions which work. It is a cross disciplinary book which a focus on social sciences and the research methodologies used predominantly in social sciences.

There are some useful conceits introduced, or were for me in any case, including the ‘literature funnel’ which models broad reading across a topic, through a funnel of contemporary issues, debates and findings to establishing a relevant and useable research question.

One of the suggested exercises was to reduce your topic to 140 characters. It can provide focus but it was other similar exercises that allowed me to think about things in different ways.

Of course, many of the issues raised in this book which will very familiar to experienced researchers so this is a book aimed at novices and primarily aimed at novices in universities with access to libraries and wide ranges of reading materials.

The examples given are from across social sciences and some of the exercises might not be useful. I like the key points which were set out at different points and above all, it is clearly written and concise which only works to its benefit.

Use in practice

I’ve mentioned this previously but this was one of the most useful books I found around methodology towards the start of my research. ‘Research questions’ can be frightening and establishing a good mix between pertenant and manageable is not always easy, especially if it is a first time research project. It might be that these are the things you learn early in university careers but if not, I’d recommend finding this book.

As well as clarity of scope and purpose, it has some useful glossaries of research terms which help when learning the different professional language needed to become a researcher. Even if you are not doing the research yourself, some of the exercises and background information about types of questions can be useful in appraising and understanding the research of others and identifying distinguishing research questions in papers that you read to keep up with the subject area in which you are working.

Conclusion

I both enjoyed reading this book and found it useful. It is a short text and it is written with a style that is conversational and therefore not too intimidating. It has provided an additional confidence in understanding what might make research both good and logical. It has definitely helped me along my journey.

Policy review: NICE Guidance on Decision-making and mental capacity

The guidance referred to is available here.

I decided to branch out from books and papers and look at some NICE guidance and maybe some policy documents too in weeks to come. I present this as very much a ‘non-expert’ but rather as someone working in this area who wants to make sure I am aware of best practice.

NICE and the place of NICE in Social Care

As a brief introduction, it is useful to note the role of NICE. The National Institute for Health and Care Excellence (NICE) was founded in 1999 as an independent body which produces advice and guidance about best practice in medicine and health. After the 2012 Health and Social Care Act, the body was asked to provide guidance on social care and the first social care guidance was issued in 2014. It is a non-departmental government body.

Background to this guidance

The guidance on Decision-making and mental capacity was published in October 2018 as NG108 . As part of the process of writing guidance, NICE committees will involve experts (including experts-by-experience). Alongside the guidance itself, NICE publish the methodology which is useful as a new researcher to understand how to write up scoping literature reviews as well a methodology although it is in a lot more depth that would usually be necessary. It includes which databases were used for searches and what phrases and words were used, which studies were included and which were excluded. They also detail the expert testimony included and who was consulted and inputted into the formation of the document.

Context

The guidance was written in the light of numerous reports and studies (which are detailed in full on the NICE website) which pointed to a mismatch between what the legislation and Code of Practice say about assessing capacity and making decisions about capacity on behalf of people when they may lack capacity to make those decisions in the context of health and social care. Of course, the Mental Capacity Act (MCA) and its scope move far beyond the health and social care sphere but for the purposes of NICE, that is where their scope lies. The guidance was actively commissioned by the Department of Health to help people using the Act in practice to engage with it.

The guidance is used alongside the primary legislation, Code of Practice and growing case law and provides practical assistance both to both health and social care professionals and organisations that employ them and those who commission these services regarding duties, expectations and best practice goals.

As the Code of Practice is being updated now, until it emerges, this is the most recent guidance that practitioners can turn to. Personally, I have found it enormously useful in my work, not least making me more aware of expectations. I know colleagues who have been more critical but for me, it’s been a useful tool.

The guidance specifically excludes reference to deprivation of liberty safeguards and areas of decision-making and mental capacity for under 16s which have different legislative frameworks.

Summary of key recommendations

The guidance divides along the lines of key recommendations and divides them into recommendations for individual practitioners, for service provides and for commissioners. So reading this, one can choose the parts that relate most to the area that impacts.

Regarding individual practitioners, as that is where my interest lie, I was disappointed that some of the key ‘know the law and apply the principles’ has to be stated. It shouldn’t need to be part of formal guidance. Some of the guidance is stuff that shouldn’t even need to be said but perhaps reflects where some of the drive has come. Areas like, ‘make sure you document past and present wishes, beliefs and preferences’ may seem like they don’t need to be said but by expressing, them it ensures expectations are clear. When we are writing records, we are not just writing for tomorrow, but also for 10 years in the future.

