Place Of The Social Worker In The Health Service

NHS history Social Care

B. E. POLLARD. 1946

Socialist Medical Association Social Services Group

Executive Function

Most of the following proposals are highly speculative. For the purposes of clarity, it is necessary to state briefly by what principles I have been guided.  I am obliged, therefore, to apologise for anticipating a little the paper which is later to be produced on the nature of social work.  Inevitably here such principles are somewhat dogmatically expressed*

Social work – Medical – and its derivatives are not one more aspect of medical treatment.  In themselves they are quite distinct from medical treatment; yet between them they cover the whole field of sickness.  Their specific field or focus is the relation between the individual patient’s sick condition and his relation to society. This last is an omnibus term meaning the whole series of the patient’s relations with other human beings.  The specific means employed by the medico-social worker is the professional relationship between the worker and the patient.  As far as I am aware, none of these statements can be made about any medical or dental function or that of any medical auxiliary.  And from this it follows in theory that social work cannot reasonably be limited to any particular group of medical conditions.  The sole determining factor once individual economic status is eliminated is the attitude of the patient to the problem of his disease.  In practice however tradition and limited resources must continue to play for a time some part.  There is no longer any need for it to be a determining one however in the selection of points in the Health Service where social work will be needed.

Agreement on such fundamental matters as those referred to in the previous paragraph will greatly assist the formulation of policy since there are many other complicating factors within the organisation of the profession itself. For example, the specific means employed by the medico-social worker is the factor which is common to every branch of social work. This at once suggests what is, in my view, the main deficiency in the basic training for the profession. In the conscious development and control of their relationship with their clients social workers have a common need for training. At present they receive almost none at all.

When they receive such a training in this the real, though largely unrecognised, unifying factor of their profession, their various functions will be much more nearly as interchangeable in fact as many social workers to-day think they could be in theory.  But under present training conditions, it seems to me there is hardly sufficient common ground between, for example, almoners and health visitors to compensate for the practical difficulties which would arise at present if their functions were generally merged.  The Bill itself recognises the specific functions of health visitors.  The present shortage of doctors and nurses too makes it an undeniable advance simply to spread the advisory service of health visitors as widely as possible over the whole field of care for the sick at home. To complicate it by extending all health visitors’ functions as social workers for which they are scarcely ready, would obstruct this improvement without providing an equivalent compensation.

There is, however, one field where a fusion of the work of the health visitor and the medico-social worker is even now urgently needed. This is the field of infant management from pregnancy to 5/6 years where physical care and psychological handling are almost the same thing.  The health visitor must specialise here and receive much more training in psychological flexibility.  This will help to fill the present lamentable gap between obstetrics and paediatrics which is partly responsible for our high infant mortality.

Another merger which it seems to me might take place at once is that of almoner and care committee organiser.  Their work already overlaps at certain clinics located in general hospitals.  There appears to be no essential difference in their functions, apart from the specialisation in children’s work which might well continue.  This new almoner’s liaison would be primarily with the school medical service and her location at the Health Centre, as I propose, would at once constitute a partial integration of one side of that service with the new comprehensive arrangements.  The organisation of voluntary help is a device which all workers at Health Centres might well take over from the care committee idea.

There follows an outline of the main executive social work functions which could be associated with the Health Service as proposed in the present Bill.  Details are omitted as being more the concern of the various experts on the committee

The Bill nowhere refers to social workers other than health visitors and this fact will have to be interpreted to the public as a deficiency in readiness for the issue of regulations.

Almoners in Health Centres (2 types) Cl. 21 (1) (d) and (2).

I think one cannot escape the conclusion that a large part of the almoner’s executive function should be performed in Health Centres. Where most patients are seen – at the local level – there is a great opportunity for preventive work.  At first the local authority and practitioner services will operate separately in the Health Centres in many places.  The result will inevitably be confusion, particularly of the patient.   Both services will be largely oblivious of the potential­ities of medico-social work and of its co-ordinating and economising effect.  The committee will need to elaborate especially the need and scope for social work at this level.

Almoners’ functions at the Health Centre will be mainly of two kinds in which it will probably be found convenient to specialise: (1) work with adults, including normal maternity cases, all of which will involve working with both the L.H.A. and the general practitioners; (b) work with school-children including liaison with the school medical service; this is the enlargement already mentioned of the function of the present care committee organiser. .

