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Malcolm Payne
Director, Psycho-social and Spiritual Care, St Christopher’s Hospice
51-59 Lawrie Park Road, Sydenham, London SE26 6DZ.
Telephone: 020 8768 4500; Email: m.payne@stchristophers.org.uk
The international definition of social work (IFSW, 2000) claims that social justice is
fundamental to it. Therefore, we might assume that health inequalities, which are
widely recognised internationally, would also be a focus of social work and also of
social work research. That this is not so arises from:
the varying role of social work and therefore its research in national
welfare regimes, and the consequences for international research;
the complex relationship between social work and healthcare;
weaknesses in social work research.
I argue that for social work research to tackle health inequalities requires a new
agenda in social work research and a structure and policy for initiating and developing
research.
healthcare, child and family social work is part of local government education
provision and social workers may be found in many other aspects of social welfare
provision and in agencies where social work is a dominant professional group.
Examining the literature discloses a number of points about social work knowledge
production:
it is often regional in character, for example associated with Africa, American,
Asian, European and Nordic regions;
it is comparative, being mainly concerned with comparisons at a fairly high
level of generality between welfare regimes within which social work is
practised in different countries;
it often relies on contacts between editors and writers through international
organisations or projects.
foundation of social work in the late 19th century. It emerged from experiments in
different countries responding to urbanisation; some of these, primarily the
settlements, the charity organisation (COS) movement and the Elberfeld system of
community visiting were internationally influential (Payne, 2005). There was also an
international municipalisation movement (Hietala, 1987), which meant that as social
work developments began to be incorporated into local government, there were
international visits, conferences and circulation of ideas. For example, when Japanese
services began to develop in the early 20th century, they were explicitly based on the
COS and Elberfeld models, although they also incorporated indigenous ideas
(Takahashi, 1997). Other primarily national developments such as the 19th century
French development of services to respond to abandon moral (moral danger) of
children had some international involvements (Schafer, 1997), and the work of and
Elizabeth Fry on prisons and Josephine Butler on women (van Drenth and de Haan,
1999; Jordan, 2001).
These developments were interrupted by the second world war, and the international
organisations restarted their activities. This accounts of them derives form Payne
(2006) There are three main ones, which continue in existence today:
International Association of Schools of Social Work (on social work
education);
the International Council on Social Welfare (representing agencies and
primarily voluntary or non-governmental agencies); and
the International Federation of Social Workers (a grouping of national
professional associations of social workers).
Although of varying strength and size, and having different purposes, these provide a
means of communication through publications, conferences and joint projects of
various kinds. More recently, specialised bodies have developed, for example the
Inter-University Consortium on International Social Development.
There are three other forms of international activity relevant to social work:
International non-governmental organisations (INGOs). Examples are
international charities and welfare groups like the International Red Cross or
Crescent, Save the Children, Caritas, and Médicin Sans Frontiéres. These
provide welfare services for people who are crossing borders, such as refugees,
and development activities or welfare services in emergencies. Although these
are not conventional ‘social work’ as it is known in Western countries, these
organisations represent international commitments to welfare in various ways.
Governmental and intergovernmental activities. Examples are the provision of
aid and joint projects such as the many European programmes which encourage
shared training, research and other transfer of expertise across the European
Union and, more widely, with the eastern European countries and the states of
the former USSR. Similar schemes exist more widely, for example between the
International social work research and health inequalities - 4
USA and Latin American and Pacific nations. An example is the Ecspress
project of the European associations to create a ‘thematic network of the social
professions’ in the 1990s (FHS Koblenz, 1999)
International organisations. Examples are the various United Nations agencies.
In this context, shared policies are represented in various UN conventions, such
as that on children. Many nations become signatories to these. They represent
policy and ideological objectives and markers against which local policies are
sometimes measured.
These different forms of organisations allow for international interchange of ideas and
to some extent of personnel.
After the war, there was a new international order in social work, since the United
Nations became the instrument of the policy of the USA to advance social work as a
way of promoting democratic government in countries devastated by the war
(Kendall, 1978). Although this was controversial from time to time and in some
countries (see for example Satka, 1995, on Finland), the main mode of American
social work, social casework and research and literature on it, became influential
internationally. For example texts by Biestek (1957), Hollis (1964) and Perlman
(1957) were widely used in Western countries. Welfare states began to emerge as a
mechanism of welfare provision, which included social work to some degree, in
Europe (Sipilä, 1997). Also, the colonial powers, particularly the UK, began to
develop community work as a form of social development as they moved towards
giving independence to colonies (Yimam, 1990). This in turn influenced the
development of community work in the UK and more widely, as colonial
administrators returned to the UK to work, and training was supplied in the UK to
colonial workers. For example, Batten (1967) wrote texts for colonial social
development work, using his experience also to contribute to general theory and
practice texts on community work.
