Social Work in General Practice

E. Matilda Goldberg, June E. Neill

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9781032053882
• eBook ISBN: 9781000438505
• Edition: 1
• Topic: Medicine
• Subtopic: Social Work

In the early 1970s general practitioners were well aware that they were being asked to deal not only with physical illness in their patients but also with the stresses relating to social and emotional problems. Increasingly often they were working together with health visitors and social workers in attempting to respond more effectively to these demands.

Originally published in 1972, this study describes the attachment of a social worker to a group general medical practice in London, indicating why, for all social groups, the general practice is an appropriate point at which psychosocial problems may be identified and treated. The authors describe the nature and range of patients' problems that come to light in the consulting room; how patients present their problems to the social worker; and the kind of help the social worker is able to offer. They explore the extent to which the general practice setting provides opportunities for preventive therapy and further describe how social work in general practice can most effectively be related to existing social services in the community, particularly to the reorganised personal social services. Their findings are supported throughout by illuminating case studies. The book also discusses the integration of the social worker into the general practice team, the problems that have to be solved and the mutual enlightenment that results.

This emerges as an extremely encouraging and instructive experiment, which will immediately interest social service departments and social workers, doctors and nurses, both students and those in practice. The wide spectrum of social problems encountered and dealt with by the social worker in a general practice make it a particularly stimulating account.

PART I THE BACKGROUND

1 GENERAL PRACTICE AND SOCIAL WORK

Long before social workers came into being, patients consulted their doctors not only about physical illness but about their social and emotional problems. Until comparatively recent times most of the medicines dispensed had few pharmocologically curative properties, hence psycho-social remedies must have been a vital ingredient of the physician’s art. But the social or emotional malaise underlying physical complaints often went unrecognised by either patient or doctor.

The steady advances during this century in the behavioural sciences, in psychiatry and in social medicine have helped to define the social and emotional factors in illness and to fashion treatment tools; though much is still unknown. At the same time, the increase in rising expectations strengthened the patients’ demands for the treatment of psycho-social ills. Patients were no longer prepared to put up with marital unhappiness, damaging housing conditions, general depression and anxiety, as inevitable burdens, and they began to look to their doctors and other helping professions for relief, if not for cure. By now it is commonly accepted that a considerable proportion of the undifferentiated complaints which general practitioners encounter are mainly of a psycho-social nature, requiring for their treatment knowledge of social resources, as well as social and psychological skills. For example, a random sample of general practitioners in Buckinghamshire thought that about a third of the patients they saw in a typical day’s work had social or psychological problems which impeded their daily activities or social relationships (Jefferys, 1965).

In 1965 Professor R. Scott, who pioneered the idea of introducing a social worker into the general practice team, put the problem this way:

‘... the aetiology of much of the disease we encounter in general practice, and many of the factors which complicate our management of the sick person, have their origins in social maladjustment and in inadequate or faulty interpersonal relationships. To the extent that this is so our therapy will become less concerned with manipulating the patient’s blood chemistry and more preoccupied with the physical, economic and social factors in the patient’s environment. The decision which is taken as to whether such problems will be regarded as the sole responsibility of the medical profession or the exclusive concern of society or as a field which requires a full partnership between medicine and other related social agencies, will be a major factor in determining the future of general practice.’ (Scott, 1965).

Since then a succession of official reports has sought to clarify the functions of the modern general practitioner, both in relation to the medical profession as a whole and in relation to other helping professions. The report of the Royal Commission on Medical Education (1968) saw the general practitioner of the future as a ‘primary physician’ of very broad competence and interests, much better acquainted with the behavioural sciences, community medicine and psychiatry than his predecessor. The report forecasts ‘a gradually increasing delegation of a variety of tasks from the qualified doctor to colleagues in other professions’. Problems are foreseen in defining the kind of non-medical staff ‘who can usefully contribute to the work of a medical practice’. The suggestion is made that ‘something more than the traditional skills and qualities of nurses and social workers will be required’, but the report does not define these additional skills.

