The Social Care Practitioner as Assessor: ‘People, Relationships and Professional Judgement’

The Social Care Practitioner as Assessor: ‘People, Relationships and Professional Judgement’ Abstract The research in this paper aimed to reflect on English social care practitioners’ accounts of their assessment practices, and includes the point of view of disabled people who are assessed. The research took place just after the implementation of the 2014 Care Act, which focuses both on the ‘well-being’ principle and on outcomes defined by service users. We report here on a grounded theory analysis of thirty qualitative interviews with social care practitioners from four local authorities; the research was set up and conducted by and with disabled people, and included their insights at all stages, including analysis. We consider the positions taken by practitioners in relation to their clients and to the wider task of social work. We found that assessors saw themselves as allies of clients; almost a quarter of our participants had lived experience of disability themselves. However, they felt they had to exert professional judgement in deciding on the needs of those who lacked competence or who asked for too much. We suggest that assessment practices could benefit from a shift away from the individual towards societal barriers, and that some of the interactional problems in assessments may best be tackled via client-led training. Assessment, 2014 Care Act, collaboration, co-production, practitioners, professional practice Introduction and background Social work in England has long aspired to a collaborative exchange between service users and social workers (Whittington, 2007; Smale et al., 1993). The drive for a more personalised approach since the early twenty-first century (Department of Health, 2006) has signalled a redrawing of the professional social work task (Lymbery, 2014), to incorporate collaboration and citizen involvement (Lowndes and McCaughie, 2013). However, research about the position of social workers has regularly revealed fundamental tensions between (i) their powerful role as gate-keeper of resources and (ii) as advocate and ally of socially excluded citizens (Duffy, 2010; Murphy et al., 2013). In times of austerity, when resources are restricted, this tension becomes even more apparent. It has always been hard to reconcile an approach which listens to a client’s wishes with one that determines their ‘needs’ (Cambridge and Carnaby, 2005; Rummery, 2002). Nowhere is that contradiction more visible than at the stage of assessment, when decisions have to be made about an individual client’s eligibility (Slasberg and Beresford, 2016), while simultaneously empowering the client to take control of the process in a ‘person-centred’ manner (see Cambridge, 2008; Abendstern et al., 2008, for a review of these issues in the context of older people). Williams (2012) has summarised evidence about the difficulties of remaining ‘person-centred’ in assessments involving people with learning disabilities, which include the difficulties experienced by the individual who is used to discussing their ‘strengths’ rather than their needs. The 2014 Care Act brought together previously dispersed policy directives and guidance with an explicit focus on client well-being and ‘outcomes’ defined by clients, thus potentially resolving some of the dilemmas (Miller, 2010). The act again urges practitioners to carry out a person-centred process, in which one of the basic principles is that the client is ‘in control’ of the nature of the care to be provided (2014 Care Act: 1(2)). The default position, as Clements (2014) puts it, is that the individual is best placed to ‘judge their (own) wellbeing’ (p. 7). However, other tensions remain; for instance, the social work role has been severely constrained by limited budgets and resources (Lymbery, 2012; O’Rourke, 2014) and so the transformation towards a truly personalised system can only be managed by restricting eligibility (Slasberg and Beresford, 2016). The assessment thus might be the point at which some disabled people are at risk of losing or failing to attract funding (Harkes et al., 2014). With all this at stake, it is scarcely surprising that a truly equal exchange during an assessment is hard to achieve, and that an institutional power imbalance can dominate (Chevannes, 2002), despite frequent calls for co-produced social care (Richards, 2000; Needham, 2008; Leece and Leece, 2011). This paper considers how practitioners accounted for these tensions during the implementation of the English Care Act. Where previous research has pointed out the difficulties faced by social care practitioners, torn between person-centred practice and guardianship of the public purse, this paper explores those tensions anew in the light of the Care Act. The underlying research question was: ‘What can we learn from the insights of practising social care assessors, which will help the Care Act to achieve its objectives in creating a more “equal exchange” between assessor and assessed?’ Methodology The study on which this paper is based had a multi-phase mixed-methods design, represented in Figure 1. In this paper, we focus exclusively on Phase Two of the study, which consisted of interviews with thirty social care practitioners and managers. Throughout the research, we sought to achieve a participatory or co-produced approach. Aware of the problem of potential tokenism in co-production, we recruited two additional researchers with lived experience of disability onto the research team, as research associates. They were fully involved in data collection, analysis, planning and production, and are co-authors of this paper. This strategy complemented our work with nine disabled adults from a peer support network in the local centre for inclusive living, who formed a ‘co-research group’ which met on a monthly basis and assisted with the analysis presented in this paper. Three members of this group had previous experience as practitioners, as well as two of the core research team, and, after the recruitment of the two additional researchers, three of the core team also had direct experience as recipients of assessments. Thus, the mixing of identity throughout the project became an interesting basis on which to question and develop the research, for instance by including in the interview schedule for practitioners a question about lived experience of disability. Although we know from our previous work that people with learning disabilities might have distinct priorities about relational control and choice (Williams and Porter, 2015), a limitation of the study remained the lack of input from people with learning disabilities in the co-research group. There were two further phases, not reported here, but which also benefitted from the co-research approach. One was the recording of social care assessments ‘in action’ (seven recordings) and the other was a series of workshops delivered for practitioners and co-produced with members of the co-research group. Informed consent was obtained from participants in all phases of the overall study. Disabled people who had helped to set up the study, as well as practitioners, wanted the research to make a difference, and summaries of findings and impact were disseminated to all participants, with a final training DVD being produced which features members of the co-research group. Ethical approval was granted by the English Social Care Research Ethics Committee. This paper thus considers data from qualitative interviews, which took place in four local authorities. Participants were recruited via information handed out to team managers, and via researcher attendance at team meetings to explain the project. All those who consented to take part did so entirely voluntarily, and in confidence, by responding directly to the research team. Thirty practitioners were interviewed: sixteen social workers, eight ‘support workers’ without social work qualifications, one occupational therapist, three team managers and two advanced practitioners (see Table 1), all of whom were actively involved in social care assessments of disabled adults. The teams from which these practitioners were drawn included four generic community teams organised around ‘promoting independence’, a sensory impairment team, a learning disability team and a hospital discharge team. Table 1 Details of participants in interviews Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Social worker x x x x x x x x x x x x x x x x Support worker x x x x x x x x OT x Manager x x x Senior practitioner x x Experienced > 20 yrs x x x x x x x x x x x x Established 11–20 yrs x x x x x x Early career 6–10 yrs x x x x x x New < 6 yrs x x x x x x Family carer experience x x x x x x x x x x x x x Identified as disabled x x x x x x x Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Social worker x x x x x x x x x x x x x x x x Support worker x x x x x x x x OT x Manager x x x Senior practitioner x x Experienced > 20 yrs x x x x x x x x x x x x Established 11–20 yrs x x x x x x Early career 6–10 yrs x x x x x x New < 6 yrs x x x x x x Family carer experience x x x x x x x x x x x x x Identified as disabled x x x x x x x All participants were female, except (1) and (2), and all were white English, except for (16) black African and (21) British Asian. Table 1 Details of participants in interviews Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Social worker x x x x x x x x x x x x x x x x Support worker x x x x x x x x OT x Manager x x x Senior practitioner x x Experienced > 20 yrs x x x x x x x x x x x x Established 11–20 yrs x x x x x x Early career 6–10 yrs x x x x x x New < 6 yrs x x x x x x Family carer experience x x x x x x x x x x x x x Identified as disabled x x x x x x x Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Social worker x x x x x x x x x x x x x x x x Support worker x x x x x x x x OT x Manager x x x Senior practitioner x x Experienced > 20 yrs x x x x x x x x x x x x Established 11–20 yrs x x x x x x Early career 6–10 yrs x x x x x x New < 6 yrs x x x x x x Family carer experience x x x x x x x x x x x x x Identified as disabled x x x x x x x All participants were female, except (1) and (2), and all were white English, except for (16) black African and (21) British Asian. Figure 1: View largeDownload slide Phases of the research study: “The Values of Assessment”. Figure 1: View largeDownload slide Phases of the research study: “The Values of Assessment”. All had recent experience of assessing disabled adults and in this paper they are referred to by number, so that the reader can check back on an individual’s role, level of professional experience and lived experience of disability. There was a strong gender imbalance, with female dominating, and nearly all were white English by origin, which was a limitation of the study. Interviews followed a semi-structured format, which allowed flexibility in pursuing lines of enquiry as they emerged, with key opening questions, followed by probes and by following up participants’ concerns. A loose topic guide was followed, consisting of three main sections: questions about the participant, their background, motivation and experience; their own accounts of how assessments are conducted, including a specific question about their views on the difference made by the 2014 Care Act; their views on success factors and challenges, together with their own case examples; this included discussion of what might improve social care assessments. Analysis was informed by the principles of grounded theory in which detailed line-by-line coding and memo-writing (using NVivo 10) were carried out by the first four authors, in a ‘bottom-up’ data-driven approach (Charmaz, 2006). A summary of the main categories coded is given below, which were checked between three different coders for consistency. Connections