Effective Social Work with Older People

EXECUTIVE SUMMARY

Introduction

1 As part of the 21 ^st Century Review of Social Work, the Scottish Executive asked the Social Work Research Centre at the University of Stirling to review the evidence base for effective social work with older people. The objectives were

• to identify effective and desirable outcomes for older people, including outcomes desired and defined by older people themselves
• to identify the distinctive skills required by social workers in order to achieve desirable and effective outcomes
• to draw out and discuss the implications for future policy and practice in this field.

2 This paper looks at effective social work with older people with a range of needs and conditions and considers desirable outcomes in a variety of domains and settings.

3 The work involved a review of various key texts and recent research. In the short time available, it was not possible to conduct a systematic study nor a comprehensive literature review.

Effectiveness - defining quality outcomes for older people

4 There are various drawbacks to standard satisfaction surveys, including limited validity. They may be particularly unreliable in eliciting older people's views.

5 Many older people attach great importance to their relationships with social workers and care staff. However, older people may not always identify or distinguish the contribution of particular professionals; rather, they may form a view about the overall quality of services received.

6 Recent consultation exercises with service users and carers in Scotland have identified the importance to them of being treated as individuals, of exercising choice and control and of a 'capacity' model of assessment. A holistic approach to assessment and service delivery is appreciated, along with sensitivity, flexibility and respect for personal dignity.

7 Older people value services which can support them in all aspects of their lives, as required, not just with personal care and relationships. Low level preventative help, like housework and gardening, enhances quality of life and helps maintain independence. However, these tasks do not require qualified social workers.

8 Effective social work with older people should focus on the key social work tasks of assessment, care management and review for people with complex needs, as distinct from the provision of social services to the majority of older people who have relatively straightforward needs.

9 A five year research and development programme conducted at York University examined outcomes of social care for older people, disabled people and carers. It identified three types of desirable outcome - maintaining current quality of life, facilitating positive change and impacts of the service process. The second of these may be most pertinent to effective social work with older people. 'Change' outcomes to aim for include improvements to physical functioning, confidence, skills and morale.

10 An alternative approach to examining effectiveness lies in performance information, although this remains a contested area. The 21 ^st Century Review Group has set up a Performance Information Subgroup to address some of the difficulties involved.

The social and policy context for social work with older people

11 A substantial number of older people in Scotland live in poverty or face financial hardship. Where possible, effective social work with older people will involve income maximisation, combined with a sensitive approach to discussing financial matters.

12 The evidence shows that older people routinely face discrimination, for example, through stereotyping and denial of opportunities available to other adults. Anti-ageism is an essential part of effective social work, along with consideration of issues of gender, race, disability and sexual orientation.

13 Recent policy initiatives in Scotland emphasise the importance of joint working and a 'Joint Future', notably through the single shared assessment first developed for older people. The Scottish Executive has not issued a framework specific to working with older people, as it has for other service user groups, but integrated services and teams have developed nationally. Critics have warned that there is little theoretical basis for this approach and research had identified a number of underlying difficulties. The Interim Report of the 21 ^st Century Social Work Review notes that social workers in integrated teams have varied experiences of their effectiveness and that clarity of roles and responsibilities, coupled with good support, are essential.

Older people: their needs for social work

14 Old age is not in itself a problem, pathology or indication of need. Older people should not be seen as an homogeneous group with a single set of needs.

15 Significant demographic changes affecting projected numbers of older people must be taken into account when planning effective future deployment of social workers. The number of people of pensionable age in Scotland is set to rise significantly while the number of people in the age groups most likely to care for older people is decreasing.

16 People with learning disabilities are living considerably longer than before. Those with Downs Syndrome have an increased risk of developing dementia. Older people with learning disabilities should have access to the same health and social care facilities as anyone else. Former residents of long stay institutions may need particular support in old age, especially if a move to a care home becomes likely.

17 The incidence and impact of dementia, and the implications for effective social work practice, are much better understood today than they were just 10 years ago. People from Black and minority ethnic communities form a growing proportion of those affected. Social workers must be aware of cultural variation in perceptions of dementia. Mainstream, person centred services should be available to all.

18 There is little research evidence about the impact of mental health problems, other than dementia, on older people. Depression is the most prevalent condition, often linked to loss or poor physical health. However, depression often goes undiagnosed and untreated.

19 While alcohol consumption generally decreases with age, alcohol and substance misuse pose significant problems for some older people. Although often overlooked, substance misuse in older people responds to treatment at least as well as for younger age groups. Older people who develop alcohol related conditions such as Korsakoff's syndrome may require specialist facilities.

20 The majority of older people aged up to 85 do not report long term illness or impairment. However, certain conditions are associated with old age and can seriously affect people's ability to carry out daily living activities. Social workers may not be best placed to provide assessment and care management in every case but where major loss and change are involved, their particular skill mix will be most appropriate.

21 One in six carers is an older person, many of whom provide a very high level of weekly care. They may have to deal with disabling conditions of their own as well as the demands of supporting another person. Where breakdown or deterioration occurs, perhaps bringing relationship stress, grief and loss, social workers have much to offer in terms of assessment, care planning and counselling.

