Mental health and social work

Mental Health Social Care

Submission to Mental Health Priority area consultation of the Labour Policy Forum on behalf of the Labour Social Work Group.

The Labour Social Work Group is a member-led group recognised by the Labour Party. We seek to contribute to improved wellbeing and life chances of some of the most vulnerable members of society, by strengthening the place of socialist principles within social work policy and practice and within the broader social care services. We work towards achieving these aims through collective action in local groups and through participation in national policy debates both within and outside the Labour Party.

The following submission accords with the views of Professor Corcoran in a submissions already on the policy review website:

Labour can change the future of the UK’s mental health by:

  • understanding mental distress as existing on a continuum of humanity,
  • recognising the sense of togetherness and collective action that emerges in practice from such a dimensional understanding
  • aiming to replace distress with wellbeing though a preventative approach that places mental health and wellbeing central in all policies

and

  • supporting a fully joined-up research, policy and practice mental health research strategy.

A Better Way Forward for Mental Health Rhiannon Corcoran, Professor of Psychology, University of Liverpool

Integrated health and social care services are essential to the prevention and relief of mental distress and diagnosed mental illness. The quote below from Professor Robin Miller of the Birmingham University Health Services Management Centre about the distance that has to be travelled if Labour is to arrive at better integrated, good quality, and cost effective health and social care services across the age groups is especially relevant to mental health services

‘We are still trying to understand what types of integration will make the greatest impact in different contexts and for which beneficiaries. ….We need greater precision as to exactly what type of integration is being proposed and between what services. At present there is often a dense conceptual and definitional fog accompanying integration. The term is being used nationally (and indeed locally) in relation to a diverse range of collaborative arrangements between a host of different organisations, services and professions in order to (hopefully) address a variety of complex issues.’

  • Mental health difficulties have neurological, medical, psychological, relational and social components, and both early help services and services when mental illness is diagnosed

and in its acute or chronic phase need professionals to collaborate to provide joined up services. This ‘team around the individual’ or more often ‘team around the family’ approach is essential, with the (profession and agency) team composition and team leadership varying at different times.

  • Going on from this, the Labour Social Work group members contributing to this submission were disappointed, not to say, disturbed, that there was no mention of the role of professional social workers in the consultation briefing: Health and Care: Mental Health: the way forward. ‘Our mental health system is struggling due to a lack of appropriate workforce and our current workforce is under increasing pressure. We are seeing high vacancy rates for psychiatry consultant posts and for mental health nurses’. Our concerns apply equally to specialist mental health social workers (who make up the majority of Approved Mental Health practitioners (AMHPs) and Best Interest Assessors (BIAs). But they also apply to the local authority child and family and adult social workers who provide support and a range of services to all members of the family when mental health problems start to arise, or for those with acute, chronic or episodic mental illness.
  • We are attaching a separate submission about the parlous state of social work generally, and concentrate here on social work perspectives and contributions to a well- functioning mental health service for people with mental health problems in the different age groups and their families. Please also refer to the more detailed submission on the role of specialist mental health social work by Dr Rob Murphy.
  • Labour needs to arrive at an overall approach to people who need a mental health service, but then consider how this can best be implemented (in governance and direct practice terms) with respect to
    • older people,
    • adults of working age,
    • adults with parenting responsibilities (including kinship carers)
    • young people transitioning to adulthood,
    • children and young people living with parents,
    • children and young people in care and care leavers
  • When considering how to best integrate services for each of these groups it has to conceptually ‘unpick’ Health, Care, Social Care and Social Work before arriving at appropriate models of governance and delivery systems for integrated services.
  • It also needs to consider services for those with a diagnosed acute or chronic mental illness and those with complex environmental, practical as well as health and relationship difficulties that either have led to or are likely to lead to mental health problems.
  • The policies of the coalition, accelerated by the Tories on their own, have considerably increased the stressors on individuals and families: cuts and delivery changes for social security payments, including the cuts in the availability of the social fund and shift to a (non-ring-fenced) local government emergency fund; ‘sanctioning’ of those in need of social security payments; unsatisfactory and often heartless disability assessments; need

for food banks; lack of social housing, higher rents, increases in housing instability, short tenures, exploitative landlords, homelessness etc etc.