The recent reports of the working party of the British Medical Association Planning Unit on Primary Medical Care (1970) and the report of the Royal College of General Practitioners (1970) have stressed once more the generality of general practice and its substantial concern with social pathology. They suggest that the behavioural sciences have much to contribute to the knowledge-base of the general practitioner whose work will increasingly involve the care of patients with degenerative diseases of middle life, chronic and multiple infirmities of old age and problems of a psycho-social nature, as well as childhood illnesses. The report on Primary Medical Care envisages that

‘the clinical skills of the primary physician should enable him not so much to attach a diagnostic label, as to unravel the undifferentiated clinical problem which is often a complex of physical, emotional and social factors and to take or initiate appropriate action. Skills should also include the capacity to work harmoniously as a member of the team.’

This concept of teamwork, sharing the work with other helpers belonging to different disciplines, contrasts with the old notion of the exclusive, if not possessive, personal relationship between the general practitioner and his patient.

Teamwork between doctors, social workers and other specialists was to be the cornerstone of the health centres envisaged in the National Health Services Act of 1947, but, as is well known, this idea did not catch on among general practitioners and hardly any health centres came into being in the fifties. The few which did—for example, Woodberry Down in North London—did not function with integrated teams, but merely provided common premises in which general practitioners, health visitors, infant welfare and child guidance clinics were located. Gradually, however, general practitioners themselves discovered the advantages of coming together in group practices. They enabled them to work more efficiently by pooling resources, and to give their patients more comprehensive care by employing ancillary staff, such as receptionists, nurses and recently, health visitors. Indeed, some group practices—such as the Caversham Centre, where the project described in this book took place—became little nuclei of health centres. By the middle sixties the concept of health centres staffed by multi-disciplinary teams began to gather momentum among forward-looking general practitioners; at the time of writing, 167 health centres are in existence and a further 189 have been approved by the Department of Health and Social Security. (HMSO 1971.)

There have been heated discussions about the threat that teamwork presents to the confidential doctor-patient relationship. But did this close relationship ever exist for the mass of working-class patients? It is also worth noting that in child guidance and adult psychiatry, both of which deal with very personal and emotionally highly sensitive areas of people’s lives, teamwork often enhances the understanding of patients’ problems. It makes their care more differentiated and comprehensive, without losing the personal touch or sacrificing confidentiality.

Despite doubts among some general practitioners, teamwork in general practice is growing, particularly in relation to community nursing. Anderson and his colleagues reported (1970) that the percentages of general practices with attachments of community nurses rose from 11 to 24 per cent in two years. The inclusion of social workers in the general practice team has been much slower to develop, although the idea goes back more than twenty years, when an almoner joined Dr Scott’s group practice in Edinburgh (Patterson 1949). In the fifties Backett and his team, after studying a small rural practice in Northern Ireland, concluded that 12 per cent of the families needed social work help (Backett et al. 1957), and several experiments have taken place since Dr Scott’s pioneering demonstration (Dongray 1962, Collins 1965, Dickinson and Harper 1968, Forman and Fairbairn 1968, Ratoff and Pearson 1970, Cooper 1971). These projects range from part-time secondment of specialist social workers, to the attachment of a full-time social worker to a practice over several years. All these social workers have found plenty of work in three capacities: as assessors of social difficulties, as links and coordinators with social services and as therapists. Recently Cooper has suggested a fourth function: that of helping to secure the patient’s co-operation in medical care. The projects indicate that one full-time social worker in a group practice of 9,000 to 10,000 patients can barely cope with the needs arising, once the doctors have become aware of them and of the possibilities of help.