Roles, tasks and skills for effective social work with older people

22 Standard social work texts contain less information about working with older people than about some other service user groups. At the same time, there are arguments against categorising older people as a separate group, as if different from other adults.

23 Effective social work with older people draws on distinctive aspects of the social work role - sensitive communication, moving at the individual's pace, starting where the client is, supporting the person through crisis, challenging poor practice, engaging with the individual's biography and promoting strengths and resilience.

24 Few studies have evaluated the effectiveness of monitoring and review or the relative outcomes of different approaches to these tasks. There are indications that insufficient attention is sometimes paid to monitoring and review.

25 In 2002, nearly 35,000 older people were resident in Scottish care homes. Standards of care are variable: social workers have a vital role in ensuring that individuals' assessed needs are met when they move into a care home and, where appropriate, in advocating for better quality of care.

26 A review of care management in Scotland reinforced an important early premise of care management - that it be directed at people with complex, fluctuating or rapidly changing needs. This requires a range of skills, including those 'traditionally' associated with social work, particularly the ability to work with complexity and uncertainty.

27 Social workers engage with older people facing various types of risk, including those who are being abused and those who, because of dementia, are no longer aware of everyday dangers. Effective social work in these situations demands a finely tuned balance between promoting independence and self determination - core social work values - while simultaneously providing adequate and sensitive protection. Here, social work tasks include building trust and support, assessing risk and vulnerability, and providing information about and opportunities to discuss different options.

28 Social workers have a number of specific legislative duties relevant to working with older people. In fulfilling these duties, for example in the role of mental health officer or when conducting assessments prior to 'significant intervention' in relation to 'incapable' adults, social workers must, again, balance individual rights with the need to protect and promote the welfare of people in need. In addition, careful mediation between the competing wishes of the older person and family relatives, or between family relatives themselves, may be required.

29 Old age may be marked by experiences of loss, change and transition. Social workers need a good understanding of the significance and impact of life course transitions and the ability to see the older person in the context of his or her life history.

30 The social work contribution to palliative care includes supporting the older person and the family through loss and bereavement, taking a 'whole system' perspective, ameliorating the practical impact of change and attending to emotional and spiritual struggles. In some cases, educating and supporting the multi-disciplinary team will be an added dimension.

31 Social workers in hospitals and other health care settings are well placed to identify and respond to the needs of older people. Research has shown that deploying social workers in Accident and Emergency wards has benefited older patients. In healthcare settings, it has been found that multi disciplinary teams led by social workers are particularly effective in matching individual needs to services.

32 Few studies of group care have looked specifically at the social work contribution. However research about care homes has identified the importance to good quality care of various tasks in which social workers can be key players - good information provision, fair and clear contract terms and, where appropriate, supporting older people to use complaints procedures.

Conclusions and implications

33 Older people do not require social work support simply because of their age. They will have largely the same range of needs for social work as any other adults. They are most likely to seek social work help or develop needs arising from a combination of conditions and circumstances, often involving loss and change.

34 Social work with older people cannot be considered effective unless older people themselves are satisfied with it. Service users want to be listened to and respected as individuals. Many older people share traditional social work values, such as a concern for relationships, and appreciate social work skills. The social work process is important, as well as the outcome.

35 Social care with older people is more effective when its intended outcomes are identified at an early stage - during assessment - and built into care planning. Older people must be closely involved in the process, with outcomes based on their wishes and priorities as far as possible.

36 Older people like services which support them in various aspects of their lives, not just personal care and relationship needs. Low level preventive services are valued.

37 Effective social work with older people should focus on intensive care management with those who have complex, fluctuating and/or rapidly changing needs. Pressure to manage budgets and establish eligibility must not reduce social workers' capacity to engage with the older person and use the full repertoire of their skills in a holistic way.

38 Social workers bring a unique mix of skills and expertise to situations of complexity, uncertainty and conflict. These include a 'whole system' view, engaging with the older person's biography, supporting individuals and families through crises associated with loss or transition, helping to ameliorate the practical impact of change and challenging poor practice.

39 Social workers must work creatively with risk. They need finely tuned skills to achieve the 'right' balance between promoting self determination and independence for the older person while, at the same time, ensuring that vulnerable individuals have adequate protection.

40 There is much scope for a positive, proactive approach to social work with older people, for example through income maximisation, promoting individual strengths and capacity, and helping people rebuild confidence and networks following loss or change. Anti-ageism is an essential element, while issues of gender, race, class and ethnicity must be taken into account.

41 Recent moves towards joint working within a multi-disciplinary setting, and the introduction of single shared assessment, make it imperative for social workers to be clear and confident about their distinctive role.

42 The ongoing debate among service planners regarding the appropriate degree and nature of specialism for social workers with older people is little reflected in the literature. However research and practice experience leads us to conclude that social workers with older people require a strong foundation of core, generic social work skills and values, on which specialist knowledge and skills can build.