Category Archives: Uncategorized

The ambiguity of ‘evidence based practice’

It has also become apparent how the contested nature of ‘subjectivity’ in EBP serves those in power well. By excluding the ‘subjective’ voice of those in society who are marginalised, their stories, their experiences and their knowledge is discarded, branded as unscientific, not rigorous, not valid …… whose interests does this serve?

Di Galpin

It has also become apparent how the contested nature of ‘subjectivity’ in EBP serves those in power well. By excluding the ‘subjective’ voice of those in society who are marginalised, their stories, their experiences and their knowledge is discarded, branded as unscientific, not rigorous, not valid …… whose interests does this serve?

Uncertainty is an inevitable aspect of social work practice, yet, the creation of certainty is a fundamental tendency of the human mind, and it is not just our perceptual system which automatically seeks to transform uncertainty into certainty. Government and wider society demand a high level of certainty from social workers, especially following high profile tragedies, and subsequent reports identifying ‘failings’ in practice. As a response to such ‘failings’ the concept of ‘evidence based practice’ (EBP) has proliferated in social work.

EBP is presented as a model of critical appraisal, designed to inform practice, where the practitioner has…

View original post 1,492 more words

The ambiguity of ‘evidence based practice’

It has also become apparent how the contested nature of ‘subjectivity’ in EBP serves those in power well. By excluding the ‘subjective’ voice of those in society who are marginalised, their stories, their experiences and their knowledge is discarded, branded as unscientific, not rigorous, not valid …… whose interests does this serve?

Uncertainty is an inevitable aspect of social work practice, yet, the creation of certainty is a fundamental tendency of the human mind, and it is not just our perceptual system which automatically seeks to transform uncertainty into certainty. Government and wider society demand a high level of certainty from social workers, especially following high profile tragedies, and subsequent reports identifying ‘failings’ in practice. As a response to such ‘failings’ the concept of ‘evidence based practice’ (EBP) has proliferated in social work.

EBP is presented as a model of critical appraisal, designed to inform practice, where the practitioner has a relatively autonomous role in searching for, and critically analysing, research evidence to inform their decision making. The latest guidance on the refreshed PCF articulates this commitment once again, and adds an additional expectation that social workers also generate ‘evidence’ to inform practice.

‘More reference throughout to importance of evidence and evidence-informed practice and the inclusion of more reference to ‘evaluation’ alongside ‘research as key source of evidence and engagement of practitioners in evidence/knowledge generation.‘ (BASW,2018)

Whilst practitioners and educators strive to adhere to this principle it could be argued as a ‘professional capability’ this ignores the complexity associated with notions of EBP at both a practical and philosophical level.

Is EBP at odds with real work social work?

Practitioners across allied professional groups are constantly called upon to manage uncertainty, ambiguity and complexity where there often seems to be a plurality of ways to understand what is happening in practice contexts.

From a philosophical perspective EBP appears to operate on modernist foundations.  For example seeking to adhere to methodological and analytic standards of rigour, which demonstrate the reliability of a scientific approach, because this will provide clarity in establishing the ‘right’ evidence is combined to create systematic and cohesive frameworks of knowledge. The belief that by adopting this approach one can achieve a level of certainty is alluring, yet, arguably, unrealistic in social work practice, and indeed may lead practitioners into a false sense of security when making decisions based on EBP.

Postmodernist frameworks are of benefit here to thinking about the multiple discourses at play in social work practices, and understandings the dynamics between them – particularly concerning power. This includes shifting from singular forms of objective understanding, to consider the diversity of subjective knowledges at play in practice contexts. This requires practitioner and academics to appreciate how objective knowledge is a contested concept which can lead to a fruitless search in complex situations for certainties that may not exist.

Peshkin (1988) provides an interesting perspective which extends, and troubles, the notion of objectivity by suggesting the ‘taboo’ of subjectivity stems from a misunderstanding of its potential role in EBP. It is our own subjective involvement in practice—not the precise replication of the event—which can provide strong theoretical insight. However, we are somewhat conditioned as practitioners and academics to see subjectivity as a ‘contaminant’. Yet, that contaminant is always present, one can never get away from one self. As Alan Peshkin eloquently reminds us

“Whatever the substance of one’s persuasions at a given point, one’s subjectivity is like a garment that cannot be removed. It is insistently present in both the research and non-research aspects of our life. … our subjectivity lies inert, unexamined when it counts ….. ” (Peshkin 1988, p.17)

The key point here is that subjectivity cannot be removed. It shapes and mediates our thinking and action in a whole range of ways. Therefore, it needs to be valued understood and utilised . Instead of trying to remove the garment and declare ourselves clean of subjectivity, it is important to acknowledge it, and draw upon it in deep analysis to inform decision making.

(for an alternative critique of post modernism in social work click here)

The practical application of EBP

Research from Scandinavia suggests whilst practitioners support the notion of EBP it is rarely applied in a way that is conducive to improved decision making. Their findings highlighted a number of fundamental flaws, which may be relevant to practice in the UK. Firstly, the research found professional autonomy is not a given , suggesting the greatest barrier to practitioners engaging in EBP is the organisational context.