  • The social work profession, with its emphasis on the social and relational contributors to mental distress, is key to working in partnership with vulnerable people of all ages to help them put together the combination of medical, psychological therapies, health care, social and other public services (including housing, and social security payments) that best responds to individual and family needs and wishes.
  • The Tory government is spending scare resources on a plethora of un-evidenced structures, supposedly to improve service integration, resulting in disruption and uncertainty to professionals and those who need their help. At the same time, it is making an assault on all the professions who may be part of teams around people with mental health difficulties. Its attack on the conditions of service of junior doctors led to effective opposition (though only partial success) in ensuring that patient safety and quality service are addressed. It has already removed bursaries for nurse training and intends to do so for most social work students. By means of its Children and Social Work Bill it plans for the Secretary of State to take direct control of the social worker Regulatory body (removing it from the independent HCPC). This includes taking control over the qualifying and post qualifying training opportunities and funding, and the detailed curriculum of mental health social workers and also of the AMHPs and BIAs.
  • These points have been made more fully in our separate submission but it is important to mention here the high costs and limited impact of the fast track Think Ahead programme that allows ‘high achieving’ graduates to register as generalist social workers specialising in mental health work after only 13 months academic and ‘on the job’ training. This is based on the Frontline fast track programme for child protection social workers. Both of these are strongly opposed by the majority of social workers, researchers and educators. This is firstly because the ‘on the job’ training itself is too limited to prepare for a career in such a demanding and high risk area of work (and the time for acquiring the necessary knowledge base is especially lacking); but also because of opportunity costs. Its availability is geographically limited, there is a lack of diversity in the trainees it recruits, and the unnecessarily generous government funding on this ‘high prestige’ initiative results in only one qualified social worker rather than the 3 who could be trained by the same amount of government funding spent on other Masters social work programmes. Some as yet unanswered questions posed by a Labour Party member contributing to this submission are: On what basis were those social workers currently employed in mental health deemed to be ‘low-calibre’, thereby requiring the recruitment of ‘high-calibre’ graduates? What skills and knowledge do these students have which make them potentially better social workers than those currently practising?

Some issues relevant to the different age and needs groups

  • It is anticipated that the policy forum will identify other priority areas that will allow us to contribute in more detail. We comment here on some more immediate Tory policies that are negatively impacting on mental wellbeing.

  • Services to older people including those who suffer from dementia are receiving most attention from government-backed new arrangements to integrate health and social care service. Labour councillors are involved in these arrangements from which older people who have high levels of medical, psychological, social, legal and direct care needs have much to gain, provided that they are adequately resourced. It will be important to ensure that a social care approach and social work services are included when these integrated services are planned and delivered, both for the older people themselves and also for the family and friends whose ability to play a continuing part in their lives is essential to the cared for and the carers (many themselves older people with health problems).
  • Working age adults who have learning difficulties, are on the autistic spectrum, suffer from diagnosed or undiagnosed mental illness or addictions have been hardest hit by the benefits and housing policies of this government. Included amongst them are some especially vulnerable adults who were in local authority care following ill treatment or sexual exploitation. The disappearance in most areas of tier 1 and tier 2 early help and recuperative community mental health services is greatly to be regretted. The move towards a ‘recovery’ service policy too readily categorises adults living alone and without people to get alongside them as ‘not willing to cooperate’ with treatment and care plans, and refuses or prematurely ends services.