between codes were then noted, with a view to creating cross-cutting themes which would be relevant to discuss with co-researchers. Throughout the second phase, the core research team sought out emerging themes and selected data which illustrated those themes. The audio extracts thus selected were taken to meetings with the co-research group, and played to them to prompt discussion, in order to identify and to validate or to challenge the coding we were developing. The eventual cross-cutting themes described in this paper thus aim to build a critique based on multiple viewpoints, but grounded very much in the discourse of the practitioners interviewed. Quotations from social care practitioners are numbered (see Table 1), so that they can be related back to the characteristics of each participant. Findings The themes discussed in this paper focus on the cross-cutting issues relating to positionality and dilemmas in social work assessments. These were sometimes discussed under the general heading of ‘clients’, sometimes as difficulties and often when considering practitioners’ own motivation and background. In summary, the themes are (i) social work assessments and social justice, (ii) balancing wants, needs and self-determination in clients, (iii) using your own identity in assessments, (iv) being at the interface between client and system and (v) using professional judgement. Social work assessments and social justice: I wanted to change the world In our co-research group, the most valued quality sought in practitioners was the genuine, deep, caring stance which was discernible in some of the data. Many of the practitioners in this research saw themselves as deeply aligned with the clients they met—a theme that was integral to job satisfaction, particularly in those who were qualified social workers. The overarching discourse on which they drew could be summarised as that of social justice: ‘I wanted to change the world when I first qualified, you know. Haven’t quite made it yet but you know! You ask all the social workers, they’ll all be the same’ (P03). The move between ‘I’ and ‘all the social workers’ in the above quotation neatly illustrates one of the discursive strategies used in signalling social justice as a key concern for the profession at large, setting oneself up as ‘typical’. However, the ‘haven’t quite made it yet’ is accompanied by laughter, and this type of self-humour was routine with qualified social workers, despite the more serious invocation of personal autonomy or ‘creativity’ as a motivator (P28) and the identity of seeing oneself as a pioneer, or ‘starting revolutions’ (P18). People shifted on a moment-by-moment basis between that tongue-in-cheek reflection on their own hopes and the real sense of serious commitment they felt—an ‘empathy’ that somehow came out in the personalised way they referred to clients. In the audio data, some of this empathy was audible via tone of voice, pausing or emotion when talking about particular clients, aspects which were particularly praised by members of the co-research group. Practitioners spoke about ‘face-to-face contact’ and their motivation in finding a role where they were engaged with people in society (P01); some had carried out voluntary work (P04; P28) or had friends who were disabled, and saw the theme of ‘helping’ as threading through their lives: ‘Even from a child, I was always wanting to help people’ (P08). How, then, did practitioners describe their actual experiences of social work? In general, participants said they had remained motivated, and had discovered job satisfaction. One of their key strategies for reflecting on their role was to set up a contrast between their own values and those of others in society who might judge social care clients in a negative way: ‘I like the challenge of advocating for something that perhaps society wouldn’t actually—that some people in society might find very difficult’ (P18). However, they also spoke of challenges at many levels in maintaining that positive view of themselves as practitioners, since, in the words of one social worker (P25), there can be a negative image of social work amongst clients themselves, particularly amongst those who may face child-protection issues, or conversely may only have contact with social workers when there may be cuts to their services. This was substantiated by more than one of our team, who told negative stories of the rigid way they had been assessed by some social workers who could be ‘very by-the-book, and one-size-fits-all’. The discourses available to social work professionals were thus still conflicting, as has been found previously, and ranged from the defensive stance of the embattled practitioner, misunderstood by society, to the personal testimony of a committed pioneer for social justice. Unqualified ‘support workers’ as well as social workers and managers used phrases from the Care Act, such as ‘well-being’, ‘advocating’ and ‘outcomes’, and these were strongly linked with reflective passages concerning the importance of stepping back from powerful positions, and encouraging clients to define their own life values: ‘It’s got to be proportionate. So you don’t have to fill in every box. If it’s an area that the customer has no concern about their well-being, or it doesn’t bother them, then it won’t bother us’ (P06). The principles of well-being, proportionality and the overriding principle of customer centred concerns were noticeable here. There was a quality of flexibility, an understanding that every client is different. Balancing wants, needs and self-determination All those in our research team who had lived experience of disability were particularly sensitive to the importance of self-determination in assessments. Some of the stories told by practitioners about individual cases reminded us of how it has felt to be out of control, without the ability to make decisions in one’s own home. Members of the co-research group talked particularly about social workers they had known who tried to ‘out-smart’ them and would make them feel stupid, as if they did not understand their own support needs. A discourse of competence and decision-making capacity was strongly in evidence when practitioners described some of the dilemmas they faced in practice. Although social workers and senior practitioners generally wished to support the agency of people who were socially excluded or disabled (P09; P18), they remarked that the wishes of some clients might be either overstated or understated. Fifteen of the thirty accounts from practitioners expressed concerns about the competence of some clients to determine their own needs; for instance, one practitioner (P04) told a story of someone whose children had been taken into care, information gained from the ‘records’, positioning the client as someone who is ‘known’. While consulting records is important, this was one of the instances where the co-research group challenged us as a team to consider the potentially threatening nature of record keeping about one’s own case. In the case described above by Practitioner 04, the precise points about children being taken into care further suggest the perspective of moral accountability of the client, although the practitioner’s own stance towards clients such as this is formulated as mild, benign and resistant to the problems. All this pre-work to the actual encounter is then mirrored in the catalogue of ‘chaotic’ problems which she learns about when visiting the client. Another example of this theme comes from a new social worker (P26) who described how she could go from a situation where a client had been trying to cope without admitting any needs into an assessment with an older woman who had experienced a stroke and ‘could just explain to me exactly what she could and couldn’t do’. Clients were seen possibly as unaware of their own needs, or conversely able to fabricate their needs. In both cases, the task of social work was somehow to get at the ‘truth’ and this was often done by appealing to family carers’ views: ‘Sometimes it’s definitely best for them to have their carer or other family members around them, and they can be incredibly supportive, and can help them to open up and say how things are’ (P01). There was a sense that clients needed considerable help to understand what support they should be having from social services; as one social worker (P08) neatly explained, ‘sometimes they need help but don’t want it, and sometimes they want help and don’t need it’. In the first category (need help but don’t want it), there were descriptions of people with mild learning disabilities who ‘fall through the gap’ (P26), some of whom were caring for children and on occasions adamantly refused social care supports (P04; P07; P10; P14) and also those with dementia or older people who may not have ever thought of themselves as needing any support (P27; P28). Clients were described who seemed unaware of the impact of their behaviour, or unaware of what an assessment was: ‘… you can’t always take the service user’s word, like they can say that they can do this, when actually they can’t’ (P26). Instead of seeing these people as extremely complex, problematic or indeed dangerous, four of the qualified social workers specifically mentioned they had normalised the problems, treating the person as ‘just another human being’. For instance, one female social worker had been allocated to a case where the client was perceived as dangerous, drug-addicted and potentially aggressive. His ability to make decisions for himself had also been called into question. However, on visiting him, she was able to learn more about his past and his identity as a travelling musician. His lifestyle choices were part of the picture which made him appear more ‘complex’ and her whole description of the case was one where the individual’s choices were seen as rational and proportionate (P28). Conversely, when someone was thought to be ‘playing the system’ (‘want help but don’t need it’), there was a sense of outrage, with the practitioner having to play the astute role of detective. One social worker (P17) talked about helping angry people, who had a ‘sense of entitlement’, and another described people who might be too ‘able’ to be eligible for care: People have actually said to me in the past, ‘I can’t do this and I can’t do that’, and ‘I need help with this and .that’, and I was like, actually that’s fascinating, because if you’ve got the ability to work that out, you probably haven’t got a learning disability! (P07). People with learning disabilities are seemingly not always believed and indeed, when they do speak up for themselves, they may be judged not to have a learning disability. The discourse about ‘undeserving’ people was prevalent in more than one account from the practitioners, with some clients being described as ‘sucking’ the system. Three practitioners mentioned previous Mental Capacity assessments of clients but, far more generally than that, the dimension of competence, or capacity, was overlaid on the actual problems with which disabled adults presented. Displaying too much capacity, as in the quotation above (P07), could make you count as undeserving; but displaying too little also led to mistrust of your decisions and autonomy as a client. In sum, clients were often deliberately talked up as ‘equal human beings’, but underlying that equality there was a complex tension between self-determination and being trustworthy. Using your own identity in assessments: having the ‘same sticks as him’ Despite the tensions involved in judging how far to allow a client to determine their own needs, almost all of the practitioners challenged any potential oppositional discourse between themselves and clients; instead they talked in ways that reflected their positioning ‘on side’ with service users, ‘helping people to make their