During the 1960s, social policy studies in the UK began to have a comparative
element (Rodgers, 1968). This had an influence on social work, since it works on
many of the issues that social policy focuses on. This comparative focus has
developed and recently, in a significant text, Clasen (2003) comments:
Recent research has demonstrated more ambition than simple country comparisons or
explorations. Two significant examples are:
studies of child protection practice in different European systems, among other
methods using idealised case studies to enable workers to explore different
approaches to similar cases (Baistow et al, 1995);
studies of carers experiences from different European countries using narrative
methodologies (Chamberlayne and King, 2000; Chamberlayne, et al, 1999;
Chamberlayne et al, 2004).
Such studies as these are particularly important because they demonstrate
methodologies that can compare different practice approaches and service user and
carer experiences, rather than focusing on structural or organisational issues.
Another approach to comparative work has been to study similar social work methods
in different countries. A pioneer study was the collection of studies of the task-centred
model of practice collected in the 1970s by the originators of the model, Reid and
Epstein (1972). More recently, the Personal Social Services Research Unit, the
originators of the use of American case management as a practice technique in
community care services, called care management in the UK, have continued to
collect and publish studies of similar methods across the world (Challis et al, 1994),
and ‘community social work’ deriving from British social work innovations of the
1980s, was applied and researched in the USA, involving UK originators of many of
the ideas (Adams and Nelson, 1995). In addition, theoretical or practice ideas generate
publications that juxtapose work in different settings, often arising from conferences.
Recent examples include the work on reflection as a means of developing practice
(Fook and Napier, 2001; Gould and Baldwin, 2004) and on social construction
methods in social work (Jokinen et al, 1999; Hall, et al, 2003).
These studies demonstrate that often the originators and promoters of methods applied
in a particular country will eventually seek to develop them in other regimes
internationally, building up a research profile for their innovation, and that innovative
ideas stimulate international responses, with empirical research arising from them.
This will not be a surprise to people familiar with the processes of building an
academic career and research record, since international impact and comparison is an
important marker of the credibility of an innovation. It also illustrates that a concept
that is attractive in one welfare regime is likely to be attractive in similar regimes, for
the same reasons that Clasen, above, described in relation to social policy research:
many developed countries face similar problems, are part of a global network of
ideas, and experiment with similar political and social responses.
From the 1970s, social work was primarily organised through the social services
departments of local authorities, and healthcare social workers were usually seconded
to healthcare settings, remaining in local government employment. The New Labour
government in power from 1997 has progressively reconstructed these arrangements,
so that social work with children and families has been incorporated into children and
families divisions of the local education authority and central government
responsibility transferred to the Department for Education and Skills from the
Department of Health. Social care services for adults are increasingly organised in
joint administrative structures with healthcare organisations, themselves frequently
reorganised. The responsible government department continues to be the department
of Health. The situation is different in Scotland, which has always had a different set
of responsibilities in local government social work departments, including criminal
justice, which in Britain has been largely the responsibility of a separate probation
service, which itself has been reorganised as part of the National Offender
Management Service.
Social workers engaged with and specialising in healthcare specialties, such as renal,
forensic or palliative care, where there are considerable social implications of
healthcare interventions with patients, are often closely integrated with healthcare
multiprofessional teams. However, except in the voluntary sector, for example, in
voluntary sector hospices, social workers have usually not been employed in
healthcare organisations. Their conception of their practice is therefore not well
understood, and healthcare organisations have not been accustomed to focusing on
social objectives.
Health inequalities, on the other hand, have often been regarded by government as
primarily matters of macro-level interventions in the public health arena. The
government has given high priority to tackling health inequalities in its programme
for Action (DH, 2003). Four long-term objectives have been set:
improvements in early years support for children and families;
improved social housing and reduced fuel poverty among vulnerable
populations;
improved educational attainment and skills development among disadvantaged
populations;
improved access to public services in disadvantaged communities in urban and
rural areas; and
reduced unemployment, and improved income among the poorest.