The research identified five significant organisational issues which impeded practitioners from adopting a more focused EBP approach to inform practice;

  1. No access to databases where they can search for, and evaluate research
  2. Time constraints
  3. ‘Organisational logic’ (predictability) prioritised over a ‘logic of care’ (unpredictability)
  4. A focus on following organisational guidelines which aligns EBP with organisational logic to guide decision making
  5. Financial considerations taking priority over research findings to inform practice

The research concludes whilst social workers were not content with the current conception of  EBP they felt incapable of challenging it. The issues highlighted in this research provide little that is new, previous research seems to support these recent findings and arguably leaves practitioners in an untenable position, from both a philosophical and a ‘professional capability’ perspective.

Creating an alternative approach in my practice

Just as practitioners may find themselves out of kilter with EBP, I too have experienced the oppressive effects of  the polarity that exists in understanding EBP when combined with organisational logic in a Higher Education setting.

As a lecturer I am more used to drawing on the objective research knowledge of ‘expert’ academic others to inform my practice, where objectivity and evidence based practice is privileged as an expression of professionalism. However, the eloquent exploration  by Staller (2007) of the interaction between a social worker and sexually abused child resonates with my experience of the polarity which exists in presenting objectivity as synominous with professionalism as she writes

He speaks about his responsibility to retrieve objective stories from sexually abused children, knowing He holds their heart in His hands‘ (p.766). Going onto to suggest ‘His need to get an “objective” story is because the alternative is subjective or fictitious’ (Staller,2007;p.776).

Staller’s experience of encountering this exchange provided a ‘trigger’ moment. Her experience has become the ‘data’ which she will explore from every angle possible to locate that moment within the social, cultural and political realms. This process then has the potential to extract new learning from her experience, to create and share knowledge which will enhance practice.

Reading Stallers work provided a ‘trigger’ moment for me, where I filtered its meaning using the theoretical lenses of modernism and post modernism,   to try and be aware of, and make sense of, how I decide what ‘counts’ as knowledge and how I create and transform data into knowledge, and then ‘evidence’ to support my professional self.  I also had to locate my thoughts in the wider context of the organisation I work in, and the current  structural frameworks which directly influence current practice within higher education (i.e. the use of metrics to ‘rate’ the quality me and my institution, and so inform prospective students how ‘good’ I am, we are – I will leave this for another blog!)

It has also become apparent how the contested nature of ‘subjectivity’ in EBP serves those in power well. By excluding the ‘subjective’ voice of those in society who are marginalised, their stories, their experiences and their knowledge is discarded, branded as unscientific, not rigorous, not valid …… whose interests does this serve? 

(WARNING – Shameless plug here: From this, and subsequent experiences,  my colleagues Annastasia Maksymluk  , who has used auto-ethnography in curriculum development & Andy Whiteford , who focuses on sustainability, and I have collaborated to create a ‘no smoke and mirrors’ research and writing partnership, from which we developed  an open access on-line peer reviewed journal the Journal of auto-ethnography for health and social care). We encourage submissions to the journal from anyone who wants to be part of producing evidence to inform practice;  students, professionals, service users, patients – all are welcome!


Regardless of whatever EBP might, or might not be, it appears practitioners are currently expected to work within a model of EBP which might be more accurately conceptualised as OBP, Operational Based Practice , where professional decision making is centred in processes designed to meeting organisational demands. This is problematic because

“ …it is argued that whatever group controls the way things are seen in some ways also has the power to control the ways things are. Whoever’s interpretation gets accepted will doubtless control how the idea is enacted.” Fook (2002:37).

From this perspective the production, and application, of ‘evidence’ is the product of deliberate, conscious human design, which is amenable to a whole host of organisational, ethical and political requirements. Evidence is not value-free and we need to ask what values and processes currently underpin the discourse that surrounds and shapes EBP in education, research and practice and whether these align to the professions values and ethics?

From a logic perspective EBP provides a neat linear model of deliberated decision making. However, real world social work is rarely a logical, or a linear activity, dealing as it does with often complex and chaotic human lives. Lives where meaning is constructed by a variety of individuals, and subjected to a plethora of structural and organisational filters that heavily influence the practice of decision makers and the lives of those they work with.

Whilst the notion of EBP has provided the profession, regulators, educators and government, with a seemingly straightforward response to improving decision making in complex cases, the structural realities of practice continue to be ignored, as do the structural inequalities that exist in many of the lives practitioners work with.

Jacob Rees Mogg analysis of problems in ‘care’ provision does not acknowledge his parties role in transforming a profession rooted  in compassion into a commodity traded in the ‘care industry’

Jacob Rees Mogg analysis of ‘care’  does not acknowledge his parties role in transforming a profession rooted  in compassion into a commodity traded in the  ‘care industry’.  Arguably, care is now perceived by government as nothing more than a product, a commodity to be bought, sold and profited from,  much like baked beans and ipads, only less regulated!

Could the vision of care as a ‘product’ be part of the reason we keep going around in circles on this issue?

The industrialisation of care as a commodity to be bought and sold, and profited from, fully emerged under Margaret Thatcher and the community care reforms of the 1980’s and 1990’s. Such an approach is now so firmly embedded within the health and social care sector it is difficult for anyone to conceptualize care as anything other than a product where “value” is equated to cost rather than any sense of ethical practice or notions of compassion for one another.

Maybe it is time for a different approach.

Can we shift the emphasis on a ‘care industry’ to providing compassionate care?

Firstly, we do not know whether we have somehow ‘lost’ our compassion for others, or whether it has ever really existed. However, we do know that over the past few years ‘compassionate care’ is not something we can assume exists in the ‘care industry’. Whether the provider of care is from the public or private sector, we cannot take for granted that care will be provided with compassion, nor that individuals will be treated with dignity and respect.

