Tuesday 9 November 2010


Another rant, I'm afraid.

First a confession. I have a fondness for Social Workers. They're oft times maligned and criticised for doing too much (bundling elderly folk into care homes, ripping families apart) or too little (neglecting elderly folk in houses going to wrack and ruin, leaving kids in chaotic households) and it's rarely recognised that their job is mostly about making difficult judgements. In our corner a lot of routine work is done by Assessment Officers, the Social Workers do the harder stuff where qualified staff forming professional opinions are necessary.

The Social Worker in our team is brilliant. Utterly, utterly brilliant. I'd truthfully rather do without my junior doctor than do without my Social Worker, since what she does and how she does it makes such a massive difference to how care's delivered. Social Worker not an Assessment Officer 'cause she makes her own mind up about things and forms her own opinion, so half the time is telling me what to do/what needs to be done.

The Social Workers in area teams have a lot of work to do. An awful lot of work. The organisation and support is nothing like that which we enjoy within our Trust. They're not in the same office as nurses and a Consultant and team leader, they're very much out on a limb. When they're chided for acting and chided for not acting, shaky confidence and a desire to check out a plan of action is understandable. Some of them are good. Some of them, frankly, are not. But the world they work in is not easy.

I've had 3 referrals recently from local authority Social Workers for cases which they said were complicated.

They weren't.

On face value, with the problem in front of us, it was all very simple indeed.

It's easy to make things more complicated than they need to be. It's easy to present something as complicated when it's not. Simple things, when understanding the details behind simplicity, can become hellishly complicated. But what we're faced with, what's right in front of us, need not be complicated.

Hot stuff. It's simple. When my youngest child was a toddler she accidentally learnt from a hot radiator what hot meant. Something being hot is a simple concept. A one year old grasped it, appreciating what "Hot!" shouted to her as she advanced towards something then meant. A demented lady can ask for a nice hot cup of tea and we know what she means by that, without it being tepid or scalding her. Stuff that's hot is, therefore, on face value, simple. Behind it it's complicated. What is heat? I guess you'd start waffling about the total kinetic energy of a system, generation of heat then transfer varying on the specific heat capacity of the different objects, conductance/convection/radiation and so on. The sun's hot, that's evident and simple. Why the sun's hot is not simple.

Social Workers took what was in front of them and simple, started drawing in the whys and what ifs and made it much more complicated than it was. In each case a vulnerable adult could not stay alone at home. The risks were clear. The risks were sustained. The risks could not be mitigated. In all 3 cases the risks had been realised so weren't just potential/hypothetical risks. The risks generated adverse outcomes for the 3 people. The 3 adults all were incapacitated adults without donnee, deputy or advance decisions (as, invariably, is always the case, still).

I was perplexed.

Why were these cases being brought to my door? No mental health diagnosis or treatment or intervention would effect meaningful change. The Social Worker had done the work and was telling me the person couldn't manage at home, it was a complex case, could I sort stuff out. There was nothing to sort out. The 3 people needed emergency respite care, managing their needs within a care home and discussion with the patient, family, GP and carers to determine placement long term within the MCA 2005 Best Interests framework.

We have this conversation often, they knew it's what I'd say. They know dementia, they knew I have no pill that could magic up a different outcome. They didn't want a Mental Health Act 1983 assessment. They didn't want a different diagnostic formulation. They didn't want an FP10 for some wondrous treatment. They didn't want ongoing input or care from me/from mental health services.

They just needed support that the decision they were making to move someone from their home, after decades of lived experiences there, of that being part of their life and their life being within that house, that what they were doing was okay, was alright, was the decent thing to do for the person who had no voice.

Although they justify Consultant Psychiatrist input through saying it's complicated, sadly it isn't. It's very simple. It's just also very very hard to do, alone.

1 comment:

Cat said...

Thanks for this. I am grateful I worked in the local authority team before moving into my current position as I know how fast-paced and stressful that work can be and I think there has been a lot of misunderstanding of different professional roles between our CMHT and the local teams - it sounds a little less fraught in your patch - but I have been in that decision-making role a few times and I think we (social workers) are perhaps less used to it that we should be but sometimes it can feel remarkably lonely when you don't have a CMHT to fall back on (where I've found we discuss and take joint decisions much more frequently).
Partly it is because the professional structures can be quite risk averse and if you go with the arguably more ethical judgement of allowing a degree of risk, it isn't always as certain as it should be that your own management will 'back you up' when 'things go wrong'.
That's why it's good to have a letter signed by a consultant..
And there is barely a day when I am not grateful that I made the move into the team that I'm in now.