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Social care 

Social care
Social care

Jo Moriarty

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Medical professionals need to be educated in how the social care system works—given the confusing array of approaches taken by different [local] authorities. (Altmann, 2011)

At the heart of this fragmentation [of services and commissioning] lies a key issue—the distinction that has been drawn between what is health care (commissioned and largely delivered by the NHS), and what is social care (mainly commissioned by local authorities and individuals, and provided by many different sources). This distinction, much discussed but little understood, arises from a succession of political compromises stretching back to the 1920s. (House of Commons Health Committee, 2012: 7)

Our … approach leads us to define social care as the activities and relations involved in meeting the physical and emotional requirements of dependent adults and children, and the normative, economic and social frameworks within which these are assigned and carried out.

(Daly and Lewis, 2000: 285)

These opening quotations illustrate both the complexity of the social care system in the UK and the challenges involved in summarizing what support it provides to older people with mental health problems. The effects of dementia and depression, the two most common mental health conditions seen by old age psychiatrists, are such that the overwhelming majority of patients and their families will need social care support. This means that old age psychiatrists working alongside those arranging or delivering social care require a broad understanding of how these services are provided. Furthermore, they are often the first point of call for patients and their families attempting to negotiate a complicated and diverse system of funding and support, given that the general public is generally poorly informed about what constitutes social care and how it is funded (Ipsos MORI Social Research Institute, 2011).

The chapter aims to describe some of the services that come under the social care ‘umbrella’, explain how they are funded, comment on their effectiveness, and discuss some of the key current policy debates. Social care is what is termed a ‘devolved matter’, so the Scottish and Welsh governments and the Northern Ireland Assembly can make decisions about how social care services will operate under their jurisdiction. Since devolution, social care policy has become increasingly divergent across the UK (Birrell, 2009). While it broadly concentrates on England, the chapter makes some reference to developments in Scotland, Wales, and Northern Ireland.

An important caveat for readers is that social care is a rapidly changing landscape in which the preferences of older people with mental health problems and their families are subject to wider political and funding priorities. At the time of writing, a number of major policy changes in England discussed in the chapter, such as the policy of personalization advocated by both the previous Labour and current Coalition government, have yet to be fully evaluated in terms of their impacts upon services for older people with mental health problems and their families. Furthermore, the government has promised but has yet to pass legislation making changes to funding for long-term care. This may resolve some of the anomalies outlined here, although the wider debates about whether social care is adequately funded are likely to continue.

At the same time, it is important not to exaggerate the rate of change. While there are signs of improvement, many of the challenges for social care services identified by pioneering old age psychiatrists, such as the need to support family carers caring for someone with dementia (Bergmann et al., 1978) or provide better treatment for older people in care homes with depression or dementia (Ames et al., 1988), are by no means settled. In this sense, the sector is characterized by both change and continuity.

Defining Social Care

The term ‘social care’ is not widely used outside the UK and, indeed, was first used to provide a generic label for the people who worked in residential care and other social services but who were not social workers, rather than to describe the support that they provided (Platt, 2007). Nevertheless, a number of attempts have been made to provide a framework for describing this rather amorphous concept. Waine and colleagues (2004) describe social care as covering:

all interventions provided or funded by statutory and/or independent agencies which support older people, younger adults and children in their daily lives, and provide services which they are unable to provide for themselves, or which it is not possible for family members to provide without additional support. They can be provided at home, in day centres or on a residential basis, including substitute family care and care homes.

(Waine et al., 2004: 1)

Increasingly, as will be discussed in more detail later in this chapter, these interventions now include ‘cash for care’ in the form of personal budgets and direct payments that allow recipients to decide how, and on what, to spend the money allocated for their support.

The origins of the distinction between social and healthcare are generally attributed to the separate jurisdictions set out in the National Health Act 1946, which established the National Health Service (NHS) in 1948, and the National Assistance Act 1948, which gave local authorities (LAs) responsibility for making ‘provision for the welfare of disabled, sick, aged and other persons’ (Means and Smith, 1998; Glasby and Littlechild, 2004). These two pieces of legislation assumed that it was possible to distinguish between people who were sick, and thus entitled to NHS healthcare free at the point of delivery, and those whose frailty and disability resulted in their having social care needs, which would be met by the LA (Glasby, 2007: 66). In reality, differences between health and social care are often blurred, particularly where a person requires 24-h care on a long-term basis, and this has been the subject of various legal cases.

