Professionalism, Boundaries and the Workplace

Nigel Malin

• Publisher: Routledge
• Year: 2002
• eBook ISBN: 9781134651597
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Professionalism, Boundaries and the Workplace is a practical text that examines a range of sensitive issues concerned with managing and maintaining professional boundaries between worker and client. It uses experiences from probation, social work, the NHS, small business and church settings. A number of issues are addressed including:
*the relationship between personal and professional values
*changing professional-client relationships
*definitions of 'being professional'
*conflicts arising from different understandings of professionalism.

Part I

Professionalism, boundaries and the health/social care context

1 Professionalism and boundaries of the formal sector

The example of social and community care

Nigel Malin

Introduction

This chapter focuses on policy directions for social and community care within the UK and assesses change and development for the caring professions. In part, the shifting, peripheral and unspecified nature of care in the community is blamed for the failure of groups to professionalise, gain control and achieve closure status. In addition the mixed economy of care has tended to emphasise the need for staff to possess appropriate values, skills and attitudes, and for this to have greater importance than forms of academic training. A drive to ‘modernise’ health and social care services led by central government in the late 1990s has been accompanied by the search for an underpinning knowledge-base, and also for greater professional and hierarchical accountability. The argument is that this is creating a challenge for caring professions and is leading to the development of different types of expertise within social care.

Policy origins and developments

Social and community care arose in part as an outcome of de-institutionalisation. The 1957 Royal Commission on the Law Relating to Mental Illness and Mental Deficiency had concluded that ‘it is not now generally considered in the best interests of patients who are fit to live in the general community that they should be in large or remote institutions such as the present mental or mental deficiency hospitals’ (Ministry of Health 1957: 17, para. 46). Yet the Commission’s vision of community care was founded on provision of a range of centres offering training, occupation or social activity and residential accommodation in private, voluntary and local authority homes and hostels. The idea of community care was not advanced as a principle during the 1960s chiefly because of lack of attention from central government and poor – almost invisible – co-ordination of services at local level. Barham’s (1992) book covering mental health policy states that ‘the declarations of government policy in this period represented not so much a new departure as an assertive formulation of trends that were already taking place’ (ibid.: 11). Social and community care were unspecified ‘simply because the character of the ex-mental patient in the community remained to a large degree unspecified’ (ibid.: 12).

Community care facilities at this time were envisaged as transitional stepping-stones between a brief period of hospitalisation and full re-integration into the community. A transitional period in a rehabilitation hostel or day centre, it was believed, would accomplish the mutation of former mental health patients into ordinary citizens, distinguishable from their associates only by their occasional attendances at out-patient clinics to review their prescriptions. The new-found psychiatric optimism about the major tranquillisers, coupled with protest about the indignities of mental hospital regimes, converged to suggest that the concept of community care did not require elaborate specification or commitment (Bennett and Morris 1983). In truth the community as a locus of care came to possess little value (Barham 1992: 14); it was neither seen as a therapeutic site nor as the arena for an interrogation of the moral crisis in the relations between people with mental health problems and the larger society, but just as the place to which people were to be returned after medicine had cured them.

A by-product of the continuing non-specification of the nature and purpose of social and community care was a failure to carve out a proper role for staff as carers, including methods of working, training and service objectives. Care work linked to the public services was seen as having professional orientation but as a subordinate partner to established medical and clinical professions. Health and Welfare (Ministry of Health 1963) provided a list of services to promote social care for elderly people, including provision of suitably adapted ordinary housing, warden-supervised housing, home helps, laundry services, provision of cooked meals, chiropody at home, friendly visiting and the availability of additional transport to help people to attend social events. Many of these ideas were also taken up for younger people with disabilities in the Chronically Sick and Disabled Persons Act 1970.