own changes’ (P25). This was informed in thirteen accounts by their own experience of having been clients of social services, witnessing the treatment of a member of their family. For instance, one social worker (P18) said that she had a disabled sister who had died as a child and had seen how the family struggled ‘to get anything for her’. Another social worker (P11), in common with several others, drew on her experience of caring for a parent, who was considered mistakenly as having lost capability and autonomy, while another practitioner (P10) described how her own family did not want to take control at the point when they were in crisis: You know, the personal budget stuff. I do believe in it, I think that people should have choice and control if they want it, but I know for sure at that time that was the last thing that we wanted as a family (P10). Support workers as well (P02) talked about connecting with clients, finding out about their own values. Beyond family experience of disability, seven of our thirty practitioners identified themselves as disabled (or with past experience of disability). These seven practitioners felt that there was a benefit in being able to identify as a peer, with one support worker mentioning a ‘quick connection’ (P06) with the client, and the following social worker emphasising the visible signs of disability: So I do think that the use of self is really important in that, that he could see that I’d got the same sticks as him, you know, and that was an instant then, he could talk to me (P09). An experienced, senior practitioner (P12), who was a hearing-aid user, explicitly said that she would ‘tap into (her) deaf identity’ and use sign language when necessary within the deaf community. Not only did these practitioners stake a claim to empathise with the dilemmas of the client being assessed, but they trusted that a display of their own disability might foster greater trust at times and produce greater equity and mutual understanding. However, the whole issue of empathy and peer identity essentially broke down for some groups of clients, including often those with learning disabilities who were most unlikely to meet with an assessor who had the same impairment. Exact matching of impairment was acknowledged to be impossible, since everyone has multiple identities. What emerged as more important was a display of empathy, some breaking of the professional distance between assessor and assessed, and maybe also some evidence of shared interests, for instance appreciation of music in one case providing a common bond. Being at the interface between client and system Empathetic social work assessments cannot thus entirely depend on sharing of experience and another important position for practitioners was effectively that of an advocate: ‘We’re negotiating on behalf of the service-user, that interface between bureaucracy, agencies, you know, hard-set policy, and using discretion, and … yeah, influence to act for the service-user’ (P12). The very vocabulary chosen here is indicative of the fellow feeling for clients, who might see the ‘bureaucracy’ as ‘hard-set’. Faced with this type of hard-to-access system, what is needed in an assessment is someone who can provide both an empathetic face, but also an ‘interface’ with that system. Thus these practitioners seemed to conceptualise the relationship between the institution and the disabled person as in opposition (or at least as in tension). It should be mentioned that the single largest category coded under ‘Difficulty’ for social care practitioners was the sheer volume of work: ‘So how are we going to do quality support for people and provide good care, and have the time to do x, y and z’ (P15). The discourse of budgetary constraint was also predictably drawn on. One practitioner spoke up for striking a ‘balance’ and reminded the interviewer that the assessor is entrusted with ‘protecting the public money’ and being ‘careful’ (P17), with another senior practitioner reminding us about the ‘limited budget’ (P9). Clearly there are pressures reflected in these discourses of budgetary boundaries, lack of time and control by the ‘system’. This was also a point at which the co-research group challenged the analysis, to ensure that we foregrounded passages where practitioners positioned themselves as ‘allies’, with the task of assessment as a joint one. Practitioner and client see themselves, in these extracts, as jointly addressing an intractable system. Professional judgement Finally, a key organising principle for nearly all the practitioners in this study was the quality of ‘professional judgement’ which they had to exert. Since there were some differences between practitioners, the data here will be presented separately for two groupings: (i) eight unqualified staff (‘support workers’) who carried out assessments, as well as one occupational therapist; (ii) the sixteen qualified social workers, along with two experienced senior practitioners and three managers of services. Group 1: unqualified staff, support workers and occupational therapist The notion of professional decisions within this grouping appeared to revolve around what was seen as relevant and practical to the assessment. For instance, one support worker mentioned the decision about which needs dominated in a person with neurological and visual problems (P20) and another what particular aids might help someone to demonstrate their capacity (P19) and the extent to which a particular client may be able to manage their own personal care. Family carers were seen as often helpful sources about practical information. Nevertheless, a rehabilitation worker (P02), for instance, admitted that there was judgement involved in deciding whose voice to listen to when family members were present. There were at least fifteen examples discussed where there was a conflict between a ‘want’ and a ‘need’; for instance, an occupational therapist (P13) described a client who needed a separate bedroom because of a health condition, but was using their designated ‘spare bedroom’ as a store for their collections and hobbies, rather than for health-related needs. While the client did not want to move to a smaller home, the OT felt it would be better for her. With a small sample, we should beware of generalisation. Nevertheless, it could be that these non-qualified social work assessors were more likely than their qualified counterparts to reach their own judgement about what was best, and to restrict the demands made by clients. For instance, a support worker (P06) discussed a situation where she had to persuade a client that it was unreasonable to ask for support with her washing, and another (P18) described how she helped a client to think about more cost-effective, family-based support before accessing services (e.g. for shopping or cleaning) and even helped clients access cheaper sources of shopping for technological aids via the internet. It was clear that, in some cases, these practitioners were prepared to solve problems of demand and supply before the final demand for services. One support worker described how she sometimes had to adjust the scores to ensure a good outcome; and this again was where professional judgement came into play: ‘Sometimes there’s no box where you can put something in that’s important’ (P16). There was also perhaps more willingness in this group of participants to rely on their own observation in checking out someone’s needs: an OT (P13), for instance, described how she would ask a client to stand up or fetch a chair, so that she could observe how they actually managed, and a support worker commented that they calibrated their assessment of need according to the client’s personality or ‘the sort of person they are’ (P16). Observational methods of assessment can be controversial, since they embody the tension that may exist between practical solutions and surveillance. That issue will be taken up again below in the ‘Discussion’ section. Group 2 Professional judgement was equally salient as a theme amongst qualified social workers. For instance, the issues of demand and eligibility were understandably also key for them. Examples of situations in which judgement was required included assessments of older people whose families felt they needed more care than they were eligible for (P25) and where clients wanted resources for which the practitioner deemed them ineligible (P14). As another social worker put it: ‘And so when we talk about choice … if you’ve got the money, you’ve got the choice’ (P15). Some of these difficult decisions had been eased by the clarity of the Care Act in respect to eligibility criteria. However, when asked to think of examples, practitioners in both qualified and non-qualified groups were hard-pressed to recall any demands made on services which had literally been turned down because of lack of resources (P16; P18; P24) or where the outcomes rule had been put into practice. A second sub-theme here was that of the interactional accomplishment of the assessment encounter; though there were common concerns around demand and supply in both groupings, the qualified social workers were far more likely than support workers to focus on the ‘professional’ aspects of conducting a person-centred encounter in the assessment itself. They talked about micro judgements at every point during an assessment meeting in deciding what was relevant and useful: I guess there’s some level of professional judgement … you think ‘OK, no, this isn’t the time or place to ask about that, because it’s too sensitive’, or you know, ‘I can see this is a hugely emotional thing for them’ (P01). Finally, the notion of a ‘holistic’ assessment was also discussed by qualified social workers, and three accounts by experienced social workers discussed the way they would observe the whole context, the living conditions and the evidence around them of what the client could do—and what they might need: ‘It doesn’t hurt to say yes if they ask if you want a cup of tea … . It helps you make an assessment, are they able to use the kitchen safely’ (P08). At this point, the position of the social work role may seem to be a long way from the caring, empathetic and equitable ‘ally’ of clients. It is perhaps the reconciliation of some of these inherent tensions where the real skill of social work lies. Discussion While firmly highlighting relationship-focused social work, this study, like past research (Rummery, 2002; Cambridge, 2008), reflected tensions. The biggest of those tensions still seemed to be the uneasy mix of professional judgement with the nurturing of autonomy and control in the client. The clients described were diverse and could be seen overall as falling along a spectrum of self-determination and competence. At some point in this spectrum, there was a flip-over point at which practitioners started to question the competence of the client to decide on their own outcomes and needs, and many spoke of the need to include and involve family carers in assessments at that point. Consideration of the rights of clients under the 2005 Mental Capacity Act was mentioned by some, but seemed unconnected with the care assessment process itself. However, several of the stories of clients which they gave included many of the principles of supported decision making: breaking the decision down into separate steps; accompanying people on visits so that they could understand their options; and returning several times to discuss the decision. What was interesting about our study was the input of disabled people as co-researchers, as well as the range of perspectives represented in the university research team, which included three disabled people with experience of their own social care assessments. However, there were limitations in this approach. The team worked together in data collection and analysis, and thus specific views