Paper Presented to the Social Work History Network, April 4Th 2008

Paper presented to the Social Work History Network, April 4th 2008.

Mental health social work in local authorities 1970-2007 - a missed opportunity.

The title should perhaps be “several missed opportunities” the first being the passage of the Social Services Act in 1970. I started work as a social worker in Liverpool in 1971 in the middle of the Seebohm reorganisation. In later years old MWOs would become misty-eyed about the former Mental Health Departments, but what I saw in 1971 didn’t suggest that the Liverpool department at least had been at the forefront of progressive social work practice.

The MWOs sat in an open-plan office at rows of sloping desks, filling in standardised reports on post-discharge visits, and this was overseen by the Superintendent MWO who in turn was responsible to the Assistant MoH, to whom all discharge letters were addressed. MWOs were only issued with a brief precis of these letters, minus all the medical details, and this practice continued in the new department until one day I was sent to visit a man who, unbeknown to me, had not only mental illness but also terminal cancer. As I was by then convenor of the social workers’ group, which met regularly with the new Director, this practice duly ceased !

Seebohm found a similar picture nationally - there was a low level of qualified staff ( only 18%), they spent too much time on routine tasks, and levels of service were variable and dependent on the enthusiasm or otherwise of the MoH.

Overall, however, the community mental health services were expanding rapidly as the rundown of the big hospitals was getting under way, and those services were run exclusively by social workers and the local authorities, and so there was a very big opportunity to push the whole mental health service in the direction of the social model, which was what Seebohm envisaged.

So where are we now, 37 years later ?

CMHS have expanded tenfold, but over ¾ of qualified staff are nurses. 7000 extra nurses have been recruited since 1997, and most will have gone into community services. Even the psychologists, who used to be as rare as hens’ teeth, now outnumber the social workers - there are only 4000 social workers but about 8000 qualified psychology and psychotherapy staff. In many of the new community teams there are no social workers at all. In addition, local authorities are rarely more than marginal players in joint services, and several have transferred all their mental health staff to the NHS.

So how did we get from there to here, and could it have been any different ?

Seebohm was not the only revolution going on at the time - before the Seebohm Committee had reported, the government had decided to review the structure of the NHS, in part because the Committee’s recommendations would move half the staff of the local authority health departments into the new SSDs. By the time the 1970 Act came into force, the decision had been taken to transfer what was left to the NHS, and this came into force in 1974 along with the transfer of the hospital PSWs to the LAs.

Seebohm argued that the SSDs would actually deliver better CMHS, and would be better able to bridge the gap between those services and the hospitals. However, this was just a “convenient belief”, which fitted with the overall aim of creating a single generic social work profession in a single department. It was entirely dependent on the new DSSs being more interested in mental health than the MoSH; if they weren’t, then after 1974 the new DHAs had the power to run their own CMHSs if they didn’t like what the LA was offering.

And they most definitely didn’t like it. In 1979, in a paper for a BASW publication, I reviewed the first eight years since Seebohm, and I calculated that, in a period of great expansion of social work numbers generally, the amount of time devoted to mental health had actually declined by about a third in real terms. Moreover, working relationships between psychiatrists and social workers, which Seebohm claimed would improve, had deteriorated drastically.

I identified several reasons for this, the first being the nature of the new intake of generic social workers. A significant percentage of the MWOs were ex-nurses, and many of the senior staff went back to the Poor Law, so they were a fairly conservative bunch who were if anything too tolerant of the traditional medical model. The new intake, however, tended to be sociology graduates who knew very little about psychiatry but a great deal about the beliefs of the “anti-psychiatry” school which was then in vogue.

They were not only anti-psychiatry but also anti-professional. Support for professional bodies declined, and loyalty transferred to NALGO - and the long-term consequences of this are now becoming apparent.

In addition, the old MHD managers virtually disappeared. BASW campaigned successfully to keep MOsH out of Directorships, so the people who had headed up the CMHS eventually went into the DHAs. Within the new SSDs, the general rule was that managers had to be qualified, and the Childrens’ Departments had 56% of all qualified staff, whilst many of the senior MWOs were “pre-qualification” and ended up as advisors.

And then there were lots of new duties to other client groups, in particular the 1969 CYPA and the 1970 CSDPA, and this was also the period when we discovered Non-Accidental Injury. To cap it all, generic SWs were appointed as MWOs under the MHA, 1900 specialists being replaced by 10,000 genericists.

In consequence, DHAs began to develop CPN services, and these were well-established by 1979, when the social workers went on strike, thus validating the policy of not having all the eggs in one basket. Development of CPN services then gave LA managers an excuse not to invest in MH services - they were no longer an exclusive responsibility as they had been prior to 1974.

That’s been the basic problem ever since - the buck didn’t stop here, as it did with other services. CMHS were no longer, in modern jargon, a “core business” of LAs.

I forecast in 1979 that, as a result, future CMHS would be largely staffed by nurses, not least because they had the only staff pool big enough to support the expansion needed (35k mental health nurses vs 10k social workers across all client groups) and I argued that SWs needed to develop a niche role, policing the entry points to the mental health system to prevent the inappropriate medicalisation of problems which were primarily social.

To address the concerns about the poor quality of the new generic MWOs, the MH Committee of BASW, of which I was vice-chair, in 1977 published a proposal for an ASW, who would have special training and need to pass an exam. 30 years later, the ASW is generally regarded as one of BASW’s better ideas, and we’ve been criticised for not defending it more vociferously, but at the time it was strongly opposed by the majority of SWs who saw it as divisive and elitist, and the exam system eventually had to be abandoned under pressure from NALGO.

