Can social work leadership be effective without evidence?

Effective leadership in mental health social work requires robust evidence about the effectiveness of social work practice and the confidence to articulate it both within the profession and beyond.

To be an effective social work leader in a multi-disciplinary team alongside health colleagues, we need to engage with the professional agendas of other disciplines. Research evidence about intervention effectiveness is one agenda that just doesn’t go away and social workers need to engage with it now, perhaps more than ever before.

When I teach on Approved Mental Health Professional (AMHP) training courses I find that experienced social workers struggle to articulate the evidence base for their practice. Admittedly, this is partly because there is not an abundance of research evidence to cite. But there is also a high level of ignorance about what evidence there is. The blame for this does not lie in the practitioners themselves, but in the systemic failure of social work in the UK to develop and articulate its evidence base.

Without a robust body of evidence to support its interventions in mental health services (and what there is has largely been adopted by other professionals), mental health social work has largely been reduced to statutory and bureaucratic functions. It is difficult to be a social work leader in mental health services when other disciplines define your role.

The personalisation agenda is perceived by many social workers as a further threat to their role, and merely a vehicle to further roll back the welfare state. However, perhaps it can be an initiative which social work can use to develop effective practice and empower people to take meaningful control over their care. By developing evidence about effective practice in this field, social work could perhaps provide professional leadership over this initiative in the same way that we do in the AMHP role.

I’ve written before about how mental health services are increasingly shaped by National Institute for Health and Clinical Excellence (NICE) clinical guidelines, which are themselves shaped by randomised controlled trials. Well, the same is happening in primary mental health care.

Last week I was teaching on an Increasing Access to Psychological Therapies (IAPT) course, which uniquely includes a module on social inclusion. It is well known that GPs feel that they are predominantly dealing with social problems during consultations which usually result in the issuing of a prescription for an anti-depressant. A new army of primary care mental health workers have been employed to resolve this, armed with evidence-based interventions such as cognitive behavioural therapy and problem solving. However, these workers battle with entrenched social problems with few weapons in their armoury. (Sorry about the war metaphor, but it is an apt simile for the current situation).

When asked why this was so, the primary care mental health workers I were teaching replied that social interventions were just not a priority in the absence of evidence of their effectiveness. They would merely ‘signpost’ the person to another agency or source of help and leave it at that. As well as illustrating the need for evidence to support social interventions in a healthcare setting, this provides a further example of practice which social work could effectively lead.

But it first needs to resolve its systemic failure to develop and articulate evidence about the effectiveness of social work interventions. Qualifying training for social workers needs to include teaching on how to understand and articulate the evidence base which currently exists. Post-qualifying training needs to provide practitioners with opportunities to undertake their own research. Social work academics need to develop intervention research programmes and the whole profession needs to foster a research culture which allows new findings to become readily translated into practice. This will not only enable us to hold our own in discussions about our practice with health colleagues. It will support what many of us came into the profession to do: to lead the battle against social problems.

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Access to social capital as an indicator of success for Time to Change

Further funding from the Department of Health and Comic Relief will ensure  that the Time to Change campaign to end mental health discrimination can continue for a further four years. This is great news as there is robust evidence that the campaign is changing behaviour, reducing discrimination and improving public attitudes. But there is more work to be done.

If public attitudes towards people with mental health problems are improving, and if discrimination against them is actually decreasing as a result of the Time to Change campaign, we should expect to see changes in the lives of people with enduring mental health problems. One way in which we would expect to see things change is that it would be easier to maintain existing relationships, make new friends and increase one’s circle of acquaintances as people become more accepting of mental health problems. Even if social networks remain static in size, we would expect individuals to find it more easy to ask for favours or obtain resources via people they know, if mental health discrimination were to decrease.

Over the next four years the Time to Change evaluation team at the Institute of Psychiatry will be measuring whether people with mental health problems will increase their access to social resources via their social networks. The team will interview a panel of 1000 people each year to see if this changes year on year.

The research questionnaire that we will be using to evaluate this is the Resource Generator-UK (RG-UK). I adapted this measure from one first developed in The Netherlands by Martin van der Gaag and colleagues. It’s quite easy to complete (and a bit of fun, if this sort of thing floats your boat!). It’s also got some robust psychometric properties which makes it credible.