related to particular impairment groups may be lost in the consensus; further, there was an absence of focus on the issues for people with learning disabilities, who were not represented in the co-research group. Further research is needed to determine how they would experience and comment on social care assessment practices. As we explored above, the social work role was often portrayed as an interface between client and system, occupying a position in which their allegiances faced both ways, both towards the client, but also as a ‘representative of the system’. In practice, this meant that practitioners could feel powerless within a bureaucracy which shaped their own practice. Additionally, most of these practitioners said that quality social work was becoming more and more difficult because of the sheer pressure of the work-load, adding to arguments mounted by Lymbery (2012, 2014) about the crisis in social work. When asked about what most helped them in their role, the most common response related to the satisfaction they had in enabling a client to live the life which they had chosen. One can see the social work practitioner as interacting both with the client and with the ‘social care system’, but positioned at a decision-making nexus between the two, where the skill of professional judgement was a key to success. Additionally, the kind of support and direction received from the immediate team manager was always vital to the feeling of success amongst practitioners, particularly at times of change, when the 2014 Care Act is being introduced into practice. Despite the frequent worries about budgets, especially in the interviews with managers, there was no evidence that packages had been reduced because of budgetary constraints. However, at least five accounts of cases were given where practitioners had monitored and advised on how to frame a client’s needs, so that these conflicts would not arise. There was a remarkable degree of empathy from the co-researchers to these difficulties, and a suggestion for greater openness and honesty. If specific supports are not able to be funded by the ‘system’, they felt that limitation should be openly discussed with a client, rather than working out covert ways of determining eligibility. This open negotiation of constraints would be the first way to move maybe towards a more equal exchange. The data in this study were collected on the cusp of the 2014 Care Act implementation and so it may of course take time to embed into practice, which limits what we can claim about ‘Care Act assessments’. It was also limited in that the views of the actual clients described in practitioner interviews were not sought. Nevertheless, some of the Care Act principles were already firmly embedded. Practitioners in this study defended the rights of individuals whose own lifestyle might be criticised in general by society and they argued that these people were ordinary citizens, with the right to choose their own path in life. For them, then, well-being was about personalised outcomes; they strongly opposed a deficit model, and they positioned themselves as champions and allies of the disabled people they assessed, very much as in Hamilton et al.’s (2015) study of the relationships between social workers and people with mental health problems. To that extent, then, their accounts reflected positively the notion underlined by the Care Act that outcomes matter—that is, that each individual should be able to decide for themselves what outcomes they wish to achieve in life. This chimes very much with the model of person-centred planning (PCP) which has long been developed in learning disability services (Sanderson et al., 2002), characterised by informality, involvement of family and friends, and support to understand, express and take action in achieving one’s own outcomes. Incorporation of the learning from PCP practice with people with learning disabilities would, we suggest, also help to equalise the relationships involved in assessments more generally. As we have seen above, social workers in this study were both reflective and resilient, and felt that they were ‘more than robots’ in a system. They could be agents of change within their teams and to some extent in the wider social care system, as Lowndes and McCaughie (2013) point out. It could be argued that an individualised approach to the task of social care merely serves to treat each client as a source of need and problems, as has been argued by Dodd (2013, p. 262), who claims that ‘personalisation is insufficiently attentive to the collective dimension of disabled people’s struggle for empowerment’. The current paper lends weight to this argument: each client was seen, separately, as a problem which had to be solved. As Dodd argues, however, this ‘personal’ budget and solution for the individual is only one part of a wider agenda of ‘equality and citizenship’ (Dodd, 2013, p. 266). Some of the practitioners in this study were passionate or even angry about the lack of rights that disabled people have in society, and wanted to be part of redressing that wrong, very much aligning themselves with Tew’s (2006) framework for emancipatory practice and maybe also the ‘civic practice’ suggested by Harington and Beddoe (2014). Maybe that task could be best undertaken in partnership with disabled people and their organisations (Beresford, 2001; Sang, 2009) and follow the model where in this paper, where findings were discussed in a series of practitioner workshops designed and delivered with the co-researchers. Via role-played scenarios based on our data, we explored some of the problematic situations described in our data, where it was hard to focus on the individual’s needs and wishes. For instance, our research highlighted the issue of the role of ‘observation’ within an assessment, which can seem like surveillance to clients themselves, and we would suggest that this element of observation could be more openly acknowledged or discussed in assessments. The co-researchers’ group produced a set of training videos following the workshops (Values of Assessment, 2017) and we hope they will be used to enable practitioners and clients to jointly construct more person-centred exchanges. A wider view of practice will move the focus, however, beyond the individual practitioner and client: more research is needed to highlight how the system itself constrains social work practice, and how that system can be reshaped so that a more open and transparent assessment process is possible (Needham, 2011). Although the social model of disability (Oliver and Barnes, 2012) is widely held to be fundamental to social work, from the evidence of this study, assessments in particular are focused still on the outcomes, well-being and needs of the individual, while the social model has a much wider focus on the ways in which contexts and society may exclude or reinforce difficulties for disabled people. It was rare for assessors in this study to tackle societal barriers directly, and this undertaking is the most important part of the ‘joint enterprise’ which our co-researchers advocated. Acknowledgements Based on research carried out for the NIHR School for Social Care Research. This article summaries independent research funded by the National Institute for Health Research School for Social Care Research. The views expressed in this article are those of the author(s) and not necessarily those of the NIHR SSCR, NHS, the National Institute for Health Research or the Department of Health. References Abendstern M. , Clarkson P. , Challis D. , Hughes J. , Sutcliffe C. ( 2008 ) ‘Implementing the Single Assessment Process for older people in England: Lessons from the literature’ , Research, Policy and Planning , 26 ( 1 ), pp. 15 – 31 . Beresford P. ( 2001 ) ‘Service users, social policy and the future of welfare’ , Critical Social Policy , 21 ( 4 ), pp. 494 – 512 . Google Scholar CrossRef Search ADS Cambridge P. ( 2008 ) ‘The case for a new “case” management in services for people with learning disabilities’ , British Journal of Social Work , 38 ( 1 ), pp. 91 – 116 . Google Scholar CrossRef Search ADS Cambridge P. , Carnaby S. (eds) ( 2005 ) Person-Centred Planning and Care Management with People with Learning Disabilities , London , Jessica Kingsley Publishers . Charmaz K. ( 2006 ) Constructing Grounded Theory: A Practical Guide through Qualitative Analysis , London , Sage . Chevannes M. ( 2002 ) ‘ Social construction of the managerialism of needs assessment by health and social care professionals’ , Health and Social Care in the Community , 10 ( 3 ), pp. 168 – 78 . Google Scholar CrossRef Search ADS PubMed Clements L. ( 2014 ) The Care Act 2014 Overview (Revised 2017), available online at http://www.lukeclements.co.uk/care-act-2014-updated-briefing-january-2017/ (accessed 10 December 2017). Department of Health ( 2006 ) Our Health, Our Care, Our Say , London , Department of Health . Dodd S. ( 2013 ) ‘ Personalisation, individualism and the politics of disablement’, Disability & Society , 28 ( 2 ), pp. 260 – 73 . Google Scholar CrossRef Search ADS Duffy S. ( 2010 ) ‘ The citizenship theory of social justice: Exploring the meaning of personalisation for social workers’, Journal of Social Work Practice , 24 ( 3 ), pp. 253 – 67 . Google Scholar CrossRef Search ADS Hamilton S. , Tew J. , Szymczynska P. , Clewett N. , Manthorpe J. , Larsen J. , Pinfold V. 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( 2008 ) ‘ Realising the potential of co-production: Negotiating improvements in public services’ , Health and Social Care in the Community , 17 ( 5 ), pp. 343 – 446 . Needham C. ( 2011 ) ‘ Personalization: From story-line to practice’, Social Policy & Administration , 45 ( 1 ), pp. 54 – 68 . Google Scholar CrossRef Search ADS O’Rourke G. ( 2014 ) ‘Older people, personalisation and personhood: Towards user informed theory’, unpublished Ph.D. thesis, University of Bristol. Oliver M. , Barnes C. ( 2012 ) The New Politics of Disablement , Basingstoke , Palgrave Macmillan . Google Scholar CrossRef Search ADS Richards S. ( 2000 ) ‘ Bridging the divide: Elders and the assessment process’, British Journal of Social Work , 30 ( 1 ), pp. 37 – 49 . Google Scholar CrossRef Search ADS Rummery K. ( 2002 ) Disability, Citizenship and Community Care: A Case for Welfare Rights , Aldershot , Ashgate . Sanderson H. , Thompson J. , Kilbane J. ( 2002 ) The Emergence of Person Centred Planning as Evidence Based Practice, York, Helen Sanderson Associates, available online at http://www.in-control.org.uk/media/85688/person%20centred%20planning%20evidence-based%20practice.pdf (accessed 12 January 2018). Sang B. ( 2009 ) ‘ Personalisation: Consumer power or social co-production’, Journal of Integrated Care , 17 ( 4 ), pp. 31 – 8 . Google Scholar CrossRef Search ADS Slasberg C. , Beresford P. ( 2016 ) ‘ The eligibility question—the real source of depersonalisation?’ , Disability & Society , 31 ( 7 ), pp. 969 – 73 . Google Scholar CrossRef Search ADS Smale G. , Tuson G. , Biehal N. , Marsh P. ( 1993 ) Empowerment, Assessment, Care Management and the Skilled Worker , London , HMSO . Tew J. ( 2006 ) ‘ Understanding power and powerlessness’ , Journal of Social Work , 6 ( 1 ), pp. 33 – 51 . 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Care and Support (Eligibility Criteria) Regulations, 2015, available online at http://www.legislation.gov.uk/uksi/2015/313/pdfs/uksi_20150313_en.pdf (accessed 4 January 2018). 2005 Mental Capacity Act, c 9, available online at http://www.legislation.gov.uk/ukpga/2005/9/contents (accessed 4 January 2018). © The Author(s) 2018. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The British Journal of Social Work Oxford University Press

The Social Care Practitioner as Assessor: ‘People, Relationships and Professional Judgement’

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved.