The guidance also emphasises the importance of sharing information including information about accessing advocacy services. Obviously I won’t list all the recommendations here as a lot of them are ‘do what the Code of Practice’ says but there is a stronger emphasis on recording reasons for decisions and involvement.

The other area that I saw was strongly emphasised was the importance of advance care planning. By nature a lot of work in a busy organisation happens when it needs to and perhaps this is more focussed on social care staff who may be working in a more preventative capacity to think about and document advance care planning and give people the opportunities to understand and make advance decisions.

When explaining the process of actually undertaking an assessment of capacity, the guidance emphasises the need for collaborative approaches to be taken and refers to particularly difficult situations where someone may have a brain injury which affects executive functioning which may call for a more structured assessment.

The guidance is clear that a documented assessment of capacity must exist before a best interests decision is made. Some research has reflected that this has not always been consistent in practice. There is also a specific section of the guidance devoted to involving family members and those who are involved when best interests’ decisions need to be made. Although this might be obvious for people using the Act and Code of Practice, it strengthened the clarity of challenge when these steps are not taken.

To organisations that provide services and employ health and social care staff, there are specific guidelines which are highlighted. These include ensuring that staff have access to better training (they talk about more investment in training). They should also ensure there are robust monitoring procedures in place including outcome measures which involve people who have been assessed and the level of collaboration in decisions being made.

They are also tasked to ensure that the systems they have in place have a clear way of recording preferences and advance care planning including advance decisions.

Commissioners have recommendations which vary in strength from asking them to ‘consider’ increasing the scope of Independent Mental Capacity Advocates (IMCAs).

There are some areas of oversight that are emphasised and recommendations about systems being in place to ensure good practice is followed but there has to be a will to change in order to do this and that is probably not the priority of some who commission services.

Thoughts on the recommendations

Generally, I’ve found the NICE guidance helpful. Although I hope it doesn’t tell people using it anything new, it is a clear representation of some of the ‘how’ in terms of carrying out a mental capacity assessment and taking best interests decisions.

Recommendations, like all NICE guidance, are just recommendations in the end. The call on commissioners and service providers to provide more investment in training is something that requires analysis of the training which has taken place and why it hasn’t been useful. I have my own theories but this probably isn’t the place for them.

Given what the scope of the project, I think the recommendations remain unambitious. Yes, we should involve people but investing in training needs outcomes of training to be measured. Having key people in place to push mental capacity as a necessary knowledge set is key and shouldn’t rely on champions who have been picked because no-one volunteers. For me, work around capacity and best interests is a fascinating area of power dynamics, control and push between state and individual which needs to be explored in more depth and given more life in practice. If it is presented and trained through online tick boxes as if it’s just another burden to complete rather than a way to work with an individual and their family or people important to them in a collaborative and exciting way, it can influence attitudes to the processes.

But that’s probably outside the scope of the guidance!

Use in practice

I have found this to be eminently useful in practice, from the clear examples given about how to involve people in decision-making to the retelling of the legislation with recommendations about how they can be used better. Some of the recommendations can be completed by individual practitioners today, others need financing and systems to be changed but anyone who is involved in assessing capacity or working with patients and service users to build pictures of individuals through care planning and incorporating advance care planning can find the guidance immediately useful.

Conclusion

I have probably not explored relevant NICE guidance as much as I should have and this is the first guidance I have seen which directly influences my day to day practice. It has been useful to read through and I have a copy on my desk at work which I direct people to. One of the key uses for NICE guidance, particularly when there are recommendations for organisations, is to highlight through management when they are not being adhered to (I’m terribly popular with my managers!).

However, even for the key steps of assessing capacity, there is useful, clearly written and up to date guidance and for that, this is worth both accessing and using actively.

Paper review: Health and social care practitioners experiences of assessing mental capacity in a community learning disability team

This paper, authored by Daniel Ratcliff and Melanie Chapman, was published in the British Journal of Learning Disabilities 2016 Vol 44 (4) p329-336

Introduction

This is an article which is very much located outside the ‘social work research’ space although it is occupied with a topic which is very much in our areas of interest, indeed, my own research is focussed on the Mental Capacity Act and ways of assessing it so there may be a tilt towards articles in this area. And this one has been enormously useful.

The premise of the paper is to look at the experiences of different professionals when undertaking the assessment task. It’s interesting to note that the study was undertaken by one practitioner (Ratcliff) and one academic (Chapman) working together. This adds another layer of interest to the paper and its analysis.