To give you some idea of the kind of information the RG-UK provides us with, please see below for a simple chart illustrating inequality of access to social resources for people with mental health problems. The square on the left is from a general population sample whereas the three on its right are from samples of people with mental health problems. It doesn’t take a PhD in statistics to observe the inequality apparent in these figures. For readers interested in the statistics behind this chart, the squares represent means and the lines above and below them are confidence intervals. You will observe that the confidence intervals for the three groups of people with mental health problems go nowhere near the bottom of the general population sample on the left. This illustrates a statistically significant difference in mean access to social resources.

If Time to Change is successful over the next four years, we would expect to see mean scores on the RG-UK increase. While we will not expect them to reach the same as in the general population, we would hope that they would increase a little. Even an increase of 2 points on the scale would make a visible difference in someone’s life and that is well worth the investment announced this week and the tremendous programme of work that goes into the Time to Change campaign.

Meaningful involvement of service users and carers in social work education

What is the meaningful involvement of service users and carers in social work education? How do you make involvement meaningful at the advanced level of the post-qualifying framework for social work, where the levels of education and practice experience are high?

These questions have bedevilled us at the Institute of Psychiatry, where we run an advanced level post-qualifying (PQ) programme for social workers. We wanted to avoid tokenism, so we conducted a small qualitative study to explore what stakeholders understood meaningful involvement to be. The findings are published online today in the British Journal of Social Work.

Karen Robinson, a service user researcher, and I co-produced a study which involved 29 stakeholders – service users, carers, social workers undertaking advanced PQ programmes, social work lecturers and employers. Karen interviewed them to explore their conceptions of meaningful involvement. We found four predominant models (consultation, partnership, political and user control) which have different implications for how service users and carers may be engaged in advanced post-qualifying social work education.

The models can be placed on a spectrum of opinion which spans from the primary purpose of involvement being to add value to students’ learning (‘added value’), to it being to empower the service users and carers involved (‘empowerment’).

Universities whose primary purpose is to ‘add value’ to advanced PQ programmes, aim to provide learning opportunities unavailable from traditional staff members which are valued by students as helpful to their future practice. Members of this school of thought are likely to argue that service user and carer involvement at the advanced level is different and perhaps more complex than at lower levels. They are more likely to favour careful selection of service users and carers to meet the specific needs of the advanced level group and the learning objectives of a particular session. They prefer the long-term, consistent involvement of a relatively small group of service users and carers through all stages of the programme following either a consultation or a partnership model. A service user or carer with substantial teaching expertise is likely to be valued as a ‘user consultant’ within these models.

Universities whose primary purpose is to seek to empower the service users and carers involved in advanced PQ programmes, aim to challenge the traditional power imbalance between social worker and service user or carer. They stress the importance of equal access to involvement by all service users and carers, and do not usually favour selection of service users or carers on the basis of specific skills. Larger numbers of service users and carers are likely to be involved, reflecting a larger number of experiences and with a more democratic style of leadership. They may argue that if sufficient resources were invested in involvement activities, and sufficient training was available to service users and carers, there is no reason why any service user or carer should not be able to make a valuable contribution to an advanced PQ programme. In general, they do not think there are significant differences between involvement at the advanced level and at lower levels.  Members of this school of thought are more likely to follow a political model of involvement and effort is made to strive towards a model of user control of advanced PQ programmes. However, a service user or carer with substantial teaching expertise is likely to be described as a ‘professional user’ within these models. This term is likely to have negative connotations.

We conducted a literature review to inform this study, which will be published separately. Most studies in this review related to qualifying social work programmes and conceptualised involvement at the ’empowerment’ end of the spectrum. However, due to alack of evaluative research, there is little evidence about which model most effectively improves outcomes for future service users of graduates of these programmes. As ever, more research is required.

The College of Social Work is preparing to take over ownership of the continuing professional development of social workers and post-qualifying training. While it would be inappropriate to stipulate a model of involvement which universities must follow, it is worthwhile bearing in mind the existence of a diversity of models and their potentially divergent outcomes for practitioners and service users.

You can download a PDF version of the paper by clicking here.