As a result, it took several years after 1983 for standards to rise significantly, with many ASWs being approved after just 5 or 6 days’ training, and the fact that standards did rise, and that relationships with the NHS improved, probably had as much to do with a move back to specialisation. Liverpool allowed me to specialise in 1975, Lancashire by the late 70s had created 30 local mental health teams, and by the late 80s most authorities had done something similar. This was an opportunity for LAs and SWs to retake the initiative.

However, the CPNs were also forming into discrete teams with dedicated managers, so we ended up with two parallel and to some extent competing services with duplicated management. Joint services of some kind were the obvious solution, although they developed very slowly - I was head of the LA side of Brindle House, the first joint CMHT, in 1977, but it was another 20 years before they became the norm, and even as late as 2003 I came across a so-called joint health and social care Trust in which the SWs and CPNs were still in separate offices with separate management.

The nature of these joint services was determined by three factors, the most important of which was who was paying. LAs basically do new things only when they have new statutory duties with new money attached, and there was no shortage of new duties and new money for other groups - there being at this period a whole raft of new disability legislation and of course the Children Act - but the main statutory duties specific to people with mental health problems hadn’t changed since 1959, and there was no new money other than Joint Finance, which came in in 1977 and paid for our CMHT, but which had to be stretched very thinly across all client groups.

The main source of new money into mental health was from the hospital closures, but the health authorities largely kept it for themselves. They didn’t keep the money from the learning disability closures, but that was because the long-term care of people with LD was something they wanted to get out of.

In the early 1980s Herbert Laming, who was then DSS of Hertfordshire, suggested that, rather than have unwieldy joint services, there should be a straight split - LAs should just run all LD services and hand over their MH services to the NHS. I rounded on him in Community Care, but a few years later I began to see his point - by then I was managing both MH and LD services, and I got over £1 million from hospital closures into my LD budget, but not a penny into MH.

The LD service consequently grew rapidly until it was 10 times the size of the MH service, but the number of joint meetings I had to attend was the same for both services. Moreover, the armies of new LD staff, hired from the job centre, largely did as they were told, whereas the ASWs were a stroppy bunch who’d modelled their behaviour on me!

The HAs, meanwhile, were continuing to invest in CPN services, so by the early 1990s the numbers of CPNs and specialist social workers were about equal. At the same time, CPNs were evolving and developing their skills, but social workers were not.

In the early 1980s SWs still had a monopoly of the social model, and of the therapeutic skills which went with it. CPN practice was still very medical - basically they were doing the routine monitoring which SWs had stopped doing, plus giving depot injections - and when Brindle House was founded we left the CPNs out of the core team as their management, which was shared with the District Nurses, would not have allowed them to do the group and family therapy that we were doing. However, things began to change once CPNs got their own managers, who tended to be from the progressive end of nursing.

At the same time, development of the social model came largely to a halt. As ASW training grew in length and quality, so it became more expensive and absorbed all the training budget, whilst CPN services were awash with training money. In the late 1980s my staff largely got their practice-skills training by gatecrashing the nurses’ training events. The mental health component of CQSW training was also being watered down as the curriculum became more crowded, and CCETSW eventually killed off the remaining PSW courses.

This had a dire effect on social workers in joint services, since these were increasingly run to NHS rules, and the NHS insisted that anyone who undertook psychotherapy of any kind had to have a certificate on the wall. The nurses now had the certificates, the social workers didn’t, and so the nurses began to monopolise the high-status therapy roles. When I went back into practice in 1993, I found that I wouldn’t be allowed to do most of the things I’d helped to pioneer in the same service 16 years earlier - if I wanted one of my clients to have any sort of therapy, I had to refer them to a nurse.

The CPNs also had a big advantage in that they kept their best people within the service. One of the big weaknesses of the LA services was that, as in the rest of social work, the most able and ambitious went into management, but in most cases that meant going out of MH, as I had to do for a period, and most never came back. Mental health nurses are, however, not qualified to do anything else. At Brindle House, we did eventually let the CPNs become full members, and our first CPN went on to be the manager of the CPN service, then the hospital, and now he’s the Chief Executive of the Trust.

However, the early 90s brought another opportunity to turn things round. At long last, new money started to flow directly into LAs in the form of the Mental Health Specific Grant.

But there were strings attached. The new money was linked with the new community care duties, and authorities spent it mostly on commissioning services from independent-sector providers, so the social care workforce increased, but the social work workforce did not. Moreover, the social workers were increasingly expected to manage complex care packages, at the expense of every other possible role apart from the ASW function.

The NHS Trusts, as they now were, also received new funds, but these were largely to create new roles for CPNs. For instance, there was new money for primary care workers, A and E liaison workers, and for court diversion schemes. These were jobs which would have been much better done by social workers, and were very much the kind of “front door” roles which I had envisaged in 1979 as being the obvious niche for them; conversely, nurses were, by training and experience more suited to care management of people with severe and enduring mental illness, and when they did it they often did it very well, partly because they were more used to following set procedures. Our Trust did at least recognise that; back in practice in the mid-90s, I was supposed to be care-managing people discharged from the Special Hospitals, but I persuaded them that that job was better done by nurses, and so I worked in the courts instead, separating out the very small numbers who actually needed to be in hospital from the vast majority who were better helped in other ways.