So how do we ensure ‘compassion’ becomes the ‘norm’ in the provision of care, regardless of the setting and who is providing it?

Firstly, a change in approach from leaders across the sector, a change from a transactional style of leadership to one that is transformational. Transactional leadership is based on bureaucratic authority with an emphasis on task orientated goals. An organisation characterised by a transactional leadership fosters a management structure which leads to the development of a ‘defensive culture’ where members are expected to conform and follow rules without challenge.

However, transformational leadership is a process that motivates followers by appealing to higher ideals and moral values. Transformational leaders must be able to define and articulate a vision for their organisations, and the followers must accept the credibility of the leader. Organisations characterised by transformational leadership are more likely to have a ‘constructive culture’ where members experience constructive cultural norms, for example, organisations set challenging but realistic goals and manage in a participative manner where relationships are constructive and open so as to achieve agreed goals. This is not to suggest transactional management is not also required in some measure, however, the transactional approach seems to have carried greater emphasis across health and social care. This has been my experience working in the public sector.

An ethos of an organisation comes from the top, an ethic of care informing leadership and management practice would make a huge difference. You just have to think about the ethos of where you work to think about how it affects you in your day to day work. It’s no different on a hospital ward, a private care home or in a care agency.

My feeling is the care sector requires inspirational leadership. Arguably the “care industry” is over managed and under led at present. There is a difference between leadership and management, although, both are required, but leaders are central to how their managers perform. When I think of a ‘good’ leader I think of people like Gandhi or Lincoln, people who are humane, humble, who inspire you to engage, to strive to achieve change for the greater good. They have a grand vision, and not a vision solely focused on targets and value for money, but higher values, such as compassion, dignity and respect is their motivation. The type of values that are the foundation stones of a humane care system.

Another key factor, I feel, involves ensuring the right people are in the workforce – we have to ask are we recruiting the right people into the care sector, whether as carers, leaders or managers? Clearly there are many good carers/leaders/managers out there, but we need a lot more, however, this has to be based on suitability not availability. On the ‘frontline’ care providers, whether public or private, have had real difficulty in attracting people into the workforce. This is not surprising when you consider how government and wider society not only undervalue such jobs, but also those being cared for, with the vulnerable being marginalised in society for being, well, vulnerable and in need of care!

Caring for people is a demanding, and rewarding job, but, carries little status and is seen as something ‘anyone’ can do. Believe me it is not. From my professional experience I’d say the best front line carers are those who have a deeply ingrained respect for others, and who genuinely like people. This is not something that can be taught, but they are the characteristics required to develop a professional, and caring, workforce. Recruitment of the right people, along with high quality support and training and decent pay and working conditions are central to turning the system around. However, already I hear the voices out there ‘how do we afford this’? Arguably we have to afford it if we really want change.

Where our vision of care does not extend beyond a discourse of free markets and cost, a strong philosophical, moral, and ethical framework maybe required to guide the provision of care. For care to become more than a commodity reform is required at a structural and individual level, founded on a new discourse that emphasises dignity over price, compassion over cost.

We are at a moment in history where society is questioning our whole economic system. Whilst it has brought much in terms of material resources for some, the cost at a moral, ethical and philosophical level in the “care industry” leaves a lot to be desired, maybe it is time to say care is too valuable to be classed as a commodity.

Social workers tell us how it really is, lets go beyond the rhetoric of resilience to establish the reality in practice today ….

‘Resilience’ in social work practice

Research in relation to resilience and social work practice, consistently refers to the idea of an innate strength or capacity available to humans enabling recovery from trauma and stress and the development of an approach to practice that seeks to identify and strengthen individual ‘coping strategies’. These interconnections have become acknowledged as a central organising feature and a ‘resilience framework’ has emerged over the past decade, aimed at guiding social workers in applying resilience in their practice with those who require services, whilst demonstrating resilience themselves to manage the day to day complexities of practice.

‘Mind the gap’- research into resilience

Whilst quantitative research findings present resilience as a viable, and relevant framework, for working with users of services, there is limited research into social workers’ experiences of the place and meaning of resilience in their day to day world of practice.

The development of  resilience has come to be seen as a method of enabling social workers to cope with the everyday stresses of their work.

However, is this possible and has this been effective?

The focus in this context appears to be on the individualising of resilience, locating responsibility for resilience with the individual, at the exclusion of exploring wider structural factors which may impact on ‘resilience’ in practice.

We believe social workers’ experience of resilience, as both a tool for practice and a professional requisite, is vital in understanding the place and meaning of resilience in professional practice today.

This research aims to listen to your experiences and build on this to develop an informed approach to understanding the place and meaning of resilience in contemporary social work practice.

What next?

If you are registered social worker with the HCPC , or with an alternative professional body if you are not a UK national or live and/or work outside of the UK, we would like to hear from you. There is a short online questionnaire you can complete, which asks about your role and your understanding of  ‘resilience’ and experience of its application in your professional role.

All responses to this initial survey are anonymous.

If you would like to be involved click here

The research team look forward to hearing from you; Di Galpin, Annastasia Maksymluk & Andy Whiteford.

Why it is hard to deliver compassionate care in a compassionless system….

Michael Sandel argues the free market is not just a mere mechanism designed to deliver goods, it also embodies certain values, and the problem is these values ‘crowd’ out non market values which are really worth caring about and preserving, such as compassion’.