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0045-3102
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1468-263X
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10.1093/bjsw/bcx154
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Abstract

Abstract The research in this paper aimed to reflect on English social care practitioners’ accounts of their assessment practices, and includes the point of view of disabled people who are assessed. The research took place just after the implementation of the 2014 Care Act, which focuses both on the ‘well-being’ principle and on outcomes defined by service users. We report here on a grounded theory analysis of thirty qualitative interviews with social care practitioners from four local authorities; the research was set up and conducted by and with disabled people, and included their insights at all stages, including analysis. We consider the positions taken by practitioners in relation to their clients and to the wider task of social work. We found that assessors saw themselves as allies of clients; almost a quarter of our participants had lived experience of disability themselves. However, they felt they had to exert professional judgement in deciding on the needs of those who lacked competence or who asked for too much. We suggest that assessment practices could benefit from a shift away from the individual towards societal barriers, and that some of the interactional problems in assessments may best be tackled via client-led training. Assessment, 2014 Care Act, collaboration, co-production, practitioners, professional practice Introduction and background Social work in England has long aspired to a collaborative exchange between service users and social workers (Whittington, 2007; Smale et al., 1993). The drive for a more personalised approach since the early twenty-first century (Department of Health, 2006) has signalled a redrawing of the professional social work task (Lymbery, 2014), to incorporate collaboration and citizen involvement (Lowndes and McCaughie, 2013). However, research about the position of social workers has regularly revealed fundamental tensions between (i) their powerful role as gate-keeper of resources and (ii) as advocate and ally of socially excluded citizens (Duffy, 2010; Murphy et al., 2013). In times of austerity, when resources are restricted, this tension becomes even more apparent. It has always been hard to reconcile an approach which listens to a client’s wishes with one that determines their ‘needs’ (Cambridge and Carnaby, 2005; Rummery, 2002). Nowhere is that contradiction more visible than at the stage of assessment, when decisions have to be made about an individual client’s eligibility (Slasberg and Beresford, 2016), while simultaneously empowering the client to take control of the process in a ‘person-centred’ manner (see Cambridge, 2008; Abendstern et al., 2008, for a review of these issues in the context of older people). Williams (2012) has summarised evidence about the difficulties of remaining ‘person-centred’ in assessments involving people with learning disabilities, which include the difficulties experienced by the individual who is used to discussing their ‘strengths’ rather than their needs. The 2014 Care Act brought together previously dispersed policy directives and guidance with an explicit focus on client well-being and ‘outcomes’ defined by clients, thus potentially resolving some of the dilemmas (Miller, 2010). The act again urges practitioners to carry out a person-centred process, in which one of the basic principles is that the client is ‘in control’ of the nature of the care to be provided (2014 Care Act: 1(2)). The default position, as Clements (2014) puts it, is that the individual is best placed to ‘judge their (own) wellbeing’ (p. 7). However, other tensions remain; for instance, the social work role has been severely constrained by limited budgets and resources (Lymbery, 2012; O’Rourke, 2014) and so the transformation towards a truly personalised system can only be managed by restricting eligibility (Slasberg and Beresford, 2016). The assessment thus might be the point at which some disabled people are at risk of losing or failing to attract funding (Harkes et al., 2014). With all this at stake, it is scarcely surprising that a truly equal exchange during an assessment is hard to achieve, and that an institutional power imbalance can dominate (Chevannes, 2002), despite frequent calls for co-produced social care (Richards, 2000; Needham, 2008; Leece and Leece, 2011). This paper considers how practitioners accounted for these tensions during the implementation of the English Care Act. Where previous research has pointed out the difficulties faced by social care practitioners, torn between person-centred practice and guardianship of the public purse, this paper explores those tensions anew in the light of the Care Act. The underlying research question was: ‘What can we learn from the insights of practising social care assessors, which will help the Care Act to achieve its objectives in creating a more “equal exchange” between assessor and assessed?’ Methodology The study on which this paper is based had a multi-phase mixed-methods design, represented in Figure 1. In this paper, we focus exclusively on Phase Two of the study, which consisted of interviews with thirty social care practitioners and managers. Throughout the research, we sought to achieve a participatory or co-produced approach. Aware of the problem of potential tokenism in co-production, we recruited two additional researchers with lived experience of disability onto the research team, as research associates. They were fully involved in data collection, analysis, planning and production, and are co-authors of this paper. This strategy complemented our work with nine disabled adults from a peer support network in the local centre for inclusive living, who formed a ‘co-research group’ which met on a monthly basis and assisted with the analysis presented in this paper. Three members of this group had previous experience as practitioners, as well as two of the core research team, and, after the recruitment of the two additional researchers, three of the core team also had direct experience as recipients of assessments. Thus, the mixing of identity throughout the project became an interesting basis on which to question and develop the research, for instance by including in the interview schedule for practitioners a question about lived experience of disability. Although we know from our previous work that people with learning disabilities might have distinct priorities about relational control and choice (Williams and Porter, 2015), a limitation of the study remained the lack of input from people with learning disabilities in the co-research group. There were two further phases, not reported here, but which also benefitted from the co-research approach. One was the recording of social care assessments ‘in action’ (seven recordings) and the other was a series of workshops delivered for practitioners and co-produced with members of the co-research group. Informed consent was obtained from participants in all phases of the overall study. Disabled people who had helped to set up the study, as well as practitioners, wanted the research to make a difference, and summaries of findings and impact were disseminated to all participants, with a final training DVD being produced which features members of the co-research group. Ethical approval was granted by the English Social Care Research Ethics Committee. This paper thus considers data from qualitative interviews, which took place in four local authorities. Participants were recruited via information handed out to team managers, and via researcher attendance at team meetings to explain the project. All those who consented to take part did so entirely voluntarily, and in confidence, by responding directly to the research team. Thirty practitioners were interviewed: sixteen social workers, eight ‘support workers’ without social work qualifications, one occupational therapist, three team managers and two advanced practitioners (see Table 1), all of whom were actively involved in social care assessments of disabled adults. The teams from which these practitioners were drawn included four generic community teams organised around ‘promoting independence’, a sensory impairment team, a learning disability team and a hospital discharge team. Table 1 Details of participants in interviews Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Social worker x x x x x x x x x x x x x x x x Support worker x x x x x x x x OT x Manager x x x Senior practitioner x x Experienced > 20 yrs x x x x x x x x x x x x Established 11–20 yrs x x x x x x Early career 6–10 yrs x x x x x x New < 6 yrs x x x x x x Family carer experience x x x x x x x x x x x x x Identified as disabled x x x x x x x Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Social worker x x x x x x x x x x x x x x x x Support worker x x x x x x x x OT x Manager x x x Senior practitioner x x Experienced > 20 yrs x x x x x x x x x x x x Established 11–20 yrs x x x x x x Early career 6–10 yrs x x x x x x New < 6 yrs x x x x x x Family carer experience x x x x x x x x x x x x x Identified as disabled x x x x x x x All participants were female, except (1) and (2), and all were white English, except for (16) black African and (21) British Asian. Table 1 Details of participants in interviews Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Social worker x x x x x x x x x x x x x x x x Support worker x x x x x x x x OT x Manager x x x Senior practitioner x x Experienced > 20 yrs x x x x x x x x x x x x Established 11–20 yrs x x x x x x Early career 6–10 yrs x x x x x x New < 6 yrs x x x x x x Family carer experience x x x x x x x x x x x x x Identified as disabled x x x x x x x Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Social worker x x x x x x x x x x x x x x x x Support worker x x x x x x x x OT x Manager x x x Senior practitioner x x Experienced > 20 yrs x x x x x x x x x x x x Established 11–20 yrs x x x x x x Early career 6–10 yrs x x x x x x New < 6 yrs x x x x x x Family carer experience x x x x x x x x x x x x x Identified as disabled x x x x x x x All participants were female, except (1) and (2), and all were white English, except for (16) black African and (21) British Asian. Figure 1: View largeDownload slide Phases of the research study: “The Values of Assessment”. Figure 1: View largeDownload slide Phases of the research study: “The Values of Assessment”. All had recent experience of assessing disabled adults and in this paper they are referred to by number, so that the reader can check back on an individual’s role, level of professional experience and lived experience of disability. There was a strong gender imbalance, with female dominating, and