How Social Care Is Funded

At the heart of the ‘much discussed but little understood’ distinction between social care and healthcare mentioned at the start of this chapter (House of Commons Health Committee, 2012: 7) is the difference between NHS care free at the point of delivery and means-tested social care. Crucially, while the 1945–51 Attlee Government was reorganizing health and welfare services in the UK, they had to adopt a mixture of pragmatism and principle. A decision was made to fund the NHS from central taxation but to fund support provided by LAs through a complicated mix of local taxation, charges, and centrally provided welfare benefits (Lowe, 2002; Thane, 2009). The end result was that the National Assistance Act 1948 gave LAs the power to charge for services provided to older and disabled people ‘in need of care and attention which is not otherwise available to them’. In practice, while all those applying for LA funding to support the cost of living in a care home were subjected to means testing, charges were rarely applied for services provided to people living at home until the 1980s (Balloch, 1994; Baldwin and Lunt, 1996). However, since then, LAs have come under increasing financial and political pressures to means test. Depending upon a person’s assets, services such as home care are now generally charged at around their full economic cost.

Lewis (2001: 349) has described this change as resulting from a ‘pincer movement’ in which increased demand for NHS services and the closure of large numbers of NHS beds for so-called long-stay patients resulted in increasingly tight definitions of what constituted healthcare, while huge increases in the number of people accessing places in care homes through the social security system created a policy imperative to reduce welfare expenditure by controlling the demand for care.

The utility of means testing is, of course, dependent upon the extent to which revenue from charges outweighs the costs of collecting assets. Over the past 25 years, the income of people aged over the state retirement age from occupational pensions, investments, earnings, and benefits has risen considerably. Between 1979 and 1997, the income of so-called pensioner households grew by 68% in real terms compared with an average 36% increase in earnings across the economy as a whole (Department for Work and Pensions, 2011). The number of older people with assets in the form of housing equity has also increased, with around three-quarters of older people owning their own home (Terry and Gibson, 2010).

Set against this increase in the number of older people able to fund at least some of their care in old age, we must set aside the costs that are needed to provide intensive care at home or in care homes for people who have very high support needs. Very broadly, under the current system, people living in England with assets over £23,250 (the limit in 2012–2013) receive no financial support from the state and need to fund their own care until they have ‘spent down’ their assets to the point at which they qualify for means-tested support. It is estimated that about 170,000 people (about 45% of all those living in care homes) are currently funding their own care. A further 168,701 people are paying for their own home care, although it is more difficult to estimate this number accurately (Institute of Public Care, 2011). Depending upon the type of care needed and the part of the country in which the person lives, someone with dementia who lives in a nursing home for the last 2 years of his or her life might spend over £100,000 (Simon, 2010).

A further complication for people making decisions about whether to stay at home or move into a care home is that housing assets are not included in the financial assessments of people living at home. However, this is not the case should they choose to move into a care home, provided they have no dependants living in their house (Commission on Funding of Care and Support, 2011). Many homeowners are reluctant to sell their home to pay for care, meaning that they are less likely to move into long-term care than those renting their accommodation (Hancock et al., 2002; McCann et al., 2012). Concerns have been expressed that this can lead to disproportionate burdens being placed on family carers. A cross-European study (Schneider et al., 1999) has found that financial concerns were one of the factors contributing to higher scores on the Zarit Burden Inventory (Zarit et al., 1980), a widely used self-report measure covering difficulties commonly faced by family carers.

Old age psychiatrists should be particularly alert to the needs of spouses caring for a person with dementia who may delay decisions about long-term care, even when they feel physically and psychologically unable to carry on caring, through lack of understanding about their entitlements under the current system or options that might be available to them, such as deferred payments or equity release. An emerging role for voluntary organizations and other social care providers is to provide accurate and tailored financial planning information for people with dementia and their families (Manthorpe et al., 2011; Samsi and Manthorpe, 2011). Some councils have piloted equity release schemes for older home owners, but it is not yet clear how feasible it would be to provide this on a large scale (Terry and Gibson, 2010, 2012).