Increasingly ‘neo-liberalism’ is up for debate. Whilst well known to economists, politicians, Guardian readers and academics (like me!) it is rarely thought about in wider society. Yet its impact on our society over the last 40 years is immense, many would say for the good, others are not so sure.

For example a report published by Lancaster University  entitled ‘A Trade in People’ clearly expresses the failure of  a neoliberal care system. The report states

‘it is clear to us that the way in which the healthcare economy has been encouraged to develop by recent governments turns people into commodities and liabilities. For local authorities and CCGs they are liabilities that they have often sought to export to other areas and for independent hospitals they are a commodity and source of millions of pounds of income and profit.’

Whilst this report is referring to learning disability services from my experience I think it could also easily apply to a  broad range individuals who require care;  older people, those with mental health difficulties, substance misuse, physical and cognitive disabilities, child care, indeed just about any care need you can think of has been turned into a commodity to be traded and profited from.

This is why I think it is important to be aware of the influence neoliberalism has in shaping our daily lives because it has provided successive governments with a framework to deliver its ideas, ideals, values and beliefs about the world and provides a guide on how life should be lived, how society should be structured and our role in society , along with that of government and the free market. Most controversially for me has been its wholesale export into the realm of health and social care, where ‘care’ has become a commodity to be profited from.

In short it determines the nature and limits of that state, what matters and whom.

There are a number of strands to neoliberalism. In recent years, from a political perspective, successive  governments have used this ideology as a vehicle  firstly, to stigmatising those who require support, just look at the reforms to welfare,  and then to disinvest in the public sector that provides their support, instead promoting open unregulated markets and the transfer public services into the free market.

This has resulted not only in the deregulation and privatisation of publicly owned assets, such as housing, but also the transfer of responsibility for those requiring public services away from government, so when there is a failure in the system, i.e. Grenfell Tower; Winterbourne View; Mid-Staffs, holding someone to account is almost impossible due to a diffused chain of responsibility government has put between it, and the individual, by creating a host of intermediary layers of officials and organisations , such as management companies, contractors and sub-contractors.

A key tenet of neoliberalism is the role of free market in delivering everything from baked beans to iPhones’ and cancer care. The free market is highly valued in neoliberal ideology because it is viewed as a more efficient system in providing goods and services, and promotes individual liberty by empowering society through consumer choice.

Whilst neoliberal ideology has indeed empowered us to upgrade our iPhone at will and purchase cheap clothing and chemically enhanced food, what has this meant for those most vulnerable in society who might require quality  care rather than consumerism?

Whilst an economic and political system premised on the commodification of people and neoliberal theory maybe a reliable form of wealth generation for some, it is also associated with little compassion for those who require support, as well as structural inequality and poverty for many.

Nobel prize winning economist Joseph Stiglitz is clear, we are now engaged in a battle which is ideological, describing free market neo-liberalism as  a stifling economic ideology which has run it course.

Neoliberalism has an insidious presence in our lives, much like the air that we breathe, everywhere, yet unseen. George Monbiot  provides a compelling argument against this ideology, which values the free market as the place in which citizens can exercise their democratic choices through consumer choice and the private provision of goods and services.    Supporters of neoliberalism maintain  “the market” delivers benefits that could never be achieved by government, and that the more unregulated the market, the better the efficiency. Within this framework everything we do, and every person is a potential commodity that can bought, sold and traded for profit.

However, for me,  the free market  is associated with a loss of compassion, dignity and respect for one another as an inactive state projects structural failure onto the individual, along with an outdated mantra of ‘private sector good, public sector bad’.

One need not dig too deep to see the flaws within the current system. The research by Lancaster University adds to a plethora of  reports, all stating the same thing. This system is broken!

Just consider  housing and the care of older people to establish the limits of the free market.

Shelter’s report on the barriers low-income households face in private renting exposes the private housing  market’s limitations,  clearly arguing significant government intervention is needed if it is to play an expanded role in preventing homelessness and housing people on low incomes.

The same issues arises in the care of older people, where significant market failure is a continuing problem.

Over two years ago the King’s Fund  highlighted what many in the sector already know, the free market is failing stating

‘Social Care is now a complex and sprawling sector – more than 12,000 independent organisations, ranging from big corporate chains to small family-run businesses, charities and social enterprises, which makes the NHS provider landscape look like a sea of organisational tranquillity. Less than 10 per cent of social care is actually provided by councils or the NHS – their retreat from long term care provision is virtually complete. But unlike the NHS, when a social care provider hits the financial rocks, bankruptcy not bail-out is the more likely scenario.  But a deeper problem is the failure to think through the consequences of shifting the bulk of our care provision to a private business model’.

This is supported by  Andrew Dilnot , former drector of the Institute of Fiscal Studies, who suggests social care is is a classic example of a market failure where the private sector cannot do what’s needed.

However, the effect of the failure of the free market and neoliberal ideology extends beyond money,   the real effect of failing markets rests upon the poorest and most marginalised in society, like the  residents of Grenfell Tower and those with social care needs in private institutions, the frail and vulnerable who require support.

The problem in government today is that many of those who govern this country are woefully out of touch and too quick to blame individuals for their descent into a commodified system of care, and those who provide care, rather than look at their own role in creating a a system of care that has no space for compassion, whilst those on the frontline still fight to demonstrate, and deliver, care with compassion, dignity and respect in an increasingly brutal system .

Michael Sandel argues the free market is not just a mere mechanism designed to deliver goods, it also embodies certain values, and the problem is these values ‘crowd’ out non market values which are really worth caring about and preserving, such as compassion’.