Social and community care policies arose later from the ‘planning for priority groups’ agenda in the 1970s. Such policies demonstrated a significant gap between aspiration and intent and the means of implementation. Most of the central government master-plans published during this period for user groups such as mental health, learning disabilities and the elderly took the view that community care could be planned rationally and incrementally through ‘local agency collaboration’ following general objectives and principles laid down by government. In retrospect this seems naive; the model for achieving change was ‘simply inappropriate’ (Lewis and Glennerster 1996: 20). The government had tried to adopt centralized, rational, comprehensive planning. It had produced a national budget and planning guidelines, and local districts and social service departments were intended to plan jointly to implement these guidelines. In practice, power in the National Health Service (NHS) and local authorities was so diverse and the competing bureaucratic interests so entrenched that such a model had little hope of success; setting achievable goals to create high quality or adequate social care within the community for vulnerable, dependent service users proved unrealistic.

Local service providers muddled through; in general they extended residential and day centre services but with the emphasis on providing basic physical care and occupation. This showed a failure to connect with any desired outcome: ‘policy throughout the 1970s was not incisive and continued to straddle community-oriented and institutional positions’ (Felce and Grant 1998: 25). It meant also that a distinction was being drawn between treatment function and the long-term supportive function of care services. Whereas the former retained a foothold in hospital provision linked to clinical skills, the latter, as located in the community, lacked a clear purpose despite eventually being seen as an alternative ‘social’ non-clinical form of care. Social care as an occupational identity was disadvantaged through its failure to organise as a corporate group, and through its dependence on a third party defining and mediating contracts between client and professional worker.

In the 1980s it was widely publicised that the majority of community care was provided by family members, mainly women. Community care policies were examined against the background of an increasingly ubiquitous carers’ lobby. The nature of care and who provided it became issues subject to frequent, rigorous analysis. In its original form, community care policy had envisaged a significant role for public services in maintaining highly dependent people outside large institutions. By the early 1980s this was less clearly the case (Baldwin and Twigg 1991). Under the twin pressures of fiscal crisis and an ideologically driven commitment to reducing the role of the state in service provision, the original vision was replaced by a much stronger emphasis on the provision of care by ‘the community’ itself (Parker 1990).

It raised the question that if care in the community was being provided by unpaid non-professionals then where was the argument for professionalising other spheres of similarly provided social care in residential homes and day centres. Within the formal sector, the notion of care was perceived as having less active connotations than certain other concepts used to describe what professionals do to their clients or patients. Terms such as treatment or therapy suggest an active intervention by a professional who has undergone training and has particular skills which qualify her to use technologies designed to achieve particular outcomes (Barnes 1997: 13). In contrast to this, care is seen to be something which can be provided without the need for professional training: the job of ‘care worker’ which exists in residential homes, domiciliary settings or day centres is usually an unqualified post. The provision of ‘care’ can imply an absence of clinical intervention directed towards cure, and when not undertaken against a background of medical technology, for instance within a hospital setting, it can be seen as activity subordinate to the work undertaken by the professionals.

Since the 1980s the problem of who provides social and community care has been taken up as a gender issue. How to ‘empower’ carers was central to the gender-based debate. In April 1997 service users were given power to select and employ their own carers through direct payments legislation. Ungerson (1997) has described the double disadvantage of mainly women being employed as low paid carers working in relative isolation from mainstream services, where informal and illegal contractual arrangements were unlikely to provide them with employment rights.

Emphasis upon values and philosophy rather than forms of professional training

The intention of the community care initiative was to help long-stay hospital patients unnecessarily kept in hospital to return to the community. The 1981 Care in the Community consultative document (DHSS 1981) began with the phrase: ‘most people who need long-term care can and should be looked after in the community. This is what most of them want for themselves and what those responsible for their care believe to be best’ (ibid.: para. 1.1). The ‘legal, administrative and financial framework within which health and local authorities operate’ (ibid.: para. 1.2) was presented as the obstacle to their transfer.