Eligibility for Social Care

In addition to the complexities of the current funding system, access to social care arranged or funded by the LA depends upon eligibility. Currently, there are various statutes governing how people living in England and Wales are eligible for social care. In general, LAs base decisions on who is eligible for social care services on the results of an assessment. Depending upon whether a person is assessed as having low, moderate, substantial, or critical needs (Department of Health, 2010a), councils can then decide what support he or she will be offered. This leads to such variation between LAs that it has been suggested that:

There are currently 152 different adult social care systems—one for each local authority in England. Entitlement to services differs across the country and people complain of a ‘postcode lottery’ of care. Different people, with similar care needs, can receive very different levels of support from their local authorities.

(Commission on Funding of Care and Support, 2011: 15)

This variability and inconsistency in eligibility and assessment processes may contribute to the misplacement of frail older people (Challis and Hughes, 2002).

Another factor determining eligibility is the extent to which assessments take account of carers’ needs as well as those of the person for whom they care. Guidance (Department of Health, 2010a) suggests that preventive social care support, such as 1 or 2 h of home care or funding to pay for home adaptations or telecare could be provided to carers of people with moderate or substantial needs—even if the council is only providing services to those assessed as having critical need—in the expectation that this will delay the point at which the needs of the person cared for become substantial. However, the former social care regulator, the Commission for Social Care Inspection, considered that while guidance emphasized the importance of assessing carers’ needs, this has ‘been lost sight of in [the] implementation’ (Commission for Social Care Inspection, 2008: 23).

Reforming Social Care—Eligibility

In 2011 the Law Commission published the results of its 3-year enquiry into adult social care. It recommended that, rather than the complex and piecemeal patchwork of legislation and guidance that exists at the moment, there should be single separate statutes for adult social care in England and Wales. Social care services would be provided at two levels, the first consisting of universal services to which everyone would have access. This would include providing information and advice to those who did not want or were not eligible for an assessment. The second level would consist of targeted services provided through an assessment. Councils would then have a duty to meet eligible needs. There would be a new duty to assess all carers, not just those providing ‘substantial amounts of care on a regular basis’, as happens at the moment, and LAs would have new duties and powers to safeguard adults from abuse and neglect (Law Commission, 2011). It also recommended that assessments should be ‘portable’ so that people moving from one part of the country to another do not have to undergo a new assessment and a possible change in the amount or type of support with which they are provided. Taken as a whole, these changes are designed to decrease the variability in social care support throughout the country. At the time of writing (spring 2013), the Coalition government’s draft Care Bill has adopted many of the Law Commission’s recommendations, including strengthened rights to an assessment for individuals and carers, and a minimum national eligibility threshold across local authority areas. If a person moves to a new area, their new LA will have to continue to meet needs met by their former authority pending reassessment. Similar legislation is currently under way in Wales, although there are some differences, including a code of practice to be laid down by the Welsh assembly on how local councils implement their social care responsibilities.

Reforming Social Care—Funding

Those responsible for planning and arranging social care recognize the inconsistencies in, and unfairness of, the current system, but partly attribute it to difficulties in funding (Association of Directors of Adult Social Services, 2011). Adult social care has enjoyed an average annual real-terms growth of 5.1% since 1994, but much of this has been absorbed by demographic pressures. There have been proportionally greater increases in funding for people with learning difficulties and physical disabilities, but spending on older people has increased by less than 3% and has not kept pace with demographic change. There are fears that the difference between the numbers of people needing social care and the amount of money available to support them could lead to a funding gap of at least £1.2 billion by 2014. This could increase the number of people in need of but not receiving social care and lead to additional pressures on the NHS (Humphries, 2011).

The previous Labour government promised to look at how care should be funded and set up a Royal Commission on Long-Term Care. The Commission’s remit includes community nursing services and continuing care hospital beds, as well as social care services and assistive technology and supported housing. It recommended that personal care (defined as nursing care provided under the direction of a nurse and personal care that involved directly touching a person’s body, e.g. to wash or dress that person) should be free, although the people living in care homes should still be expected to pay for their ‘hotel’ costs (charges for food, laundry, and accommodation) (Royal Commission on Long-Term Care, 1999).