Health Visitors in Health Centres (2 or 3 types)Cl.24 (1) p.18.

Health Visitors also will do the bulk of their work from the local Health Centres. It seems to fall into two, possibly three, main branches in which it appears to me that for the present at least there should be specialisation.  These branches are (1) work with pregnant women, young mothers and infants up to 5 or 6 years, in the psychologi­cal aspects of which it has been suggested health visitors require a greatly improved training; (2) work with households where there are sick schoolchildren and adults (other than those suffering from tuberculosis or venereal diseases); and, possibly, (3) work with households where there is tuberculosis.  The contact with all these patients will be mainly in the home but also sometimes at the Centre.  Health Visitors might take over almoners’ functions to the extent of doing normally any visiting that is required on the cases.  This suggestion is made in deference to the widely expressed wish of social workers and of socialists to, reduce the number of visits made by social workers to any one home.  It should, however, be borne in mind that the new development of the social services, which is already certain under the Labour Government, will itself automatically reduce visiting not only by the improved co-ordination involved but also by further limiting the field of the voluntary social agencies.  I cannot, for example, see what future the Invalid Children’s Aid Association has as a caseworking agency.

Controversy still continues, but it is at least certain that specialist services for outpatients will be the ultimate responsibility of the hospital service.  Owing to the shortage of specialists and of equipment they will probably be for some ten years to come mainly provided at hospitals.   At a later stage they may be available at periodical clinics which will really be outposts in the Health Centres of the hospital and specialist part of the Service.

When this stage is reached they may well be given at first in a selected number of Health Centres only.  These presumably would be the more centrally situated ones which some medical officers of health have called “District or Divisional Health Centres”.  A few very well developed specialist services, such as certain local authorities’ chest clinics might become exceptionally outposts of the hospital service located from the first at local. Health Centres.

Almoners in Specialists’ “Outpost” Clinics Held at “District” Health Centres.

Almoners will be needed to work from the first with consul­tants’ clinics for adults where and when these are held at Health Centres, The extent of this arrangement and the degree of specialisation by the almoner in this connection will vary locally very much for a long time to come.

Children’s Almoners in Specialist Clinics in Hospitals & “District” Centres.

The alternative arrangement is the existing one in outpatients’ departments in hospital with specialisation by almoners in some fields. In either case it would probably be desirable to have one almoner or more specialising in children’s work, thus continuing the fusion already suggested of the care committee organisation with medico-social work.

In certain regions it is possible that re-distribution of specialist services could take place without expansion.  Thus, the fuller utilisation of the Health Centre by the specialist services or the reductions of the numbers of hospital outpatients is the sort of change which the medico-social worker must, on behalf of the patient, be ready to press for as soon as it becomes possible,

Psychiatric Social Workers in “District” Health Centres. (Child Guidance)

Child Guidance clinics are one specialist service which could in many places be located at Health Centres at an early stage, since they already exist in school medical services.  This will bring psychiatric social workers into the Health Centres.

Specialised Health Visitors at “District” Health Centres.

When tuberculosis or chest clinics and, possibly, venereal diseases clinics operate from Health Centres they will need health visitors who specialise in the hygienic management of these conditions in the home.  There are arguments for and against the specialisation of health visitors.  On the whole, however, it seems that our control of these conditions is still too precarious to permit the forfeit of the special skill built up in exchange for the theoretical advantage of having all health visitors interchangeable.

Mental Deficiency Workers at “District” Health Centres?

If the school medical service is to be integrated with the wider Health Service, then the social workers who supervise mental defectives might be regarded as medico-social workers. There are, doubtless, also arguments for their integration with the education service, and their first liaison with it would in any case be close. On the first view the limited incidence of deficiency would probably lead to their being located with the other more specialised workers at District Centres.

Almoners in General Hospitals

However, the distribution of medico-social workers at the level of the hospital and specialist services as such must be consid­ered as well as their distribution at the local level.  As the Health Service evolves, there may well be a reduction in the size of some or all hospital outpatient departments.  Whether this reduces the number of hospital almoners will partly depend on the extent to which special­isation continues or develops.   (I have already mentioned “children’s” almoners).  This is another of the points on which the committee will need expert advice.  Possibly the ensuring of adequate social work in all hospitals is a step which should take precedence over all other developments.  Visiting must almost certainly diminish as part of the work of the hospital almoner.  Local almoners familiar with small areas will be able in a large proportion of cases to report on home conditions far more efficiently.  To the extent that tuberculosis and venereal diseases are dealt with at the hospital level, hospitals will have to employ for a time at least specialist health visitors. Such clinics cannot yet delegate their visiting.