Methodology

The study was very much located within the qualitative space, exploring the experiences of eight professionals, from health and social care backgrounds, using semi-structured interviews which were then analysed using thematic network analysis.

All those interviewed worked within a community learning disability team and had done for at least seven years. In terms of professional breakdown, there were three nurses, a physiotherapist, a speech and language therapist and two social workers. All of the team members worked in the same team and had received the same in-house training.

The data, which was the transcribed interviews, was analysed using thematic network analysis. Thematic analysis looks at identifying common themes which emerge from the data and the researchers focussed on networks within the data which linked to the themes identified.

Context

The paper starts with a brief literature review relating to the current situation regarding the use of the Mental Capacity Act (2005) in England and Wales. It identifies, from previous research, that there are known variations in the quality of work around use of the MCA in practice including gaps in knowledge and lack of confidence in implementation of knowledge and that despite training, this had not, seemingly, led to improved practice.

The Mental Capacity Act (2005) while being generally acknowledged as a positive move in legislation relating to those whose capacity to make specific decisions may be doubted, has led to continuing conversations, over 10 years after implementation (which was in 2007) about the lack of embeddiness in health and social care services. The Act is used in all areas of health and social care practice (apart from under 16s) but it has been particularly used relating to adults with cognitive impairments, whether permanent or temporary. In terms of social work practice, this is most commonly identified in work with adults with learning disabilities and work with older adults where deteriorating cognitive functioning may be identified, for example, with some dementias.

Key learning points

The study identified five significant themes which emerged from the thematic analysis of the interviews.

  • Systematic barriers to assessment
  • Capacity assessment as a challenging process
  • Person-specific challenges
  • Protective practices
  • Protection of a fundamental human right

Basically, there were organisational and structural issues in place which might impede quality assessments. This could be about the workload pressure of staff or the ethical tensions between organisational need and outcome of specific assessments, particularly noted around attitudes towards risk

…there was service level pressure to ensure that risks of harm to individuals were limited as far as possible, thereby conflicting with the practice of positive risk taking and allowing capacitious individuals to make unwise decisions.

p332

There was also an expression that a ‘capacity assessment’ could take time and effort to ensure it was carried out in the best way, particularly with involvement of carers. While the legislation explicitly encourages family involvement it can be more challenging when there are differences around the decisions made.

Practitioners raised the challenge of difficult decisions where it was not a straightforward outcome but where there might be a different interpretation, for example, relating to specific decisions.

Participants noted that joint decision-making was helpful and support from other colleagues in thinking through the processes. They also said more specific guidance could be helpful.

There was a general positive response to the impact the MCA had made on practice. It had put into legislation, some of the importance of emphasising the individual and their human rights. There was a feeling it had improved practice and the rights of people who used the services they provided.

The researchers identified a ‘global theme’ which enveloped the data collected as ‘freedom to act versus restrictions on action’. Without understanding more about the coding process, I relate this back to the initial title, which summarises the experiences of those using the MCA in this setting.

Reflections and gaps

The study is acknowledged to be a small-scale study which has taken place within one team where professionals have worked with the same organisation and often with the same people (they have all been in the team for a minimum of seven years). This means there may be a further risk of extrapolating from this data where practises and the culture of the team and organisation may have embedded and reflected on the responses.

Language, attitudes and values can be shaped by the organisation as well as the individual attitude. The study does not reflect (possibly because it is not different and the same size was so small they could be identified) if the professional background of the interviewee was a factor in reflecting the differences.

It is useful to see practitioners directly involved in research, particularly noting the interviews were carried out by the practitioner. It would have been useful, although this might be for a longer piece, to know if he had links to the team in which the research was taking place. It makes no difference to the outcomes, but it an interesting context in which to place the research.

Use in practice

It is good to see an example of research of practice taking place involving a practitioner and academic working together, particularly as the issue is one that can have an impact on the way teams work.

There were a number of issues identified in the study that I can take with me to practice. One is about the usefulness of support. Often this can be looking at supervision and training but the key that this piece draws out is those informal conversations with colleagues, highlighting a need which emerges from the paper, for a consideration of peer groups among professionals. Personally, I’m wondering if there is a scope for multidisciplinary peer groups which a focus on learning from each others’ practice and reflecting on potential improvements in practice together, in my work setting.