The Labour government accepted many of the Commission’s recommendations but rejected the free personal care option. However, the Scottish Government (then Scottish Executive) chose to fund free personal care in people’s homes and care homes. Since then, although definitive empirical evidence on the impact of these changes is lacking, commentators have praised the decisiveness of the Scottish Government and drawn attention to the strong public support for this decision (Bowes and Bell, 2007; Dickinson et al., 2007; Vestri, 2007). However, they also recognize that those whose needs for personal care are met by their family carers have benefited less from this decision. Here, concerns have been identified with flexibility (Bowes and Bell, 2007) and gaps in the amount of social care support that older people and carers living in Scotland receive (Innes et al., 2005; Vestri, 2007).

This highlights the need for funding systems that take account of the needs of family carers as well as considering the needs of older people with mental health problems. The Northern Ireland Assembly and Welsh Government have expressed support in principle for providing free personal care, but have rejected the option as being too expensive.

Upon its election in 2010, the Coalition Government set up the Commission on Funding of Care and Support, headed by Andrew Dilnot. Many of the Commission’s (2011) conclusions on the need for greater transparency and consistency in funding mirrored those made by the Law Commission (2011), which had reported 2 months earlier. The Dilnot Commission was especially concerned by what it saw as the unfairness of a system in which a small proportion of people were faced with what it termed ‘catastrophic care costs’ while the majority might expect to pay only for comparatively small amounts of care in the last few weeks of their lives. It recommended that the asset level at which people should be asked to pay for their social care should be raised to £100,000 and that a cap of £35,000 should be set on the amount that any individual is asked to pay for his or her care. It specifically noted that people with dementia and other long-term neurological conditions who are likely to have significant social care needs would benefit from this change (2011: 66). The Commission’s proposals met with strong support from voluntary organizations representing people using services and their families and from various think-tanks, such as the King’s Fund. However, the government has decided that the current economic difficulties mean that they must set the cap at £72,000. This limit would only apply to care costs and not to the costs of accommodation, meals, and so on. It does not envisage implementing these changes until 2016. As a general election is due to be held before this date, the final form of any funding changes remains uncertain.

Reforming Social Care—Personalization

Until the last quarter of the twentieth century, the majority of social care services were directly provided by the state and choice was not an important factor in how they were organized. However, from the late 1970s, choice of provider has been the main way in which successive governments have sought to improve service quality (Stevens et al., 2011). In the UK, as in the majority of the more developed countries, the option for people using services to choose either services directly provided to them or to receive cash that they can use to purchase services (so-called cash for care schemes) has become an important policy objective (Glendinning et al., 2004). This development was particularly welcomed by members of the disability movement, mainly consisting of people aged 18–65 with physical disabilities, for whom choice was an important way of achieving greater independence and autonomy (Prideaux et al., 2009; Stevens et al., 2011). While control and empowerment are important ends in themselves, a key policy rationale is that people are better at identifying what will support them most effectively, and can potentially draw on informal networks. This will, it is hoped, enable formal social care resources to work in a more complementary way with individuals and their families (Netten et al., 2012).

The option to choose a direct payment instead of directly provided services was first made available to people living in the UK following implementation of the Community Care (Direct Payments) Act 1996. Payments were generally used to pay for a support worker or personal assistant to provide help with personal care and domestic tasks. The original legislation excluded older people and people who lacked capacity to manage their own money, although it was later extended to include these groups. However, take-up remained comparatively low, particularly among older people (Leece and Leece, 2006).

In 2005, the Department of Health invited 13 LAs with social services responsibilities to pilot an individual budget scheme which differed from direct payments in that it would combine different funding streams from social care, housing, and benefits, with the exception of money for healthcare. The amount that individuals would receive depended on what needs they were assessed as having. The funds would then be spent in accordance with a support plan agreed by the service user and a care manager or social worker or an external ‘broker’. The aim of the pilots was to see if this system would increase choice for the service user—for instance, would an older person choose to go out for a meal in a café or pub rather than receive a hot meal delivery service (meals on wheels)? There would also be opportunities to look at how assessments could be integrated to improve working across different agencies and reduce the number of assessments that an individual might be expected to undergo (Moran et al., 2011).