nearly all were white English by origin, which was a limitation of the study. Interviews followed a semi-structured format, which allowed flexibility in pursuing lines of enquiry as they emerged, with key opening questions, followed by probes and by following up participants’ concerns. A loose topic guide was followed, consisting of three main sections: questions about the participant, their background, motivation and experience; their own accounts of how assessments are conducted, including a specific question about their views on the difference made by the 2014 Care Act; their views on success factors and challenges, together with their own case examples; this included discussion of what might improve social care assessments. Analysis was informed by the principles of grounded theory in which detailed line-by-line coding and memo-writing (using NVivo 10) were carried out by the first four authors, in a ‘bottom-up’ data-driven approach (Charmaz, 2006). A summary of the main categories coded is given below, which were checked between three different coders for consistency. Connections between codes were then noted, with a view to creating cross-cutting themes which would be relevant to discuss with co-researchers. Throughout the second phase, the core research team sought out emerging themes and selected data which illustrated those themes. The audio extracts thus selected were taken to meetings with the co-research group, and played to them to prompt discussion, in order to identify and to validate or to challenge the coding we were developing. The eventual cross-cutting themes described in this paper thus aim to build a critique based on multiple viewpoints, but grounded very much in the discourse of the practitioners interviewed. Quotations from social care practitioners are numbered (see Table 1), so that they can be related back to the characteristics of each participant. Findings The themes discussed in this paper focus on the cross-cutting issues relating to positionality and dilemmas in social work assessments. These were sometimes discussed under the general heading of ‘clients’, sometimes as difficulties and often when considering practitioners’ own motivation and background. In summary, the themes are (i) social work assessments and social justice, (ii) balancing wants, needs and self-determination in clients, (iii) using your own identity in assessments, (iv) being at the interface between client and system and (v) using professional judgement. Social work assessments and social justice: I wanted to change the world In our co-research group, the most valued quality sought in practitioners was the genuine, deep, caring stance which was discernible in some of the data. Many of the practitioners in this research saw themselves as deeply aligned with the clients they met—a theme that was integral to job satisfaction, particularly in those who were qualified social workers. The overarching discourse on which they drew could be summarised as that of social justice: ‘I wanted to change the world when I first qualified, you know. Haven’t quite made it yet but you know! You ask all the social workers, they’ll all be the same’ (P03). The move between ‘I’ and ‘all the social workers’ in the above quotation neatly illustrates one of the discursive strategies used in signalling social justice as a key concern for the profession at large, setting oneself up as ‘typical’. However, the ‘haven’t quite made it yet’ is accompanied by laughter, and this type of self-humour was routine with qualified social workers, despite the more serious invocation of personal autonomy or ‘creativity’ as a motivator (P28) and the identity of seeing oneself as a pioneer, or ‘starting revolutions’ (P18). People shifted on a moment-by-moment basis between that tongue-in-cheek reflection on their own hopes and the real sense of serious commitment they felt—an ‘empathy’ that somehow came out in the personalised way they referred to clients. In the audio data, some of this empathy was audible via tone of voice, pausing or emotion when talking about particular clients, aspects which were particularly praised by members of the co-research group. Practitioners spoke about ‘face-to-face contact’ and their motivation in finding a role where they were engaged with people in society (P01); some had carried out voluntary work (P04; P28) or had friends who were disabled, and saw the theme of ‘helping’ as threading through their lives: ‘Even from a child, I was always wanting to help people’ (P08). How, then, did practitioners describe their actual experiences of social work? In general, participants said they had remained motivated, and had discovered job satisfaction. One of their key strategies for reflecting on their role was to set up a contrast between their own values and those of others in society who might judge social care clients in a negative way: ‘I like the challenge of advocating for something that perhaps society wouldn’t actually—that some people in society might find very difficult’ (P18). However, they also spoke of challenges at many levels in maintaining that positive view of themselves as practitioners, since, in the words of one social worker (P25), there can be a negative image of social work amongst clients themselves, particularly amongst those who may face child-protection issues, or conversely may only have contact with social workers when there may be cuts to their services. This was substantiated by more than one of our team, who told negative stories of the rigid way they had been assessed by some social workers who could be ‘very by-the-book, and one-size-fits-all’. The discourses available to social work professionals were thus still conflicting, as has been found previously, and ranged from the defensive stance of the embattled practitioner, misunderstood by society, to the personal testimony of a committed pioneer for social justice. Unqualified ‘support workers’ as well as social workers and managers used phrases from the Care Act, such as ‘well-being’, ‘advocating’ and ‘outcomes’, and these were strongly linked with reflective passages concerning the importance of stepping back from powerful positions, and encouraging clients to define their own life values: ‘It’s got to be proportionate. So you don’t have to fill in every box. If it’s an area that the customer has no concern about their well-being, or it doesn’t bother them, then it won’t bother us’ (P06). The principles of well-being, proportionality and the overriding principle of customer centred concerns were noticeable here. There was a quality of flexibility, an understanding that every client is different. Balancing wants, needs and self-determination All those in our research team who had lived experience of disability were particularly sensitive to the importance of self-determination in assessments. Some of the stories told by practitioners about individual cases reminded us of how it has felt to be out of control, without the ability to make decisions in one’s own home. Members of the co-research group talked particularly about social workers they had known who tried to ‘out-smart’ them and would make them feel stupid, as if they did not understand their own support needs. A discourse of competence and decision-making capacity was strongly in evidence when practitioners described some of the dilemmas they faced in practice. Although social workers and senior practitioners generally wished to support the agency of people who were socially excluded or disabled (P09; P18), they remarked that the wishes of some clients might be either overstated or understated. Fifteen of the thirty accounts from practitioners expressed concerns about the competence of some clients to determine their own needs; for instance, one practitioner (P04) told a story of someone whose children had been taken into care, information gained from the ‘records’, positioning the client as someone who is ‘known’. While consulting records is important, this was one of the instances where the co-research group challenged us as a team to consider the potentially threatening nature of record keeping about one’s own case. In the case described above by Practitioner 04, the precise points about children being taken into care further suggest the perspective of moral accountability of the client, although the practitioner’s own stance towards clients such as this is formulated as mild, benign and resistant to the problems. All this pre-work to the actual encounter is then mirrored in the catalogue of ‘chaotic’ problems which she learns about when visiting the client. Another example of this theme comes from a new social worker (P26) who described how she could go from a situation where a client had been trying to cope without admitting any needs into an assessment with an older woman who had experienced a stroke and ‘could just explain to me exactly what she could and couldn’t do’. Clients were seen possibly as unaware of their own needs, or conversely able to fabricate their needs. In both cases, the task of social work was somehow to get at the ‘truth’ and this was often done by appealing to family carers’ views: ‘Sometimes it’s definitely best for them to have their carer or other family members around them, and they can be incredibly supportive, and can help them to open up and say how things are’ (P01). There was a sense that clients needed considerable help to understand what support they should be having from social services; as one social worker (P08) neatly explained, ‘sometimes they need help but don’t want it, and sometimes they want help and don’t need it’. In the first category (need help but don’t want it), there were descriptions of people with mild learning disabilities who ‘fall through the gap’ (P26), some of whom were caring for children and on occasions adamantly refused social care supports (P04; P07; P10; P14) and also those with dementia or older people who may not have ever thought of themselves as needing any support (P27; P28). Clients were described who seemed unaware of the impact of their behaviour, or unaware of what an assessment was: ‘… you can’t always take the service user’s word, like they can say that they can do this, when actually they can’t’ (P26). Instead of seeing these people as extremely complex, problematic or indeed dangerous, four of the qualified social workers specifically mentioned they had normalised the problems, treating the person as ‘just another human being’. For instance, one female social worker had been allocated to a case where the client was perceived as dangerous, drug-addicted and potentially aggressive. His ability to make decisions for himself had also been called into question. However, on visiting him, she was able to learn more about his past and his identity as a travelling musician. His lifestyle choices were part of the picture