Teaching Functions of Almoners. Report of Inter-Departmental Committee on Medical Schools, 1944.

The Hospital like the local almoner will sometimes be asked to co-operate in the teaching of medical students, but the major respon­sibility in this matter will fall on the social work department of the regional teaching hospital as proposed in chaps. 11 & 13 of the Goodenough Report.  This in itself is a cogent reason for that develop­ment of the theory of social work which this committee has already foreseen as an essential part of its own task.

Almoners in Rehabilitation Centres, Convalescent Homes & Sanatoria.

The residential rehabilitation centre has developed on lines which reveal, on the whole, a grasp of the modern conception of almoners’ work.   It seems reasonable to suppose that the existence of good standards in this respect will influence in time the allied institutions, convalescent homes and sanatoria, especially as they are to be integrated with the hospital service.  But it will probably not occur without educational activity by social workers themselves.

Psychiatric Social Workers- in General & Mental Hospitals.

When all general hospitals are part of the Health Service, there will be no further excuse for running psychiatric outpatients’ departments and observation wards without social workers.  This consideration will apply with even greater force to mental hospitals. In rural areas, especially, work with adults will often be combined with child guidance as is sometimes done already with great advantage.

? P.S.Ws, in Rehabilitation Centres, Convalescent Homes & Sanatoria.

Psychiatric social workers have begun to extend their scope to rehabilitation centres and it is even conceivable that in an capacity they may later extent it further to convalescent homes and sanatoria.

The development of social work in specialised residential institutions, necessarily often placed at great distances from patients’ homes raises the question of home conditions and contact with relatives in a specially acute form.  Obtaining reports from distant colleagues sometimes serves to emphasise rather than solve the difficulty.  In this sort of situation, the unevenness of technical standards in social work and the weakness already noted of the basic training becomes most evident

It is the same fundamental weakness which, in an official, more closely integrated service, will unless remedied give rise to a further difficulty.  Questions of authority and status, regrettable as it may be, must become more acute.   In a general hospital with a large almoner’s department, what should be the relation of the psychiatric social worker to the chief almoner?  Owing to the inadequacy of the basic training the latter sometimes regards the technique of the former as an unnecessary piece of mystification, whereas it should, on the view already expressed be equipment much of which is common to both,

Administrative Functions

Hitherto the proposals of the Health Bill have been surveyed in so far as they bear upon the executive aspects of medico-social work. The full implications of the view expressed here also suggest that social work should play its part in the administration.

The attitude of the whole administration of a hospital towards the patient as a person is a matter in which the almoner has a special interest.  The general conduct of the children’s ward ought, for example, to be felt to be the legitimate concern of the P.S.W, on the child guidance staff, if on her visits she finds the children are often without toys or occupation.  But hospitals are not the only institutions in the Health Service which will be in need of humanising partly by the influence of social workers upon the general structure and day-to-day management.  New emphasis on rehabilitation ought to make sanatoria of all kinds and convalescent homes a much more real concern of social work. Health Centres in the early stages of their history will be utilised by various mutually suspicious officers and organisations who will suffer from a general lack of cohesion.  Social workers immediate concern with this state of affairs will be the confusion of and disservice to the patient.  In her administrative capacity she will need to strive consciously for the focussing of the services on the individual patient and not on separate vested interests.  One formal device which she could promote for this purpose would be the establishment in local Health Centres of patients’ committees.

Hitherto the distribution of social workers’ functions has been discussed on the basis of the professional experience of the social worker herself.  But this experience has its natural complement in one of the principles of general social administration also.  T. S. Simey in his “Principles of Social Administration” (1937) expressed it thus:-“The (social) services lose much, if not all, their effectiveness unless a high degree of coherence is maintained between them.  This is not a mere matter of social justice, of giving the citizen in Northumberland the same rights as his fellow in Cornwall,  It must be kept in mind that the only unifying factor in social administration is provided by the individual.  This is the focal point of the social service”.