Evaluation of the pilots was undertaken through a randomized multimethod comparison group study in which 510 individual budget holders living in the 13 pilot authorities were compared with 449 people receiving conventional services in the same locality (Manthorpe et al., 2009; Moran et al., 2011; Netten et al., 2011; Stevens et al., 2011). The overall conclusions from the evaluation were that individual budgets produced positive outcomes in terms of service users’ quality of life and sense of control. Benefits could also be seen for their carers, who also reported a better quality of life and considered that they had more opportunities to have a social life (Moran et al., 2012). However, the evaluation concluded that individual budgets were not a ‘magic bullet’ (Netten et al., 2011: 13). In particular, older people were less likely to use innovative support, and were more anxious about the process of planning and managing support. These findings were thought to suggest that more work was needed on tailoring approaches to the needs of different groups of service users.

Anticipating the results of the individual budgets pilot, the then Labour government issued its Putting People First strategy (HM Government, 2007) which stated that personal budgets (as they were retermed) would be provided to everyone eligible for publicly funded adult social care support other than in circumstances where they required emergency access to provision. People could choose to receive an individual budget in the form of a direct (cash) payment held directly by the person or, where they lacked capacity by a ‘suitable person’ such as a carer or advocate who could act as their representative, by way of an ‘account’ held and managed by the council or another third party in line with the person’s wishes, or by a combination of the two. In November 2010, the Coalition government confirmed that it too supported this system, stating that:

The time is now right to make personal budgets the norm for everyone who receives ongoing care and support—ideally as a direct cash payment, to give maximum flexibility and choice.

(Department of Health, 2010b: 16)

It set a timetable of April 2013 for local councils to provide personal budgets for everyone eligible for ongoing social care. However, a key difference between these proposals and the individual budget pilots was that there was no integration of different funding streams, thus potentially missing some opportunities to avoid duplication and achieve greater flexibility (Moran et al., 2011).

The Vision for Adult Social Care (Department of Health, 2010b) also distinguished between personal budgets and the wider policy of personalization. Personalization was a term first coined in services for people with learning difficulties to convey attempts to place the interests of service users above the interests of those arranging or providing services, and to give them independence, choice, and control over the services they use. Personal budgets and direct payments are viewed as important ways of achieving personalization. Underpinning the government’s vision are seven principles (sometimes referred to as the 7 Ps) (see Box 26.1).

Research undertaken across the UK suggests that personal budgets (or, as they are termed in Scotland, self-directed support) have developed most extensively in England (Davey et al., 2007). In Wales, they are almost exclusively used by younger people, and in Scotland there are around 18 people using traditional home care services for every person using self-directed support (Samuel, 2011). At the time of writing, direct payments are available in Northern Ireland but not personal budgets.

At this stage, there are no clear answers to the question whether personal budgets will benefit older people with mental health problems. It is only comparatively recently that people with dementia have had access to personal budgets or direct payments, and a report by the Alzheimer’s Society (2011) expressed concern that few people with dementia have been offered them. Furthermore, people with dementia and their carers were dissatisfied with the amount of information they were given and the amount of support they were offered in managing payments, illustrating the importance of the advice expressed by Netten and colleagues (2011) that systems need to adapt to the needs of different groups of service users. Goodchild (2011) suggests that LAs must develop money management systems, so that it is not always the carer who is expected to manage the personal budget, and ensure that advocacy services are available to help people with dementia and their carers decide what is best for them. Manthorpe and Samsi’s (2012) interviews with Adult Safeguarding Coordinators highlight the need for workers to be aware of the risks of financial abuse among those receiving a personal budget, but also identify opportunities for social workers and support planners to work with people with dementia and their families to minimize the risks of abuse.

Who Provides Social Care?

The policies towards marketization discussed in the section Reforming Social Care—Personalization have created considerable variation across social care providers. In the past, LAs employed the majority of people working in the sector, although some care was also provided by voluntary organizations. Changes to social security rules in the 1980s led to a rapid expansion in the number of privately run care homes. This was followed by an expansion of in the number of home care providers. Taken as a whole, Eborall and colleagues (2010) estimate that there are 40,600 units providing social care (excluding self-employed individuals). While some of these include care homes owned by large national and multinational chains, the majority of social care enterprises are small or small to medium businesses. Around three-quarters of employers have fewer than 20 employees and half have fewer than 10 (Eborall et al., 2010). These figures exclude the increasing number of self-employed workers who work for people receiving personal budgets and the rising number (albeit one that is hard to quantify) of people organizing and paying for their own care.