Training is necessary for legal literacy but use of training can vary. It is worth considering how understanding and knowledge can be on a continuous basis rather than a snapshot in time. I come back to the peer support groups and wonder whether this is an aspect that can improve.

The paper talks about the need for organisational changes to ensure that there is sufficient time to ensure that work can happen in the best environment. This could be written about any aspect of health and social care and isn’t something we can often change as individuals. There is an aspect about usefulness of templates and examples which might be able to be shared to make the decision-making better informed. Perhaps sharing some model anonymised good practice examples which are referenced with up to date case law and research. Sometimes the time spent searching for new information can be saved if it is well-disseminated.

Conclusion

This is a useful study and a useful paper in all. As someone who has developed an interest both in how the MCA is used and understanding different research methodologies, it has been an interesting piece. The research is clearly explained and the gaps identified.

I think while the literature review is well-presented, the sample size is small but produces some useful content which reflects some of the previous research in the field. The commentary around the piece including the themes identified, in some ways seems more useful than the specific data. It is very useful to see practice-focussed research. I’d like to see more about any differences between professionals and how that links to attitudes to the legislation as well as the experiences of people who have differing levels of post-qualification experience.

Saying that, the paper is useful, particularly as the researchers identify explicitly, the potential use in practice. It does leave us begging a lot of questions for more research in this area though.

Book review: Research and Evaluation for Busy Practitioners : A Time-Saving Guide

This is a review of Research and Evaluation for Busy Practitioners by Helen Kara first published by Policy Press in 2012. I have a copy of the first edition so I have reviewed that but there is a second edition available.

Introduction

This book is written by an independent researcher and writer, Helen Kara, who has written a number of books about research. This book fills a space because it is very much aimed at practitioners who are employed in ‘non-research’ roles, like, well, social workers but by no means only that, who are thinking of starting research and/or evaluation projects in a work setting. Through writing the book, Kara interviewed 20 different professionals who contribute. The writing is interspersed with key ‘advice’ quotations which stand out from the text. I have to say my favourite one was

You don’t have to read the unreadable

p35

Research is useful, doing research is an important professional skill and using research evidence is necessary to stay current in work environments. However, not all research is good research and critical analysis needs to accompany the reading/writing/doing of research, just as it does in practice environments.

Context

The place this books inhibits is partly about a guide to research for non-researchers and partly taking people who are confident and experienced practitioners and putting them in a ‘research’ space.

I found the most useful part of the book was the tone. Often, and I have read a lot of ‘how to research’ and ‘beginning research projects’ books which are entirely aimed at first year undergraduates or at least, early stage postgraduates.

While I have an MA in social work, and for that, I needed to complete a dissertation, it was entirely using secondary data and as part of a qualifying course, research methods and methodology was not emphasised beyond the immediate need and the push to make things as easy as we could for ourselves in getting through the degree programme.

Kara is able to speak to people like me. I am not new to my subject (in this case, social work) but having qualified in 2000, I have not been used to the language of academia. There is a particularly useful glossary at the back of the book which gives very short, one or two sentence definitions for research terms which will be second nature to those within academia but can increase the distance for those on the outside. Often, in many sectors of work, knowing the language and the terms is such a key part of understanding what is being said and how to say things. Finding the common language is key and that’s where I’ve found a lot of this book incredibly useful.

Key points

This book, as the title says, takes the busy practitioner who has a job alongside research, through the process of defining what project it is that will be undertaken, looking for research questions and better defining the tasks and best way of gathering data to answer the questions, gathering the data, including use of interviews, focus groups and quantitative data sources. Then glances through data analysis and dissemination.

These are all the same key points that would be made in many research texts for those who are new to research. What sets this book apart is that it is not aimed at academics or students. There is a useful pragmatism and an acknowledgement that perfect isn’t possible in a messy world with competing priorities. I had never read, for example, the distinction between a document review and a literature review or thought about why designing a research project on the basis of what is most feasible is not a ‘get out of jail free’ card but an entirely legitimate approach.

Kara touches on all the key parts of research, including research ethics and involving people who use services you might be working in including a breezy nod to the importance of being a practitioner in the development of emancipatory research and action research as well as an explanation of the difference between them.

Use in practice

The whole book is very much built about being able to use its contents in practice but for me, the key take-aways, apart from the additional knowledge of research and the language it uses to sometimes create a veil of mystery around the work of researchers, has been a re-stating of the idea that research doesn’t sit in a box distinct from practice. It is a challenge to integrate research into practice until you realise what you are doing anyway is using a lot of research skills, particularly if you are involved in audits and evaluation work.