A 2010 target has been set for a number of specific interventions among
disadvantaged groups that are considered likely to have an impact:
reducing smoking in manual social groups;
preventing and managing other risks for coronary heart disease and cancer such
as poor diet and obesity, physical inactivity and hypertension through effective
primary care and public health interventions – especially targeting the over-50s;
improving housing quality by tackling cold and dampness, and reducing
accidents at home and on the road;
International social work research and health inequalities - 7
improving the quality and accessibility of antenatal care and early years support
in disadvantaged areas;
reducing smoking and improving nutrition in pregnancy and early years;
preventing teenage pregnancy and supporting teenage parents;
improving housing conditions for children in disadvantaged areas. (DH, 2003:
4-5)
The Wanless report (2004) on effective public health spending focuses on similarly
high-level targets. The Programme document claims: ‘To reduce health inequalities
and achieve the targets will require us to improve the health of the poorest 30–40 per
cent of the population where the greatest burden of disease exists. Nor does this
Programme for Action exclude assisting all groups in society from improving health.
Our intention is to improve the health of the poorest fastest.’ (DH, 2003: 4).
While social workers might be involved in all this at a local level, and some of the
disadvantaged groups that are the main focus of action are likely also to be users of
social work services, most interventions are not likely to call on social work as a
primary mode of intervention. Support for children in early years, help in improving
housing, and supporting teenage parents are the most likely to be relevant to social
work.
Internationally, there have been claims from the proponents of producing a stronger
evidence base for practice (Kirk and Reid, 2002; Sheldon and Chilvers, 2000; Thyer
and Kazi, 2004) that social work has not achieved a significant base of evidence for
practice. There have been many positive studies, there is evidence for particular
interventions and for the role of social work in the constellation of health and social
care services generally. This position is controversial, since it represents a focus on
positivist empirical view of research that, with its full implications, not all would
accept (Webb, 2001, 2002). Moreover, the critique of social work on these grounds is
not restricted to it, but is also applied to medicine, which generally has a more robust
empirical knowledge base (Gibbs and Gambrill, 2002). It appears that this debate is
mainly a conflict between academic and practitioner interest groups in both (and
other) fields. However, it does reflect the reality that social work is a relatively small
International social work research and health inequalities - 8
field in relation to healthcare, and has not had the academic and personnel resources
and research investment to develop a significant research base rapidly.
Another factor that is relevant is the political position of social work as a profession.
Social work has historically played a role in the maintenance of a moral social order.
This was explicit in its early days, when it supported the management of potentially
restive poor people through the Poor Law and the Charity Organisation Societies.
However, this role continues as a social expectation in the many assessment and
reporting roles that social workers have in the societies in which they operate to
(Payne, 1999), and often in the views of service users. This conception of social work
emphasises its role in maintaining a social order on behalf of powerful elites in
society, rather than in achieving social change on behalf of the oppressed. Taking this
view implies that empirical analysis of therapeutic of social outcomes is not relevant
to the achievement of the objectives that social work is set in political and social
debate. It might be argued that this is one of the reasons that practitioners do not seek
to achieve empirical outcomes. The supporters of evidence-based practice argue this
as strongly, as those who have doubts about the radical potential of social work.
Social work has a variable and marginal role in the main focus of work on health
inequalities, which suggests that its professional commitment to social justice has not
been played out in this field. I suggest this is mainly because this ideological
commitment is not always foremost in the political and social debate about the role of
social work, which forms the role allocated to practitioners in social services systems.
While social workers primarily work with deprived groups, and these typically also
suffer from the effects of health inequalities, social work practice has not been
focused on health inequalities, or the health consequences of deprivation and social
inequality. Concern has been expressed in the context of influencing policy
development, rather than intervention. In general, social work has had a weak
empirical research base, and the most developed area of international research has
been on comparative systems analysis rather than on analysis of social work
interventions that might be relevant to health inequalities. The most extensive work
International social work research and health inequalities - 9
has been done on poverty in relation to population control or family planning, and on
the role of women, in social development work in the southern hemisphere.
Responding to this scenario, the ESRC seminar series seems to have a number of
options to achieve progress in a commitment to address health inequalities through
social work and social work research.
However, social work has a potential, which is hidden in the ambiguities of the
profession. It seeks to make a difference at the social level, by intervening in the
personal and local. It makes the political personal, and hopes thereby to make the
personal political. Doing something about health inequalities requires personal and
local interventions. Perhaps the failing of much of the effort to deal with health
inequalities is that they are only identifiable at the level of a large population, while
they are created by processes that are not well understood at the level of the personal
and local. Social work, therefore, has the potential to make a different impact to that
of many other interventions in health inequality at the population level. Research will
certainly be needed to demonstrate the possibilities of such a contribution.
International social work research and health inequalities - 10
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