My peers across social work sectors have written eloquently in this magazine about the challenges and triumphs of these times. I wonder what else I could add of value, apart from one more voice in the groundswell of informed scholarly opinions, lived experiential accounts and cold facts to re-create a profession that now needs the brute force of numbers to be heard in the wider field of the politics of health and social care. More now than ever, we need to infect each other with hope (Christian Kerr and Michael Clarke), a sense of solidarity (Nick Burke and Mark A Monaghan), and a greater awareness of the underlying social structures that affect our personal and professional lives (Dr. Sweta Rajan-Rankin).
Over the past 18 years in my time as a mental health social worker and social work manager, I have witnessed a seismic shift in social work which has become largely process orientated. The processes and procedures are admittedly to ensure standardised services and quality assurance, but this comes at the high cost of erosion of personalized care and quality involvement. I have both attended and chaired innumerable safeguarding meetings. All professionals attending, in good faith, can tick each and every box to be legally compliant, and yet the person whom we intend to safeguard is more likely than not, just as vulnerable to harm or abuse as a result of these procedures. People have complex relationships, and often the person who is allegedly perpetrating the abuse or neglect is also the person who provides practical or emotional support and comfort in other areas of their lives. As one of my clients mother who had taken control of her son’s finances and cashpoint card once told me ‘he is my son, nobody cares for him as much as I do’. She didn’t want him buying cigarettes which he would do if he had access to his money. He had the capacity to make the decision to buy cigarettes. So he was at every liberty to make this choice and according to UK law (Mental Capacity Act 2007), his mother could not stop him from making it. Safeguarding procedures were initiated, prompted by recording systems, team meetings, monthly statistics on safeguarding etc. He gained control of his finances, smoked at will, which led to an admission to ICU. Crucially, they are immigrants from an Asian country, deeply rooted in their cultures and at odds with UK norms and laws. What we need for meaningful interventions is time and support for staff, both increasingly in short supply and flexible creative solutions that families themselves create.
People who use services have been suffering changes for over a decade. Social distancing is nothing new for the hundreds of thousands of people who are socially isolated due to mental illness, with day care centers one by one being shut down. Staying at home- for those that do have a home- is nothing new to people who suffer mental illness and who don’t have a carer to accompany them, for fear of ridicule, of crowded places, of losing one’s way, having a breakdown in a public space, or the fear of being assaulted or sexually molested, or in a city such as London, the fear of gangs and coming under crossfire. The viral pandemic seems to me like a wave in a roiling ocean of cuts, closure of services, posts lying vacant, undertows of racism and sexism and lack of real opportunities of employment for people with histories of mental illness.
The new legislature Coronavirus Act 2020 includes the Care Act Easements (Department of Health and Social Care, 1 Apr 2020) which on the face of it is good to expedite services to the most vulnerable populations cutting out the lengthy and time consuming paperwork required to secure funds for clients. But in the long term it can put people deeper in debt as it stipulates that the easements are time limited, and that all assessments need to be completed in full including financial assessments and that people will be liable to pay retrospectively for services received. To illustrate, this is like buying a loaf of bread and being informed of its price at a future date when the customer will become liable to pay for it.
The act also temporarily suspends the need for Deprivation of Liberty Safeguards (DOLS) for changes to care or treatment. These are safeguards put in place for people who are ‘under continuous supervision’ and who are required to reside in a particular accommodation, depriving them of their liberty. Normally when there is a change to care or treatment, such as administering a new medication, or a change of care home, the care home or hospital needs to request a standard authorisation from the local authority. This is a lengthy process and requires 6 assessments, including that of capacity, best interest decision, mental disorder, and so forth. In the face of COVID 19, this means people can get quick care and treatment, but potentially engaging the following Articles of the Human Rights Act 1998-Article 5- Right to liberty and security, Article 8- Respect for your private and family life, home and correspondence and Article 14- Protection from discrimination in respect of these rights and freedoms.
As an Approved Mental Health Professional (AMHP)- a person who coordinates a Mental Health Act assessment (under the Mental Health Act 1983 (Amended 2007)) and makes an application to the local authority toward detaining a person suffering from a mental illness in a hospital or some such care setting, we routinely manage volatile situations with very unwell patients, their families and significant others. This is without any of the protective equipment used by the police or the safety of working in a team that doctors have. With only a pen and a piece of paper – the application for detention, we have thus far managed unsafe, often unhygienic and potentially physically dangerous situations whilst carrying overall responsibility for the safety of the patient.