As practitioners we have interviewing skills, skills to manage groups, skills to discern quality of evidence provided. These are all research skills.

There are some handy practical tips as well, such as managing information, making notes and keep track of references which has been immediately useful. The book also addresses issues such as funding and allowing time (or not) for research alongside work, often full-time.

One of the areas which is probably a bit outside the scope of the book that I think I’d have liked to see more of, was less about the doing research which is very robustly covered and a bit more about using the research evidence in practice and tying research into practice contexts, particularly when there isn’t time or support to carry out full research projects. Some more examples of the small projects which have to run alongside work would be useful.

Saying that, I found this an incredibly useful resource and it is a clearly written text which occupies a gap in the market and as such I’d definitely recommend it.

Summary

This was a book which spoke to me because it catered to a professional, skilful audience who are just not in synch with the language of academia and some of the skills of research. Although one of the key takeaways that I found particularly helpful was the idea that often use the same skills that are needed to undertake research and evaluation, in a work environment but don’t always recognise them as such. We have conversations (interviews.. ), we write assessments (reports), we analyse information which is provided to us and determine the output based on evidence.

Being spoken to, as this book does, as a skilful and knowledgeable professional who just wants to know more about how to do research in a work environment which may not always be supportive, rather than as an 18 year old undergraduate who is at university for the first time, is a great relief.

I have read a number of Kara’s books, which no doubt I will return to at other times but if you fall into the category of ‘wanting to start research but not really sure of some of the things that everyone takes for granted’ this is a perfect place to start. Even in the third year of the studies, I found it a refreshing.

We need research in practice and we need to undertake research in practice. We need to understand the basis of evaluation work and need to speak the language of evaluation and research to thrive in a professional context and this book is a great start.

The book can be bought here (I’ve linked to the second edition on Amazon – this is not an affiliate link – although I may add some later, I will always state explicitly when I use affiliate links).

Paper review: The Mental Health Act Assessment Process and Risk Factors for Compulsory Admission to Psychiatric Hospitals – A Mixed Methods Study

This post refers to ‘The Mental Health Act Assessment Process and Risk Factors for Compulsory Admission to Psychiatric Hospital : A Mixed Methods Study‘ – Wickersham, A, Nairi, S, Jones R and Lloyd-Evans, B. Published in British Journal of Social Work in April 2019.

Introduction

This paper presents a mixed method study using data from mental health act assessments followed by interviews with AMHPs (approved mental health professionals), s12 doctors and some AMHP managers in a focus group.

A Mental Health Act Assessment is a formal process in England and Wales, which relates to the provisions of the 1983 (as amended 2007) Mental Health Act. It is the process by which a person can be compulsorily detained in a hospital which is registered to provide care and treatment. An application for detention is made by an AMHP (who is a social worker, nurse, occupational therapist or clinical psychologist who has received additional specialist training and is approved by the relevant local authority) and it requires the recommendation of two doctors, at least one of whom should be independent (the other can be the treating psychiatrist or can be a GP) and who has preferably received additional training under section 12 of the Mental Health Act.

This process is commonly known a ‘sectioning’ a person.

Methodology

The study is described as ‘mixed methods’ because it integrates elements of quantitative and qualitative research methodologies. The researchers took a range of data from AMHP reports following Mental Health Act Assessments and the information held on electronic databases within the trust to analyse some characteristics and outcomes of people who were assessed under the Mental Health Act within a specific time period. 150 records were analysed, including retrospective case record audits of which 146 were included. The researchers noted that there were fewer, and less complete records for assessments which had not resulted in detention which meant they covered a longer period in order to ensure some were included.

Only assessments which took place in the community were included and anyone who was recalled on a CTO was excluded.

Some of the characteristics identified or used to differentiate included what, if any, diagnosis the person assessed had, whether the reason for assessment was due to concerns about risk of harm to self and/or others and whether a ‘lack of capacity or insight’ was noted (I’ll come back to this).

Then the researchers undertook semi-structured interviews with 4 AMHPs, 4 section 12 doctors and ran a focus group with 3 AMHP service managers. These were subject to thematic and content analysis.

My first thought was that it was a small group of interviews and that it might reflect a lack of balance in the importance of each conversation but the number of AMHPs within one trust is small so as a representative sample of 53 AMHPs employed it was a fair percentage.

The paper refers to the outcome of the study being discussed with the AMHP leads and involving ‘a research colleague who has lived experience of using services and working as a peer support worker in the participating trust’ but that just begged a few more questions in my view.