which made him appear more ‘complex’ and her whole description of the case was one where the individual’s choices were seen as rational and proportionate (P28). Conversely, when someone was thought to be ‘playing the system’ (‘want help but don’t need it’), there was a sense of outrage, with the practitioner having to play the astute role of detective. One social worker (P17) talked about helping angry people, who had a ‘sense of entitlement’, and another described people who might be too ‘able’ to be eligible for care: People have actually said to me in the past, ‘I can’t do this and I can’t do that’, and ‘I need help with this and .that’, and I was like, actually that’s fascinating, because if you’ve got the ability to work that out, you probably haven’t got a learning disability! (P07). People with learning disabilities are seemingly not always believed and indeed, when they do speak up for themselves, they may be judged not to have a learning disability. The discourse about ‘undeserving’ people was prevalent in more than one account from the practitioners, with some clients being described as ‘sucking’ the system. Three practitioners mentioned previous Mental Capacity assessments of clients but, far more generally than that, the dimension of competence, or capacity, was overlaid on the actual problems with which disabled adults presented. Displaying too much capacity, as in the quotation above (P07), could make you count as undeserving; but displaying too little also led to mistrust of your decisions and autonomy as a client. In sum, clients were often deliberately talked up as ‘equal human beings’, but underlying that equality there was a complex tension between self-determination and being trustworthy. Using your own identity in assessments: having the ‘same sticks as him’ Despite the tensions involved in judging how far to allow a client to determine their own needs, almost all of the practitioners challenged any potential oppositional discourse between themselves and clients; instead they talked in ways that reflected their positioning ‘on side’ with service users, ‘helping people to make their own changes’ (P25). This was informed in thirteen accounts by their own experience of having been clients of social services, witnessing the treatment of a member of their family. For instance, one social worker (P18) said that she had a disabled sister who had died as a child and had seen how the family struggled ‘to get anything for her’. Another social worker (P11), in common with several others, drew on her experience of caring for a parent, who was considered mistakenly as having lost capability and autonomy, while another practitioner (P10) described how her own family did not want to take control at the point when they were in crisis: You know, the personal budget stuff. I do believe in it, I think that people should have choice and control if they want it, but I know for sure at that time that was the last thing that we wanted as a family (P10). Support workers as well (P02) talked about connecting with clients, finding out about their own values. Beyond family experience of disability, seven of our thirty practitioners identified themselves as disabled (or with past experience of disability). These seven practitioners felt that there was a benefit in being able to identify as a peer, with one support worker mentioning a ‘quick connection’ (P06) with the client, and the following social worker emphasising the visible signs of disability: So I do think that the use of self is really important in that, that he could see that I’d got the same sticks as him, you know, and that was an instant then, he could talk to me (P09). An experienced, senior practitioner (P12), who was a hearing-aid user, explicitly said that she would ‘tap into (her) deaf identity’ and use sign language when necessary within the deaf community. Not only did these practitioners stake a claim to empathise with the dilemmas of the client being assessed, but they trusted that a display of their own disability might foster greater trust at times and produce greater equity and mutual understanding. However, the whole issue of empathy and peer identity essentially broke down for some groups of clients, including often those with learning disabilities who were most unlikely to meet with an assessor who had the same impairment. Exact matching of impairment was acknowledged to be impossible, since everyone has multiple identities. What emerged as more important was a display of empathy, some breaking of the professional distance between assessor and assessed, and maybe also some evidence of shared interests, for instance appreciation of music in one case providing a common bond. Being at the interface between client and system Empathetic social work assessments cannot thus entirely depend on sharing of experience and another important position for practitioners was effectively that of an advocate: ‘We’re negotiating on behalf of the service-user, that interface between bureaucracy, agencies, you know, hard-set policy, and using discretion, and … yeah, influence to act for the service-user’ (P12). The very vocabulary chosen here is indicative of the fellow feeling for clients, who might see the ‘bureaucracy’ as ‘hard-set’. Faced with this type of hard-to-access system, what is needed in an assessment is someone who can provide both an empathetic face, but also an ‘interface’ with that system. Thus these practitioners seemed to conceptualise the relationship between the institution and the disabled person as in opposition (or at least as in tension). It should be mentioned that the single largest category coded under ‘Difficulty’ for social care practitioners was the sheer volume of work: ‘So how are we going to do quality support for people and provide good care, and have the time to do x, y and z’ (P15). The discourse of budgetary constraint was also predictably drawn on. One practitioner spoke up for striking a ‘balance’ and reminded the interviewer that the assessor is entrusted with ‘protecting the public money’ and being ‘careful’ (P17), with another senior practitioner reminding us about the ‘limited budget’ (P9). Clearly there are pressures reflected in these discourses of budgetary boundaries, lack of time and control by the ‘system’. This was also a point at which the co-research group challenged the analysis, to ensure that we foregrounded passages where practitioners positioned themselves as ‘allies’, with the task of assessment as a joint one. Practitioner and client see themselves, in these extracts, as jointly addressing an intractable system. Professional judgement Finally, a key organising principle for nearly all the practitioners in this study was the quality of ‘professional judgement’ which they had to exert. Since there were some differences between practitioners, the data here will be presented separately for two groupings: (i) eight unqualified staff (‘support workers’) who carried out assessments, as well as one occupational therapist; (ii) the sixteen qualified social workers, along with two experienced senior practitioners and three managers of services. Group 1: unqualified staff, support workers and occupational therapist The notion of professional decisions within this grouping appeared to revolve around what was seen as relevant and practical to the assessment. For instance, one support worker mentioned the decision about which needs dominated in a person with neurological and visual problems (P20) and another what particular aids might help someone to demonstrate their capacity (P19) and the extent to which a particular client may be able to manage their own personal care. Family carers were seen as often helpful sources about practical information. Nevertheless, a rehabilitation worker (P02), for instance, admitted that there was judgement involved in deciding whose voice to listen to when family members were present. There were at least fifteen examples discussed where there was a conflict between a ‘want’ and a ‘need’; for instance, an occupational therapist (P13) described a client who needed a separate bedroom because of a health condition, but was using their designated ‘spare bedroom’ as a store for their collections and hobbies, rather than for health-related needs. While the client did not want to move to a smaller home, the OT felt it would be better for her. With a small sample, we should beware of generalisation. Nevertheless, it could be that these non-qualified social work assessors were more likely than their qualified counterparts to reach their own judgement about what was best, and to restrict the demands made by clients. For instance, a support worker (P06) discussed a situation where she had to persuade a client that it was unreasonable to ask for support with her washing, and another (P18) described how she helped a client to think about more cost-effective, family-based support before accessing services (e.g. for shopping or cleaning) and even helped clients access cheaper sources of shopping for technological aids via the internet. It was clear that, in some cases, these practitioners were prepared to solve problems of demand and supply before the final demand for services. One support worker described how she sometimes had to adjust the scores to ensure a good outcome; and this again was where professional judgement came into play: ‘Sometimes there’s no box where you can put something in that’s important’ (P16). There was also perhaps more willingness in this group of participants to rely on their own observation in checking out someone’s needs: an OT (P13), for instance, described how she would ask a client to stand up or fetch a chair, so that she could observe how they actually managed, and a support worker commented that they calibrated their assessment of need according to the client’s personality or ‘the sort of person they are’ (P16). Observational methods of assessment can be controversial, since they embody the tension that may exist between practical solutions and surveillance. That issue will be taken up again below in the ‘Discussion’ section. Group 2 Professional judgement was equally salient as a theme amongst qualified social workers. For instance, the issues of demand and eligibility were understandably also key for them. Examples of situations in which judgement was required included assessments of older people whose families felt they needed more care than they were eligible for (P25) and where clients wanted resources for which the practitioner deemed them ineligible (P14). As another social worker put it: ‘And so when we talk about choice … if you’ve got the money, you’ve got the choice’ (P15). Some of these difficult decisions had been eased by the clarity of the Care Act in respect to eligibility criteria. However, when asked to think of examples, practitioners in both qualified and