Services to families living in stressful circumstances where there are mental health issues or diagnosed mental illness

  • It is not possible to separate out mental health services for parents and children from the broader range of local authority led child and family ‘tier three’ services. Local authorities have a duty to assess and provide services for children ‘in need of additional services’ and to co-ordinate child and vulnerable adult protection services. Other public sector services (including health services) have a duty to collaborate with them. In integrating mental health and social work services for children and adults with parental responsibilities, the lead accountability should continue to lie with local authorities (including their Adult Social Services and Children’s Social Care Departments, Health and Wellbeing Boards and Public Health departments).
  • The Labour Policy Review should consider whether it is time to follow the lead of those local authorities that have brought back together their adults’ and children’s social services under one department. This may be a desirable move since, with local management of all schools and accademisation of many, the Local Authority Children’s Services Departments’ major responsibilities are for children’s social care services. Perhaps more importantly, for many children in need or in need of protection, especially when there are concerns about emotional or physical neglect, the physical and mental health issues of parents are major contributors to family stress and the need for a whole family approach,
  • For parents who are referred for a specialist mental health assessment or therapy, their mental distress will almost certainly be impacting negatively on their children. The fact of being parents should therefore be taken into account when deciding on prioritisation

for assessment and treatment. The high thresholds even for a mental health assessment and almost total disappearance of tier 2 mental health services in most areas means that more parents get to crisis point before they have a psychiatric assessment. This can result in total family breakdown with children needing to come unnecessarily into care, or mental health problems for those of their children who have taken on a caring role.

  • The policy revue should give particular consideration to the small but extremely vulnerable group of parents with addictions whose children may be or currently are the subject of care proceedings. Labour should support the extension of the Family Drug and Alcohol Court system (FDAC) to more geographical areas. Whilst adoption is necessary for some, it is our view that it is being used too widely when better co- ordinated addictions, general mental health and social work services could result in more children being brought up safely by parents or relatives. Parents who have lost their children to adoption or long term care are particularly in need of continuing services but often find the specialist mental health services end once their child has been adopted. Labour should support the availability of co-ordinated mental health, addictions and social work services to help avoid repeat admissions to care of children born to mothers and fathers who have lost children to adoption.
  • A further point for the Policy Forum to take on board is that ‘officially recognised neglect and emotional abuse occurs in the context of poverty and investigative responses place blame on parents without reference to the role poverty plays in creating the conditions that reduce the ability to parent well (Paul Bywaters and colleagues, 2014). These poor material conditions contribute to stresses and relationship tensions, between parents which contribute to mental distress. For parents with a mental health problem and for parents and children seeking to recover from early trauma, these stressor can trigger serious mental health problem.
  • At present, difficulties experienced by families and within families tend to be described primarily in individual behavioural (choices) and increasingly biological terms. This leads to a range of responses by the state, from (franchised) programmes to fix people to removal of children.
  • We argue that, whether at the early stages of problem development, or when an acute mental illness episode requires psychiatric intervention, or a child needs to be admitted to care, a multi-agency team around the family approach is essential. Sometimes this service will be provided by a health or social work-led integrated multi-agency team (a CAMH or a Family Centre for example) (see our response to the Policy Forum’s Early Years priority area). Most often the appropriate response will be for a network of professionals and family members to be formed around a particular child or whole family.
  • In most areas, long waiting times after referral for a CAMH service mean that specialist mental health professionals often do not join these teams until problems have become acute, or do not bring their expertise to bear in very complex situations affecting the mental health of children and parents because of un-evidenced ‘rules’ about the sorts of referrals they can accept.
  • In some areas CAMHS services will not prioritise adolescents who have clear indicators of mental distress like self-harm or having suicidal thoughts if they believe that the

contributory factor in this is a behavioural issue rather than an underlying mental health problem.

  • Sexual abuse in children and adolescents and sexual exploitation will most often contribute to mental distress. Many CAMHS will not accept these cases and the young person’s behaviours can progress to serious mental health problems due to lack of provision at an earlier stage. The investment is going into detecting and addressing CSE but not addressing the impact it has on the victim’s mental health.
  • We hope that the Policy Forum will shortly identify as priority areas the special issues around child abuse and neglect, children in care and care leavers, adolescents with serious difficulties including episodes of acute mental distress, sexual exploitation, trauma-related problems. We would want to contribute to these and can provide additional evidence from research and practice on the points we have raised in this submission.