Context

This study took place in one London trust. It is described as an ‘inner London trust covering two local authorities’ which, for anyone who knows London mental health, narrows it down to one trust. I had to try to stop myself being distracted by this because I was an AMHP in one of those boroughs, in that trust, so kept thinking of people I used to work with, but that’s not the best perspective from which to start reading a paper in a neutral manner. However, it does emphasise the truism that we don’t read papers in isolation of our own experiences and knowledge of situations. So while, in one sense, I am trying to move away from that and read the paper as if I had no idea where it was and who might be being interviewed, I am also able to acknowledge the role that self, and background knowledge always plays when we read papers and research.

The aim of the study was to focus on potential increases in the level of detentions and to look at any barriers to alternatives to admission or what might or might not influence decisions to detain someone under compulsion which is an extreme action regarding the deprivation of liberty of another person in the context of state infringement of the human rights of another person.

Key learning points

Some of the themes identified will be familiar to those who have worked in this field for any length of time. One related to the potential difficulties caused by not having three professionals assess at the same time. A doctor may make a recommendation and this can be followed up by an assessment with a doctor and an AMHP attended at the same time. One of the issues identified was that the first recommending doctor may be influenced to recommend detention, as the paper states

‘ one doctor suggested that, as the first to do an assessment, it can feel safe to recommend detention and pass responsibility to the second doctor’

p12

This was followed by the further discussion that the AMHP and second doctor may be influenced by the first recommendation.

Issues were raised as well about the individual different in attitudes, experience, knowledge and confidence with understanding risk thresholds which can be key to the outcome. Personality and unconscious bias may play a role in the outcomes of assessments.

One of the key themes to emerge, unsurprisingly, was that the impact that lack of alternative options to admission, made on the decisions to detain. If there were no places in crisis houses, capacity in crisis resolution teams, day services that met the needs of the person who required support, family and informal support in place, it could have a significant impact on the outcome and decisions made. Lack of access to substance misuse services may also have an impact on some decisions.

It may also be about the assessing team not knowing what the alternatives are for that person. One of the key pieces of learning the researchers emphasise is the potential difference in outcome when someone has a member of their community team present, or a family member or someone who knows the individual. This can help to identify both options and the lack of suitable options.

There were some issues raised around poor operational processes including the role of inpatient services. This included poor discharge planning which led to hasty readmission and poor continuity of care between community and inpatient teams. There were some additional factors which might be more relevant in the type of area it is, around access to support for people who are non-UK residents. This is an area which may include some people who are visiting the area.

Reflections and gaps

The paper identifies some of the difficulties in identifying data in the assessments considered for inclusion and reflects that out of the 150 assessments analysed, 22% had missing or incomplete AMHP reports.

The identification of ‘lack of capacity or insight’ as one of the categories in which the assessments were sorted, indicates to me a lax approach to the term and use of ‘capacity’. I never want to see the term ‘lack of capacity’ in any document that doesn’t refer to what the lack of capacity is for. I accept this is my pedantry, but is if it ‘lack of capacity to consent to an admission to hospital for assessment or treatment’ it wouldn’t take many more words to say so and these phrases add to the general misconception around capacity and/or insight, that it can be applied broadly, or maybe it’s me not understanding the implicit suggestion that this is specifically capacity to consent to admission.

The sample size is local to one trust so the findings can’t necessarily be used to evidence situations in other geographical areas. The interview sample sizes are small which can attribute far more importance to one or two, what might otherwise be, throw-away lines. That doesn’t mean that the importance of what is said isn’t valuable. It is, but it needs to be recognised in the context of the sample of assessments and the sample of interviews.

The involvement of management staff was key to understanding some of the context in which the study happened and the management team reviewed the data which was prepared for inclusion but that does offer a consideration about any self-imposed restraints that those interviewed might have felt in terms of criticism of the organisation, given that the sample size was so small. However, saying that, there was a fair bit of criticism for the organisation coming through but it may have been a factor.

The study only looked at community assessments because the focus was on avoiding hospital admissions. This meant that the voices of those who are detained in hospital and views of inpatient teams are lost. It is possible, especially with longer admissions, that some inpatient staff may have built up a different perspective about blockages and this aspect was intentionally lost. That is due to the limitations of the study rather than a lack of thought in the process.