non-qualified groups were hard-pressed to recall any demands made on services which had literally been turned down because of lack of resources (P16; P18; P24) or where the outcomes rule had been put into practice. A second sub-theme here was that of the interactional accomplishment of the assessment encounter; though there were common concerns around demand and supply in both groupings, the qualified social workers were far more likely than support workers to focus on the ‘professional’ aspects of conducting a person-centred encounter in the assessment itself. They talked about micro judgements at every point during an assessment meeting in deciding what was relevant and useful: I guess there’s some level of professional judgement … you think ‘OK, no, this isn’t the time or place to ask about that, because it’s too sensitive’, or you know, ‘I can see this is a hugely emotional thing for them’ (P01). Finally, the notion of a ‘holistic’ assessment was also discussed by qualified social workers, and three accounts by experienced social workers discussed the way they would observe the whole context, the living conditions and the evidence around them of what the client could do—and what they might need: ‘It doesn’t hurt to say yes if they ask if you want a cup of tea … . It helps you make an assessment, are they able to use the kitchen safely’ (P08). At this point, the position of the social work role may seem to be a long way from the caring, empathetic and equitable ‘ally’ of clients. It is perhaps the reconciliation of some of these inherent tensions where the real skill of social work lies. Discussion While firmly highlighting relationship-focused social work, this study, like past research (Rummery, 2002; Cambridge, 2008), reflected tensions. The biggest of those tensions still seemed to be the uneasy mix of professional judgement with the nurturing of autonomy and control in the client. The clients described were diverse and could be seen overall as falling along a spectrum of self-determination and competence. At some point in this spectrum, there was a flip-over point at which practitioners started to question the competence of the client to decide on their own outcomes and needs, and many spoke of the need to include and involve family carers in assessments at that point. Consideration of the rights of clients under the 2005 Mental Capacity Act was mentioned by some, but seemed unconnected with the care assessment process itself. However, several of the stories of clients which they gave included many of the principles of supported decision making: breaking the decision down into separate steps; accompanying people on visits so that they could understand their options; and returning several times to discuss the decision. What was interesting about our study was the input of disabled people as co-researchers, as well as the range of perspectives represented in the university research team, which included three disabled people with experience of their own social care assessments. However, there were limitations in this approach. The team worked together in data collection and analysis, and thus specific views related to particular impairment groups may be lost in the consensus; further, there was an absence of focus on the issues for people with learning disabilities, who were not represented in the co-research group. Further research is needed to determine how they would experience and comment on social care assessment practices. As we explored above, the social work role was often portrayed as an interface between client and system, occupying a position in which their allegiances faced both ways, both towards the client, but also as a ‘representative of the system’. In practice, this meant that practitioners could feel powerless within a bureaucracy which shaped their own practice. Additionally, most of these practitioners said that quality social work was becoming more and more difficult because of the sheer pressure of the work-load, adding to arguments mounted by Lymbery (2012, 2014) about the crisis in social work. When asked about what most helped them in their role, the most common response related to the satisfaction they had in enabling a client to live the life which they had chosen. One can see the social work practitioner as interacting both with the client and with the ‘social care system’, but positioned at a decision-making nexus between the two, where the skill of professional judgement was a key to success. Additionally, the kind of support and direction received from the immediate team manager was always vital to the feeling of success amongst practitioners, particularly at times of change, when the 2014 Care Act is being introduced into practice. Despite the frequent worries about budgets, especially in the interviews with managers, there was no evidence that packages had been reduced because of budgetary constraints. However, at least five accounts of cases were given where practitioners had monitored and advised on how to frame a client’s needs, so that these conflicts would not arise. There was a remarkable degree of empathy from the co-researchers to these difficulties, and a suggestion for greater openness and honesty. If specific supports are not able to be funded by the ‘system’, they felt that limitation should be openly discussed with a client, rather than working out covert ways of determining eligibility. This open negotiation of constraints would be the first way to move maybe towards a more equal exchange. The data in this study were collected on the cusp of the 2014 Care Act implementation and so it may of course take time to embed into practice, which limits what we can claim about ‘Care Act assessments’. It was also limited in that the views of the actual clients described in practitioner interviews were not sought. Nevertheless, some of the Care Act principles were already firmly embedded. Practitioners in this study defended the rights of individuals whose own lifestyle might be criticised in general by society and they argued that these people were ordinary citizens, with the right to choose their own path in life. For them, then, well-being was about personalised outcomes; they strongly opposed a deficit model, and they positioned themselves as champions and allies of the disabled people they assessed, very much as in Hamilton et al.’s (2015) study of the relationships between social workers and people with mental health problems. To that extent, then, their accounts reflected positively the notion underlined by the Care Act that outcomes matter—that is, that each individual should be able to decide for themselves what outcomes they wish to achieve in life. This chimes very much with the model of person-centred planning (PCP) which has long been developed in learning disability services (Sanderson et al., 2002), characterised by informality, involvement of family and friends, and support to understand, express and take action in achieving one’s own outcomes. Incorporation of the learning from PCP practice with people with learning disabilities would, we suggest, also help to equalise the relationships involved in assessments more generally. As we have seen above, social workers in this study were both reflective and resilient, and felt that they were ‘more than robots’ in a system. They could be agents of change within their teams and to some extent in the wider social care system, as Lowndes and McCaughie (2013) point out. It could be argued that an individualised approach to the task of social care merely serves to treat each client as a source of need and problems, as has been argued by Dodd (2013, p. 262), who claims that ‘personalisation is insufficiently attentive to the collective dimension of disabled people’s struggle for empowerment’. The current paper lends weight to this argument: each client was seen, separately, as a problem which had to be solved. As Dodd argues, however, this ‘personal’ budget and solution for the individual is only one part of a wider agenda of ‘equality and citizenship’ (Dodd, 2013, p. 266). Some of the practitioners in this study were passionate or even angry about the lack of rights that disabled people have in society, and wanted to be part of redressing that wrong, very much aligning themselves with Tew’s (2006) framework for emancipatory practice and maybe also the ‘civic practice’ suggested by Harington and Beddoe (2014). Maybe that task could be best undertaken in partnership with disabled people and their organisations (Beresford, 2001; Sang, 2009) and follow the model where in this paper, where findings were discussed in a series of practitioner workshops designed and delivered with the co-researchers. Via role-played scenarios based on our data, we explored some of the problematic situations described in our data, where it was hard to focus on the individual’s needs and wishes. For instance, our research highlighted the issue of the role of ‘observation’ within an assessment, which can seem like surveillance to clients themselves, and we would suggest that this element of observation could be more openly acknowledged or discussed in assessments. The co-researchers’ group produced a set of training videos following the workshops (Values of Assessment, 2017) and we hope they will be used to enable practitioners and clients to jointly construct more person-centred exchanges. A wider view of practice will move the focus, however, beyond the individual practitioner and client: more research is needed to highlight how the system itself constrains social work practice, and how that system can be reshaped so that a more open and transparent assessment process is possible (Needham, 2011). Although the social model of disability (Oliver and Barnes, 2012) is widely held to be fundamental to social work, from the evidence of this study, assessments in particular are focused still on the outcomes, well-being and needs of the individual, while the social model has a much wider focus on the ways in which contexts and society may exclude or reinforce difficulties for disabled people. It was rare for assessors in this study to tackle societal barriers directly, and this undertaking is the most important part of the ‘joint enterprise’ which our co-researchers advocated. Acknowledgements Based on research carried out for the NIHR School for Social Care Research. This article summaries independent research funded by the National Institute for Health Research School for Social Care Research. The views expressed in this article are those of the author(s) and not necessarily those of the NIHR SSCR, NHS, the National Institute for Health Research or the Department of Health. 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The British Journal of Social WorkOxford University Press

Published: Feb 8, 2018

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