Some enthusiastic general practitioners and notably Forman (Forman and Fairbairn 1968) see general practice as the most promising community base for the development of social work. However, recent studies in London, Birmingham and York reveal clearly that social work remains largely an unknown quantity to general practitioners. A survey of all general practitioners in one London borough (Harwin et al. 1970), showed that few of the practitioners have regular or frequent contact with any social agency and that the majority do not feel the need for such contact. Of the interviewed doctors, 14 per cent expressed definite interest in the possibility of a social worker attachment and a further 27 per cent welcomed the idea of regular meetings and case discussions with a social worker, but a third firmly rejected the notion of teamwork. In a survey carried out among Birmingham general practitioners (McCulloch and Brown 1969) the majority (62 per cent) of doctors preferred a nursing background for social workers and saw the social workers’ functions as mainly concerned with concrete and practical tasks, rather than with psychological help. Only about a quarter of the general practitioners welcomed a new, well-organised local authority social work department, outside the control of a medical man. An inquiry into the use which general practitioners in York made of mental welfare officers and psychiatric social workers in the community-care of their psychiatric patients, indicated that general practitioners were not sure of the psychiatric social workers’ functions and that few had any sustained contact with them, although the social workers were freely available at a mental health centre. The high turnover of the social workers seems to have contributed to this situation, as has the social workers’ inability to communicate the nature of their skills to the general practitioners.

On the other hand, the rapid growth of the Derby scheme of social worker attachments to general practices, following initial apathy or even hostility, suggests that the general practitioners were converted to the idea of medico-social teamwork by example rather than precept (Cooper 1971).

The Seebohm Report (1968), which forms the blueprint for the reorganisation of the local authority personal social services, discusses the reasons for the poor collaboration between doctors and social workers when both are so dependent on communication and so involved in a common concern. The authors of the report suggest that the complexity of the social services, or sometimes the lack of them, can put off the keenest family doctor, and they refer also to the ‘pre-occupation of some social workers with psycho-dynamics, often formidably expressed which may not be what a harassed family doctor or the situation self-evidently requires’. The report sees the more fundamental sources of difference between medicine and social work in the contrasting developments of the two professions. The social workers’ emphasis, as the members of the Seebohm Committee saw it, is on patients gaining understanding of their situation and on the acquisition of personal insight and empathy on the part of social workers. Medicine, on the other hand, is concerned with refining its objectivity and technology. The authors argue that these two approaches are ‘as different as they are obviously complementary’. The assumption that the doctor must always be the leader in any team of which he is a member was thought to be another factor in poor collaboration. The report refers to the need for social workers to learn more about the doctor’s job and about advances and problems of medicine today. It also implicitly criticises the social workers’ comparative lack of interest in evaluating the results of their work. The authors state unequivocably that they regard teamwork between general practitioners and the social services as vital, and suggest that health centres would provide a proper base for joint working. They recommend that social service departments should make a determined effort to collaborate with local general practitioners, that a variety of experiments in teamwork should be started and that as soon as doctors in a health centre or a sizeable group practice feel that they want the help of a social worker from the social service department, the department should do everything possible to meet such a request.

These quotations from the Seebohm Report which plead so forcibly for the closest collaboration between social work and medicine, contrast oddly with the cries of consternation that have arisen in the medical profession about the disservice this report and the reorganisation of the personal social services have done to the welfare of patients, by separating social service from medicine. If the project described in this book shows anything at all, it is the great difficulties and barriers to close collaboration which the fragmentation of the social services presented to the general practice team. And this applied whether the social worker was working in the health department of the local authority or elsewhere. All the members of the Caversham team were eargerly looking forward to the days when they no longer would have to adapt their patients’ multiple needs to the special eligibility requirements of the different social services and when there would be one relevant area-office with which they could work and one telephone number to ring.

The Seebohm Committee wished they could have recommended the attachment of full-time social workers to all health centres and group practices, but they felt that not only was there a scarcity of social workers, but general practice was not yet ready for such a programme and more knowledge was needed about how doctors and social workers could most usefully collaborate.

This very theme formed the basis of the Caversham project which came into being through the convergence of two quests—the longstanding desire of the senior partner of the Caversham group practice, Dr Hugh Faulkner, to include a social worker in his team of doctor, nurse and health visitor, and the pioneering spirit of Dame Eileen Younghusba...

Table of contents

• Cover
• Half-Title Page
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Caversham Project Consultative Committee
• Practice Staff
• Foreword
• Table of Contents
• Acknowledgements
• Part I The Background
• Part II The Caseload
• Part III Social Work in Action
• Part IV Conclusions
• Appendix
• Index