Where values and ethics are weak in any system which seeks to support those in need, we need a strong and active state to intervene, where both are weak those most vulnerable in society will continue to be denigrated and exploited.


Going dutch – lets put ‘care’ back into our health and social care system ….

I first wrote about Buurtzorg 4 years ago, at last Buurtzorg is now developing in the UK.

The Dutch model of Buurtzorg Care provides an alternative model of care across health and social care,   could we learn from this tried and tested model?

The provision of care for older people is a case in point. The organisational culture of some providers in our current system leave some older people neglected and without support where surviving the ‘system’ takes precedence over ‘thriving’, and often leads to unnecessary hospital admissions through poor levels of support at home. This is not about lack of resources but the poor allocation of resources.

As a social work practitioner I saw at first hand how good quality home care could reduce admissions to hospital. Good quality care at home can reduce, or even prevent, carer breakdown. It can support good nutrition which is essential to optimise both physical and mental health, for example by reducing UTI’s (urinary track infections) one of the core reasons I found for many avoidable admissions to hospital.

Avoidable and unnecessary admissions are incredibly detrimental to older people, and especially for those whose lives are touched by dementia, not to mention extremely costly. Decisions re admissions are not taken lightly, however, GP’s are often faced with the dilemma of admitting someone with dementia to hospital because that is the only option, not the best option. Any savings made on reducing the cost of unnecessary admissions to hospital would, I’m pretty sure, more than cover any cost incurred in reconfiguring care services provided at home.

We know care provision in the future is going to have to cope with growing numbers, so we need a system that is sustainable. The notion of sustainability in this context could draw on the ecology movement, where sustainability is defined as “development that meets the needs of current generations without compromising the ability of future generations to meet their needs”. This captures two important issues facing care today, the need to support those currently requiring care without compromising the future of the care system to accommodate a growing number of users within budgetary constraints. At first glance the two may appear irreconcilable, however, by building on the drive for personalisation and person-centred dementia care, alongside reshaping organisational ‘cultures’ new concepts and models are able to evolve which can contribute to developing relationship based complete care.

Complete Care: a model in practice – Buurtzorg Nederland

Providing a new form of service provision able to incorporate the principles of relationship based care and capability, along with notions of ethical practice and sustainability will require a re-organisation of the way in which we currently use resources to deliver care at home. Research from KMPG International (2012) highlights how Buurtzorg Nederland might provide a blue print for such a model.

The founder of Buurtzorg Nederland, Jos de Blok a district nurse, became frustrated with the way traditional services were focused on policy, targets and administration rather than on care and compassion. So he decided to develop his own model where his role as a nurse regained its explicit social value to the community he worked with. Buurtzorg was founded 10 years ago and started with an initial team of four. The system that evolved deploys teams of up to 12 nurses, who are responsible for between 40 and 60 people within a particular area. There are now around 900 teams in the Netherlands, supported by no more than 50 administrators and 20 trainers.

In the Netherlands, the financing and delivery of care in the community is highly fragmented with various tasks – such as washing the patient, serving meals and putting on elastic compressions – paid through different reimbursement schemes and, more often than not, executed by different professionals. As a result, patient care tends to lack coordination, making it difficult for the care providers to respond appropriately to changing patient conditions, which in turn leads to compromised continuity of care and low patient satisfaction.

At the same time, many home care service providers have cut costs by fine-tuning the minimum skill level required to accomplish each task. Dutch home care also tends to be focused on responding to patients’ current problems rather than preventing deterioration, meaning that interventions are generally added on only once the patient’s condition has already worsened.

To respond to these challenges, the home care organization Buurtzorg (meaning neighbourhood care) was created to focus on increasing patient value. Essentially, the program empowers nurses to deliver all the care that patients need. And while this has meant higher costs per hour, the result has been fewer hours in total. Indeed, by changing the model of care, Buurtzorg has accomplished a 50 percent reduction in hours of care, improved quality of care and raised work satisfaction for their employees.

How it led to productivity improvement

One of the keys to the program’s success is that Buurtzorg’s home care nurses organize their work themselves. Moreover, rather than executing fixed tasks and leaving, they use their professional expertise to solve the patient’s problem by making the most of their clients’ existing capabilities, resources and environment to help the patient become more self-sufficient, visits focus on the person not the task. Simply put, even though Buurtzorg professionals’ visits are not time limited the aim is to make themselves superfluous as soon as possible, versus other providers who tend to execute tasks without truly focusing on the patient’s overall capability.

Buurtzorg uses small self-steering teams (with a maximum of 12 nurses) who attend to an area of approximately 15,000 inhabitants and work together to ensure continuity of care. As a result, the professionals build durable relationships with their community, which further strengthens their ability to find local solutions for patients’ problems. Although the teams are independent and self-steering, they are supported by a centralized service organization which provides management information to both the team and the organizations’ leadership in order to minimize local overhead and maximize the professional’s face-to-face time with patients. Every team is responsible for its own clientele and is in close contact with those who use services, their families and doctors. Teams are also responsible for their own financial results.

Key results

In just two years, more than 2,000 nurses have joined the program despite the increasingly tight labour market for nurses in the Netherlands. Indeed, by 2011 Buurtzorg employed 4,000 nurses and nurse assistants working in over 380 autonomous teams.

Preliminary results show that Buurtzorg‘s patients consume just 40 percent of the care that they are entitled to and half of the patients receive care for less than three months. As a result, patient satisfaction scores are 30 percent above the national average and the number of costly episodes requiring unplanned interventions has dropped.