With the current threat of Corona virus infection, there has been no clear enough guidance nationally on the use of PPE for AMHPs, and it has been left to AMHP leads and local authorities to come up with solutions. Sadly, there has been even less consideration for PPE and safety for people and patients we assess. Often AMHPs go into homes, by force if need be, with the use of a warrant executed by the police. In these circumstances, people will not have a choice about letting the professionals in. Plus patients we assess come from economically deprived areas and live in cramped conditions. Such an assessment necessarily puts both the professionals, patients and their family at a greater risk of contracting the corona virus, and rendering meaningless the calls for social distancing or hand washing by the government.
A council leader of a London borough few days ago sent out a statement in an e-letter to council staff that ‘…..all the more poignant by the sad news of the first care worker in xxxxx to die of coronavirus’. I am shocked that this person can use such a word, ‘FIRST’, because the subtext here is this is most likely not the last and there will be more fatalities. As I write this article, there have been 2 more care staff fatalities. Is it a matter of time before an AMHP is counted among the fatalities? Is there anything we can do to minimize the risk we and our patients face? There have been suggestions and discussions around using video interviewing among AMHP lead networks. As an AMHP of 8 years experience, it is my opinion that this will not work. Firstly, the people we assess are mostly unwilling to engage with us, and hence the need for an assessment under the Mental Health Act. Secondly, patients are often suspicious of technology, and fear they are being recorded, are socially isolated and rarely use tools such as Skype or Whatsapp. Thirdly, if they are not averse to the use of social media tools, they often don’t have access to the internet due to financial constraints. There are no easy solutions here. Employers need to ensure staff that have underlying health conditions are not exposed to such work environments, and to take swift action of removing staff that show any signs of being infected by corona virus. Regarding safety of the patient, AMHPs must go back to the guiding principles of the Mental health Act 1983 (amended 2007), specifically the least restrictive principle and ask- is a mental health act assessment really required and have all other means of engagement and treatment been explored? Has therapy been offered? What has worked or not worked for this person before?- and to proceed from there.
At huge costs to councils and trusts, independent companies are contracted to streamline processes and reduce bulky paperwork. These people have no experience in social care or mental health care. Given the circumstances, working from home could mean care staff giving feedback on forms they routinely use- for safeguarding procedures, Care Act assessments, care planning etc and for senior managers to trust that their frontline staff know their client group, relevant legislature and policies to make sensible, legally compliant and practical amendments. Needless to say, disproportionately, frontline staff are BAME, senior managers white (Kline, 2014), and external corporate staff also white (personal observation). Perhaps this can bring about a much needed balance in power in social care and address some of the institutional racism BAME staff face on a daily basis.
Other ways going forward is for academia, social workers and managers to have more dialogue and solidarity. Quality research and evidence based practice in collaboration with frontline staff can give the field of social work the credibility enjoyed by psychology and psychiatry. In turn, frontline staff need to use the support of literature and research and speak up when we see casual micro aggressions in our work places- calling out a colleague who is mockingly imitating ones accent, or speaking up when we see discrimination, such as at trainings where BAME senior managers are visibly absent. Academia, frontline staff, service users, carers, and managers all as a collective need to speak more to the media about social work. At the time of writing this article, 10 social workers have died from COVID 19 (Samuel, 2020). There has been no national coverage of these deaths. On the other hand, media and popular culture continues to portray negative stereotypes of social work. We know we are not a nosy, officious, goofy, needlessly rebellious, untidy, uneducated, alcoholic and generally dispensable lot.
So what are we?
Raksha Sidhu, Social Worker with specialist interest in mental health and anti-racist social work
Jones, R. (2019) Mental Health Act Manual, 22nd Edition, London : Sweet and Maxwell.
Kline, R. (2014) The “snowy white peaks” of the NHS: a survey discrimination in governance and leadership and the potential impact on patient care in London and England, Middlesex University Research Depository.
Samuel, M. (2020) 10 Social Workers have died fom COVID 19, official figures show, Community Care Online