This is research which is about the outcomes of Mental Health Act Assessments and the process of completing them. The study was focussed on professional views and records. There was a researcher who was there to review, who had lived experienced and the purpose of this research was to present a professional perspective but I wonder if there are more gaps around involving people who have experienced detention, in the processes of research and using social work research as empowerment. I know there are other studies which have and are doing this so it does feel like an unfair criticism but I felt it would be remiss to ignore it totally.

Use in practice

So what does the paper tell us that we can use in practice? The key headline and of course, this may be increasingly difficult in the face of cuts in services, is the importance of having someone who knows the person being assessed, present as part of the assessment, whether that is the care coordinator, or a family member or person who works with them through a third sector organisation.

It is also preferable to have the assessing team carry out the assessment at the same time. Often this is not lacking because there is an intention to make the process more challenging but due to availability of staff who are more frequently pressed by competing needs. It is useful to point to a study which evidences this as a factor.

The other aspect is to keep pushing for better options around prevention. This isn’t something that everyone can change but we can keep advocating and shouting for improved services which lead to better outcomes . I don’t know how much difference this makes when it is a factor that is far bigger than the individual practitioner, team or even organisation but it always needs to be referred to and having the evidence to do so is helpful.

Conclusion

This was a very useful paper to me in a lot of ways. It helped to show the way that mixed methods can be used effectively and how they can form a cohesive approach to understanding a problem. The outcomes and concerns raised were ones I recognised and I suspect will be recognised by those of us working in this space. Did I learn new things? Possibly not, but I found I have evidence to back up some of the assumptions made and that is key to pushing changes and improvements. If organisations can be presented with evidence linking the lack of capacity in the service, to involve people who know the person being assessed in the assessments and show that this leads to more admissions and therefore more cost, it may be a trigger to change systems.

And even if it isn’t, it allows us to talk about about what we see with more authority.

Book review: Street-Level Bureaucracy – Dilemmas of the Individual in Public Spaces

This is a review/reflection of Street-Level Bureaucracy : Dilemmas of the Individual in Public Spaces, first published in 1980 by Michael Lipsky (Russell Sage Foundation – New York). I have a copy of the first edition so am referring to that.

Introduction

‘Street-level bureaucrats often spend their work lives in a corrupted world of service. They believe themselves to be doing the best they can under adverse circumstances, and they develop techniques to salvage service and decision-making values within the limits imposed upon them by the structure of the work’

Lipsky – Street-Level Bureaucracy : Dilemmas of the Individual in Public Spaces (1980)

The aim of this book is to frame the role of the public sector employee in particular fields, where there is direct contact with members of the public, as a ‘street-level bureaucrat’. This includes social workers, obviously as that has been my focus in the reading, but also teachers, members of the police service, people working in benefits offices and many other examples of those who are responsible for putting government policy, both national and local, into action.

These groups of people have enormous impact on the outcome of policy decisions of the state as they are the ones making decisions on a day to day basis. The book looks at presenting the role of this group of ‘street-level bureaucrats’ within the role of having understanding of where and how decision-making can follow them, understanding how they work and make decisions and oversight and controls in place to guard against poor decision-making which can be discriminatory and full of individual bias, organisational structures which can concede control (not always a bad thing) but which can lead to vastly inconsistent outcomes for those who have no option but to engage with the work of street-level bureaucrats.

Context

Lipsky published this book in the United States in 1980. While it isn’t hard for me to remember that as I read it (I have a battered, old copy of the first edition which I bought second hand!), it is important to remember the times within which he was writing, forty years ago. There are changes that need to be allowed for in terms of time as well as location. Lipsky’s background is as a Professor of Political Science. He is writing from a broad perspective and expertise around policy and policy-making (because that’s exactly what politics is). His view is very much from the ‘how is policy implemented’. Reading this, as a ‘street-level bureaucrat’ adds another layer through which to analyse the role we play and the power we have in nipping at the heels of poor policy-making or even how we can dissemble the best intentions of good policy making, in practice.

Key points

While it is a classic in the field, it is one I picked up with an expectation of duty rather than enjoyment. I felt a sense of guilt in the amount of discovery I made because it is a 40 year old text. It is not a difficult read. It is written in a style that does not need an understanding of someone who is well-tuned to the language and style of academia.

The usefulness of the premise and content, reflects the thought that I have attributed to it. Lipsky considers the impact of street-level decision-making by the individual in one of those roles who need to be both thoughtful and autonomous enough to make differential decisions on an individual basis yet simultaneously adhere to guidance, eligibility criteria and standards which allow for consistent implementation of policy in relation to the citizen who is dependent on them.