I spoke with Jos de Blok a couple years ago, and in the years since it’s inception he is as enthusiastic as ever and rightly proud of the difference his teams are making to the lives of those who require support in the community, as well as the professionals delivering care. Surely these would be good outcomes for us all?

One issue is funding: the Dutch model is tailored to payments by health insurance companies, not a state healthcare system like the NHS or means-tested social care. I’m no advocate of privatisation, I believe models such as this could be utilised within a National Health and Social Care Service, which is publicly funded, to provide sustainability for the future by reinvesting profit into the system, rather than giving it to shareholders and bonuses for CEO’s and the like.

It is suggested another potential issue is the scrapping of hierarchies and specialisms within the nursing teams: a Buurtzorg nurse might administer wound care, but may also help someone to wash or get dressed. I feel the segmentation of care needs  is dehumanising as individuals become defined by a series of tasks, rather than the person they are. If I undertook wound care, would I really mind also washing and dressing that person, no I would not, I would see it as part of caring for that person. So I do not see a problem with this.

Some might see a third challenge, in that the model requires management to back off and allow their teams considerable latitude, with much less performance monitoring than has become the norm in, for instance, the UK. Bureaucracy is reduced to a minimum.

Many professionals in the current system would see this as a positive!

Government has to change its focus on the continued privatisation and marketisation of care as a commodity to be bought, sold and traded.

How we design and deliver  ‘Care’ tells us something about us as a society, the constant focus on profit disfigures us all.

Why the Social Work accreditation scheme is a waste of money , £8.5 million to be precise…….

Community Care recently publicised that £8.5 million was given to private companies to develop the social worker accreditation scheme. This information was released by government over the christmas period. I am sure the timing of the release of this information was designed to ensure it disappears without trace so as not to attract the attention of those, such as myself, who are disillusioned by governments failure, and those who represent social work to government, to do nothing but tinker around the edges and not address the real issues which face both those who receive and deliver social work services.

I am perturbed by this news for two reasons. The proposed accreditation system is a costly red herring which detracts attention away from the real issues impacting social work practice today. Secondly the future of social work in the UK appears to be being shaped by a few powerful and well connected individuals and multi-national corporations rather than the voice of those in practice and those who require social work support.

Firstly, lets consider how the new proposed accreditation process might have improved the practice of the manager who was recently made subject to a 12-month conditions of practice order by the HCPC for ‘supervision failure’, despite the fitness to practice panel saying he worked with “a heavy caseload, poor working conditions, inadequate management support of him in his role as a manager and significant personal health issues”. At one stage, the social work manager was responsible for managing about 120 cases, whereas 65 cases was deemed an optimum caseload.

How many people reading this are now thinking, this could be me I wonder ?

I do not believe the proposed accreditation process would make a difference to those in a similar position because it will not address the failure by government, and those who represent the profession, to get to grips with the real issues that significantly impact on professional practice and individuals lives.

Factors such as high case loads, diminishing resources, bureaucratic systems; organisational culture, burnout, limited opportunity to give or receive high quality supervision, lack of a coherent and funded CPD programme, political failure to address issues such poverty in income, food poverty, fuel poverty, poor housing, job insecurity, inequality and a pervading sense of hopelessness as both those who require services and deliver services see little authenticity in governments approach to effect genuine improvement.

My second concern is the continued involvement of private companies, such as  Morning Lane Associates, in shaping the future of social work. Morning Lane is a consultancy company  co-founded by the current chief social worker Isabelle Trowler. A previous investigation  into the chief social workers role in the development of the accreditation scheme found the chief social worker had been consulted on the bid, worth an initial £2.6m..

This is not a one off in successfully attaining funding either, in addition Morning Lane has received millions as professional advisor and training partner to Frontline, alongwith £4m in Innovation Fund money to roll out its Reclaiming Social Work model to five authorities.

We will see more involvement of Morning Lane in 2018 when Frontline receives more funding via additional funding for fast track social work training schemes in 2018. In respect of this funding the DfE says £35m was invested in Step Up and Frontline between 2010 and 2015 and £100m will be invested over the next four years.

However, the Department has refused to provide a breakdown of how the funding was split between the two programmes.

While there is no suggestion of legal wrongdoing, fears continue that children’s social work is being pushed in a particular direction by the agenda of a small number of powerful well connected people with a large amount of influence, and a large amount of resources at their disposal.

For example it is reported Frontline’s support comes from across the globe,  receiving ‘pro bono’ support from several powerful, and influential private multi-national companies, for example;

  • The Boston Consulting Group, an American worldwide management consulting firm with 90 offices in 50 countries. The firm advises clients in the private, public, and not-for-profit sectors around the world, including more than two-thirds of the Fortune 500 and is one of the ‘Big Three’ strategy consulting firms.
  • The Alexander Partnership which is Europe’s leading provider of executive coaching, leadership and culture development.
  • Abbott Mead Vickers BBDO (AMV BBDO) is an advertising agency that works with over 85 brands, including BT, Sainsbury’s, Diageo, Walkers and Mars. AMV is part of the BBDO network, the third largest agency network in the world and part of the Omnicom Group.
  • Baker McKenzie, founded as Baker & McKenzie in 1949, is a multinational law firm. As of August 2017, it is ranked as the second-largest international law firm in the world . It is also ranked as the second largest law firm in the world in terms of revenue with US$2.67 billion in annual revenue

One wonders why social work in the UK requires steerage from multi-national corporate influences and this begs the question just how does the current approach align with social work values as defined within a global perspective?