It is, therefore, desirable on general grounds that the special approach of the social worker to questions of health and sickness be fully represented on bodies concerned in the administration of the Health Service.  That approach, on the view set out in the opening paragraphs of this paper is quite distinct from that of any type of medical auxiliary.  Unlike the auxiliaries, social workers are primarily concerned with the non-medical factors in health and disease. The administration of the Health Service requires at all levels the help of those whose professional activity is wholly with the individual as such and with his relation as an individual to society.

Social Workers in Regional and Central Offices of the Ministry,

It seems likely, though little has been said in public about this, that at the regional level the Ministry of Health will require a considerable organisation, including the advice of experts, to administer the hospital and specialist services,  These will be decentralised sections of a government department responsible jointly presumably to the Minister and the regional hospital board.  Although they will have much greater practical responsibility, it will be extraordinary if the Ministry is not influenced in this matter by its wartime regional experiments.  Those included the use of doctors, nurses and welfare officers at the regional offices.  In the administration of the Hospital Service itself it will be remarkable if similar officers are not appointed.  The committee should make it clear that it expects some of these to be medico- social workers.  During the war the regional pattern was reproduced in the Whitehall office and it should be so for the Health Service. Almoners are already engaged on specialised jobs in Whitehall,  But the Ministry of Health requires the advice of nurses on general matters and its need for that of medico-social workers is certainly no less.  The committee might also do what it can to insist on this principle and to see that such personnel as are appointed are, in fact, likely to give a really distinctive and deter­mined lead.  Few social workers know how astonishingly easy it is to be overawed or outmanoeuvred by the machinery of government.  This is still true despite all the experience of the last six years.

Most of the practical functions of the Board of Control are to be transferred to the Ministry  This is an additional reason for what is desirable in any case on general grounds, namely the appointment of psychiatric social workers both to the regional and central offices.

Statutory Local Health Committees

4th Schedule Part 11 Paras. 3 & 4,  Summary Para. 91.

Local authorities will have the right, as now, to co-opt useful members of the public on to their statutory health committees, which will now have the legal status hitherto enjoyed only by education committees. The S.M.A, might well urge the Party office to give a lead to local parties in extending the co-option of medico-social workers.  The aver­age party member is still completely ignorant about this new profession,

The summary of the Bill issued by the Minister suggests the use of ad hoc “co-ordinating committees”, doubtless as one remedy for the plan’s obvious lack of cohesion.  Social workers in the Health Service should group themselves or their representatives for the discus­sion of the problems affecting their aspects of the various disjointed sections both on the local and the regional level.  They will thus rapidly increase their capacity for contributing distinctively to the improvement of the plan.

I think that social workers must openly demand representation on hospital management committees and the house committees of teaching hospitals.  Doubtless the nursing staff will be represented. The change which is to come offers our profession a convenient occasion to abandon the inferiority feelings, which have hitherto limited the service we render the community.  This argument might be held to apply also to representation on regional hospital boards, and the boards of teaching hospitals, but there the S.M.A, believes the Minister will firmly refuse as hitherto, to allow direct representation of interests.

The Central Health Services Council is in a different position. There the Bill in its First Schedule specifies a long list of medical Auxiliaries who are to be represented. On this point the Bill requires emendation now and we should get the S.M.A. to have it moved at the report stage this month in the Commons and if necessary in the Lords. It is merely absurd for the Bill to specify for example that a midwife and a pharmacist should be members of this body and to omit all mention of social workers whom a government report has recommended should share in the education of medical students.

In any case the committee through the S.M.A. must see to it that a Standing Advisory Committee on social work is appointed of whom the co-opted members must all be professional.   The Bill already permits this.

Clause 16 (1) and(2)

Not only in teaching, but also in research for which the Service will probably make fuller provision, greatly increased opportun­ities lie before medico-social workers.  These, like most of the grow­ing points in the new scheme, make greater demands of social workers than their training at present equips them to meet,

Perhaps the greatest single weakness of the Bill as a whole is the failure to bring industrial medicine into the Health Service. Something can be done to enable coordinated effort by social workers by means of contacts, which they should regularise as much as possible, with industrial welfare workers.

Finally, a survey of the possibilities for social work in the new Health Service brings out more clearly than ever the inadequacy of the supply of social workers to the demand.  As far as I am aware, when the present wave of ex-service entrants assisted by temporary government grants is over, the annual intake of the profession will revert to nearly its pre-war level,   S.M.A. policy should be to urge adequate state aid for workers’ children who wish to enter this profession.  Their point of view is badly needed,