He has space to differentiate between the role of the street-level bureaucrat who is in direct contact with citizens, and the role of the management and organisation within the processes of allocating resources, oversight of practitioners and, in a particularly pertinent chapter, which doesn’t seem to have aged, the role of goals and performance measures in guiding practice.

Lipsky contends that the place of goals, whether organisational or relating to individual workers, will always have some ambiguity and fuzziness because working with people is different to working with things. As he says

The ability of street-level bureaucrats to treat people as individuals is significantly compromised by the needs of the organizations to process work quickly using resources at its disposal

Lipsky – Street-Level Bureaucracy : Dilemmas of the Individual in Public Spaces (1980) p44

Lipsky covers the challenges faced as all those working in these public facing roles consider themselves to be ‘doing their best’ when that effort itself may need to be rationed. Sure, advocacy can be a key part of the role across the board, but advocacy as a street-level bureaucrat, can, he argues, focus on work with an individual to the detriment of other individuals because the time and resources available to the practitioner are rationed and some people may need more time. How are the decisions made about where priorities will lie? This is the power of the street-level bureaucrat who possesses, what Lipsky describes as ‘unidirectional power’ in relation to members of the public using their services.

The book is far more wide-ranging that I’ve been able to give credit but I was struck by the amount the spoke to me having worked in these roles for over 20 years. Lipsky has enabled me to place my practice as a social worker in a far broader context of public functions and professional roles including teaching, prison officers, police and benefits administrators, including call centre personnel – although he doesn’t refer to them, but in an updated version, they would be the people making some of the immediate responses and being the face of the government vis a vis the individual.

In terms of challenges faced, the context of the book being written 40 years ago when professions and semi-professions referred to would operate in different ways, probably needs a different focus. As public sector work is increasingly farmed out, and I am thinking of probation services, and prison services as well as social services, the element of profit-making hasn’t been taken into account in terms of the pressures of work as a street-level bureaucrat in the 2020s.

Lipsky is writing from an outsider context as well. I don’t see this as a disadvantage, rather an as a vantage point which differs. Indeed, it can be both positive and helpful to draw on expertise from a range of areas. One of the most interesting aspects for me has been to draw parallels that he did, with other public service professions.

Use in practice

When I read, I always read within the context of trying to understand what I have read that will change my practice as a result of the reading. Of course, not everything does.

With this, it was about drawing links with other public-service professions as a ‘street-level bureaucrat’ and draw out the similarities between social work and policing, teaching etc which are subject to continual policy changes dependent on which way the political climate blows. This is why it is useful to read from the perspective of political science rather than social work specifically.

Social work is politics and vice versa but politics is action. Every decision taken to prioritise one piece of work, or patient (because I work in a hospital), means that resources including time, may be limited to another. This does not mean these are ‘wrong’ decisions, but they are decisions and it is right that we should be accountable. In thinking about this book, and it’s message, it makes me consider who is actually holding me accountable. It might be the organisation or management through supervision but that is dependent on my interpretation and perspective on framing the work I do.

In a previous job, when we were working to Fair Access to Care Services (FACS) criteria, I used to joke that I could write an assessment to get anyone to meet ‘substantial’ need. And honestly, I pretty much could, because it was about how to wrote and interpreted criteria. Was it ethical though? Did it mean other people weren’t getting services? Individually, I didn’t see this because I am not an organisation. My role was to advocate for those I was allocated to.

I was also particularly struck by the role that unconscious bias can take in the decision-making at an individual level and the role that perception including race, gender, language and accent, even might take on assumptions that are built into the daily decisions made. While I don’t think I choose to discriminate, I work in a context of institutionalised racism and discriminations which may well be internalised so being aware of the impact and actively making decisions to own any internal prejudices is key to me challenging those assumptions and practices myself.

Will the book change the way I practice? I don’t know if it will change my decision-making but it will make me more aware of the context in which my decision-making takes place.

Summary

Coming at one a well-recognised and classic text, has been a useful refresh of some of the ideas I had germinating in my head for a while. It has been particularly useful to read the book in the context of broader views of professional groups beyond health and social care, where most of my reading has been located to date, and also beyond the UK.

Lipsky notes that people who have most contact with street-level bureaucrats are more likely to be poorer and have more services imposed on them. It is a responsibility, in all these areas, to own that and try to work within it.

I’d definitely recommend it if you are looking to broaden the perspective of the environment in which we work, bearing in mind the age of the text. I understand there is a second edition which has some updates and may well try and track it down.

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