The rise and rise of Frontline is a good example of the changing world in which social work education is emerging. Ark is a charity which co-founded Frontline. However, it is also a profit making company and was set up as an alternative investment industry focusing on global education. The power of such organisations are changing the educational landscape and is increasingly highly influential in shaping public policy and redefining the role of government and businesses in the production, management and  delivery of public services embracing neoliberal ideology. (see World Yearbook of Education 2016: The Global Education Industry)

It’s all a very long way away from the social worker on the real frontline who enters the complex lives of those they work with on a daily basis. Neither can imagine what it must feel like to enjoy the resources, power and influence of those shaping both their futures.




Older people still dominate Safeguarding practice, will this ever change?

Has there ever been a ‘golden age’ where older people were consistently valued, respected cared for and protected by family and the institutions that make up wider society?

Latest figures in respect of Safeguarding referrals under s42 of the Care Act 2014 found for the 2016-17 reporting year there were 109,145 individuals that were the subject to a safeguarding enquiry, an increase of 6 per cent on 2015-16.  Of these individuals at risk, 63 per cent were aged 65 or over and two thirds of these were over 74 yrs of age.

This will come as no surprise to many within the health and social care professions, and indeed many feel the numbers could possibly be an underestimate given previous statistics. For example a House of Commons report on elder abuse published in 2004 stated

Other witnesses also commented on the estimate of “half a million” older people abused at any one time. Both Bill McClimont, Chair of the UK Home Care Association, and Sue Fiennes, National Lead for Older Peoples Services of ADSS, suggested that the figure was an under-estimate. Mr McClimont commented that it was likely that there was greater reporting in the part of the care sector that was currently regulated. As regulation spread to other parts of care, detection and reporting were likely to rise.

This may well be accurate when we consider the abuse of older people is a global issue.

The World Health Organisation suggests the abuse of older people occurs in many parts of the world with little recognition or response. This serious social problem is often downplayed or hidden from the public view, and considered mostly a private matter. Even today, the abuse of older people continues to be a taboo, mostly underestimated and ignored by societies across the world. However, evidence has accumulated to indicate that the abuse of older people in the UK is an important public health and societal problem.

The full extent of abuse is unknown, however, its social and moral significance is obvious. As such, it demands an active response, one which focuses on protecting the rights of older persons, and a change in our perspective on whom, and what, we value in society.

Although representations of old age and societal responses to older people have differed over time it could be argued old age has always been viewed as negative.

In ancient Greece old age was portrayed as sad, with the Greeks love of beauty marginalising the old. Although some commentators suggest the reality was more complex with the portrayal of older people in the classics as ‘both pejorative and complimentary’ (Thane, p.32). For Plato reverence toward old people was a guarantee of social and political stability, whereas Aristotle disagreed with such positive images. Cicero’s work De Senectute, written in 44 BC, points to the variety in individual experiences of ageing, acknowledging that for those who are poor and without mental capacity ageing is miserable, however, suggesting older people need to strive throughout their life to remain intellectually and physically able.

Arguably this belief still underpins social care legislation and policy today in respect of older people.

It has been suggested older people’s status in society is linked to their ability to participate in society from an economic perspective, especially in terms of activity in paid employment. Historically where older people have been unable to participate in paid employment, help and support has been provided through a mixture of family and state support, with an emphasis by government on the former rather than the latter. However, commentators suggest, post industrial revolution, another victim of change were older people. The old did not merely lose power, they also lost respect. The rise of the alms-houses, and institutionalised poor-relief, may indicate their children were increasingly shedding responsibility for their support and transferring it to the community.

Although Thane  argues, this may have been due to families own depths of poverty, rather than lack of care or a shedding of responsibility.

The abuse of older people was not something government identified as a problem throughout this period, although, self-neglect was identified as an issue which government sought to address in the 1948 National Assistance Act.

This is not to say it did not occur, for example, the 1942 Exceptional Needs Enquiry found most older people living with families were there under sufferance. They were often less well off than those who lived with strangers, and lacked essential items of clothing, bedding or household equipment as families used any provision, such as clothing coupons, for personal use. Whether this constituted abuse is not clear as many families who cared for older relatives were often living in poverty themselves and older people often willingly gave their families any support they could, even if this meant going without themselves. Of course, records do not exist to either confirm or deny whether such relationships were abusive or mutually supportive, however, it might suggest in terms of individual worth and personal identity, a cultural norm existed where the welfare of the younger generation was prioritised over that of the old by both young and old.

However, Peter Townsend’s landmark study  of long-stay institutional care for older people in 1950’s Britain, provides a little more insight into the experiences of older people receiving care. One of the interviews he recorded was with a matron of a small private residential home in Greater London, which Townsend suggested was by far the worst home he had visited, was clearly describing abuse, as defined in legislation today.

This suggests the abuse of older people has been going on for a long time, both nationally and internationally.

How will we ever change this I wonder?

Government claims “families are too selfish to care for their ‘elderly’ parents”… Really?

Government minster, Phillip Lee, suggests families in Britain  are too selfish to care for their ‘elderly’ relatives.

Whilst there are ‘selfish’ people in society from my experience of coming into contact with primarily women trying to care for older relatives, successive governments policies and economic strategies has done little to support them in this task.