The policy of the Conservative government was not to fund de-institutionalisation nationwide but to set up demonstration projects where lessons could be learned, particularly with respect to managing joint health–local authority finance. The real motive of government was to cut the formidable expense of long-term hospital care and later to promote more cost-effective, cost-efficient varieties of care through separating the role of purchaser of care from that of provider. The emphasis would be upon altering the means rather than the outcomes (unless cutting the overall state financial contribution counted as an outcome). In a 1983 circular, the government established a number of pilot projects to investigate ways of moving long-stay patients out of hospital (DHSS 1983). Twenty-eight demonstration projects were centrally funded for three years (13 in the first round which began in April 1984, and 15 in the second which commenced a year later). Most of the projects represented models of care for people with mental illness or learning difficulties, and for elderly or elderly mentally infirm people. Together these pilot projects expected to provide services which would enable about 900 hospital patients to move into the community (Renshaw et al. 1988: 34). As the Personal Social Services Research Unit (University of Kent) evaluation indicates, by March 1987, 456 people (only) had moved out to the community, from a planned total of 896 (ibid.: 173). The main problems concerned finance (for example, ‘double funding’ – transitional costs required to put a new service in place before the old one can be removed), timescales (nearly all projects found that every step took far longer than had been anticipated), and professional resistance.

Professional resistance included efforts by health service staff to slow down the pace of hospital closure, coupled with the failure to demonstrate approval for care being provided by non-clinically qualified personnel. For the majority of demonstration projects this initiative created an opportunity to begin formulating objectives for care in the community and in so doing, to recognise the significance of the philosophy of care and values held by staff. The success of any project was seen to hinge on the quality of staff (Renshaw et al. 1988: 134). Back in 1980 the King’s Fund Centre project entitled ‘An Ordinary Life’ decided that skills for residential care ‘are mainly very ordinary ones: because staff themselves live in society and do most of these activities for themselves every day, they have the skills already’ (King’s Fund Centre 1980: 33). This seminally influential report on planning localised provision for people with learning disabilities concluded that most tasks which staff undertake fell into one of two categories: ‘teaching’ and ‘doing’. It identified that staff needed training in the techniques of identifying need, deciding priorities, setting programmes and teaching skills to clients, and that ‘in many cases the formal qualifications of staff and programmes of training currently provided for them are quite irrelevant’ (ibid.: 33).

The 1980s Care in the Community projects emphasised in-house training for staff and evaluations focused upon its function in providing support, boosting morale and in clarifying service values and objectives. The tendency was to distance training from professional agendas, to reinforce local ownership, for staff to become partners in a local project; hence across the country much of the staff training evolved in a fragmented fashion. The PSSRU studies reported: ‘our research showed that in-service training was positively related to expressed job satisfaction’ (PSSRU 1990: 15).

Brown’s (1992) analysis ofjoint training (between nursing and social work) as it applies to learning disabilities demonstrated that such modes of training arose as a result of the marginalisation of learning disabilities from mainstream services and competition for ownership between the two main caring professions. For staff training in the field of learning disabilities this divide-and-rule mentality lessened their claims to professional status and competence. When in the early 1990s government increasingly questioned occupational boundaries and addressed workforce issues, including training, in ways that challenged traditional demarcation, such collaboration between nursing and social work have provided lessons of relevance to their professions as a whole. By looking for links within and among the training for caring professions, the result had been to undermine rather than to enhance any special claim for identity. In learning disabilities, much of this had its roots in the Jay Report (Jay Committee 1979), whose remit was to recommend patterns of training, but which largely sidestepped the issue of professional alliance and concentrated upon the nature of the care task in an arguably apolitical manner: ‘we did, however, feel strongly that it was a central part of our remit to look at the essential nature of the tasks of caring, without being constrained by how that task is currently allocated between particular professions or agencies’ (Jay Commit...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Table of Contents
• List of contributors
• Introduction
• Part I Professionalism, boundaries and the health/social care context
• Part II Professionalism and enterprise culture
• Part III Professionalism and new managerialism
• Part IV Professionalism and credentialism
• Professionalism and emotion management
• Index