The Carers Trust provides some insight into the demographics of care in the UK. Their figures suggest

  • 58% of women are carers
  • 1 in 5 people aged 50-64 yrs of age is a carer in the UK
  • 60% of carers have used all their saving to cover the cost of care
  • 61% of carers have to borrow money to make ends meet

From my professional, and personal experience, I have found caring for older parents tends to fall upon women between the ages of 55 and 65 years of age. These women are also carers of their grandchildren, because their children cannot afford the high cost of childcare and/or afford to pay high rents due to unaffordable housing, or to afford a large mortgage due to inflated housing costs linked to government policies.  Reports suggest many families would have to give up work if grandparents did not help out with childcare. Also we need to keep in mind many of these woman are also trying to support themselves, because they now have to continue to work until they are 67 yrs of age before they can get a pension.

So, Mr Lee, we have many  women in the UK today who still work to support themselves, they support their children, their grandchildren and their ‘elderly’ parents. They are not rich women, they often work in low paid jobs, physical jobs, with no professional pension to fall back on.

Indeed in my view these women are heroes, and on top of that they contribute to the estimated £132 billion unpaid carers save the tax payer every year.

So I think it would be nice if these heroic women were recognised and thanked by the Minister.




To deliver good, safe, sustainable care, leaders need to think beyond traditional boundaries ……

Our care system is at breaking point. People are struggling to find a good care home when they desperately need it. With demand for beds set to rise, the time for action is now. Help us convince the regulator to confront the care crisis before it’s too late.’ (Which?)

CQC have confirmed in their State of Social Care report the problems many requiring social care already know, the system needs reform.

As Which?  and CQC yet again bring to government and wider societies attention to the problems and poor levels of care some older people experience, one wonders will we ever get to grips with this issue? The transformation of ‘care’ into a commodity that can be bought by families and those who use services, like any other product, dominates current health and social care reform, however, discussion on what ethical principles underpin the delivery of such care has not emerged. This raises the question for me, is it wise to continue to build a system of care provision with no clear ethical foundation outside of that of the free market? Arguably, we need greater ambition in developing great care for older people and a more strategic approach to make real improvements. But how?

Developing ethically sustainable care for older people

Drawing on the ecology movement sustainable development is defined as “development that meets the needs of current generations without compromising the ability of future generations to meet their needs”. This captures two relevant issues; the need to support those older people currently requiring care, without compromising the future of the care system.

Need, capabilities and the ‘good life’

A first step in developing ethically sustainable care involves reframing our understanding of ‘need’. Need in a health and social care context is often used to refer to a function to be fulfilled, i.e. nutrition, physical care. Such needs are viewed as a necessary condition for survival. However, we should also view older peoples’ needs in terms of security, respect, love and justice.

The failure to distinguish between different types of need has led to limiting our understanding of how to care for older people, and has subsequently influenced how service provision has developed. Amartya Sens’ concept of ‘capabilities’ provides an alternative approach Sen is concerned in this model with identifying what individuals require to flourish and live a ‘good life’. In this model it is recognised older people require different capabilities to flourish, depending on their personal circumstances and the community they live in, whether that community is within an in-patient/residential setting or in the wider community. Successive governments’ appear to believe an expansion in a consumer culture within health and social care provision is the only route to a ‘good life’ for older people, as it enables individuals to increase choice and control by becoming consumers of care, rather than receivers of care.

Yet many older people are clearly not flourishing in a culture that defines the good life in terms of their ability to engage as a ‘customer of care’. A more useful way of thinking about this, from an ethical perspective, links Sen’s idea of capabilities and Aristotle’s vision of the ‘good life’. From this perspective achieving quality of life is central, rather than just meeting physical needs. In other words it is not just about achieving an ‘average’ notion of well-being but about the opportunities available to the individual which will enable them to develop their full potential, whatever that might mean for that individual.

This approach moves beyond ensuring older people have the ability to flourish to consider whether they are actually flourishing. Commentators suggest there are five areas in which older people need to flourish to live a good life, regardless of where they live. These are: belonging to a family; belonging to a community; having access to material goods for sustenance, adornment and play; living in a healthy environment; and having a spiritual dimension to life. Arguably the commissioning and delivery of service provision based on achieving these five areas might enable older people to receive care that is both compassionate and dignified.

The way forward

Conceptions of what constitutes a good life are varied, however, within health and social care provision it is prudent to assume a good life involves at a minimum care provision that is not abusive to older people.

Within the public sector the organisation and delivery of care is structured to focus on the meeting of targets rather than enabling an individual to flourish. The health and social care sector is arguably over managed and under led. In the private sector it could be argued a free market economy contains structural incentives for business to pursue a notion of the good life that supports the sale of a narrow range of care ‘products’, whilst there are not mechanisms in place to ensure the market operates within a clear ethical framework outside of the profit ethos.

By not actively endorsing care provision from an ethical stand point the government and regulatory bodies may actually be unwittingly aiding the abuse of the most vulnerable within the care system. A shift in focus from human need to human flourishing has already begun with the development of the personalisation agenda and emphasis on voice, choice and control however, this agenda has been overshadowed by a managerial approach to consumerism and consumption in a low paid, low status care system and this is undermining the ability of the care system to develop ethically.

Markets versus Values

Michael Sandel argues markets are not a mere mechanism designed to deliver goods, they also embody certain values, and the problem is these values ‘crowd’ out non market values like compassion and dignified care. Where values and ethics are weak we need a strong and active state to intervene, where both are weak those most vulnerable in society will continue to be exploited and abused. This begs the question can we afford not to have an ethical care system?