The final part of this chapter now considers what we know about different social care workers and social care services providing support for older people with mental health problems and their families.

The Role of Social Workers

Social workers and those who have similar responsibilities for arranging social care assessments, such as care/case managers and care coordinators, play an important role in achieving social care support that fits in with what people using services and their families want. Interviews with older people suggest that their experiences of social workers are variable, but that they are most appreciative of those who offer the skills and knowledge to provide specialist advice and help ‘navigating’ the system (Manthorpe et al., 2008).

It is perhaps significant that the clearest evidence for the effectiveness of social work with dementia comes from the Lewisham Care Management Scheme which operated during the 1990s. This involved basing care managers employed by the LA in a community mental health team. People with dementia who were in the experimental group that received intensive care management remained at home for longer and experienced better quality of life (Challis et al., 2002). In contrast, social workers in ‘standard’ teams not providing specialist mental health support could expect to spend more of their time on assessments and less time considering how to refine the care plans they had set up (Weinberg et al., 2003).

Since these studies were undertaken, the changes to eligibility criteria mentioned earlier have meant that social workers are increasingly seeing people with very complex needs and there is evidence that safeguarding is becoming an increasingly central part of their role (Manthorpe et al., 2009). It is possible that the developments in personalization will alter the dual emphasis on assessments and safeguarding, leading to the suggestion that it might lead ‘either to a reinvigoration or erosion of social work skills dependent upon the nature of local implementation’ (Jacobs et al., 2013: 18). Another suggested potential role for social workers is for them to become more involved in memory clinics where their experience in breaking bad news might mean that they could have a role in supporting newly diagnosed people (Manthorpe and Iliffe, 2009). Social workers could also become more involved in preliminary screening for identifying possible dementia among people living at home (Clarkson et al., 2012).

It is important to recognize that social work qualifying education is currently generic, and it is not entirely clear how much teaching students receive on the needs of older people with mental health problems. However, as the availability of dementia studies programmes in higher education increases, there are now more opportunities for social workers to undertake continuing professional development in this area, especially as these courses generally offer the opportunity to study flexibly, either part time or thorough distance learning. Social workers’ recognition of depression in older people is thought to need improvement, so there are opportunities for continuing professional development in this area too (Clarkson et al., 2012).

Direct Care Workers

In contrast to the comparatively small number of professionals working with older people with mental health problems, such as social workers, occupational therapists in community reablement teams, and nurses in nursing homes, there is a far larger group of direct care workers, many of whom do not possess any vocational or professional qualifications. Temporary workers are overrepresented in the dementia care workforce (Hussein and Manthorpe, 2012). Low levels of pay and poor status are generally cited as key reasons why it can prove to be difficult to retain staff (Moriarty, 2010; Hussein and Manthorpe, 2011).

Care Homes and Extra Care Housing

Low levels of training and poor rates of retention are thought to contribute to the poor quality of care received by some older people with mental health problems in care homes (Mozley et al., 2000, 2004; Dening and Milne, 2009). Confidence in responding to behavioural difficulties is a particular issue (Hughes et al., 2008) and many care home managers would welcome specific advice from old age psychiatrists on this topic (Purandare et al., 2004). In Scotland, the appointment of a nurse with a specific remit to liaise with care homes to help them care for people with behavioural problems has been evaluated positively by care homes (Scottish Government/Alzheimer Scotland—Action on Dementia/Dementia Services Development Centre, 2009).

Extra care housing in which people with dementia can live independently but have access to support workers is emerging as an additional option to moving into a care home. People with dementia value the extra independence and choice that living in extra care housing offers (Evans et al., 2007), but there are no comparative studies of the two options.

A study of people in care homes with depression found that after training from members of the local community mental health team, care staff were able to work individually with residents on activities such as re-establishing contact with friends and attending social activities. These interventions produced significant reductions in residents’ scores on a recognized measure of depression (Lyne et al., 2006).

Home-Based Care

High rates of depression (Banerjee and Macdonald, 1996) and dementia have been found among people using home care (Livingston et al., 1997). Home-based care can cover a range of support, from workers to help with personal care, to support workers whose role is to enable the person with dementia to take part in leisure activities and hobbies, to services designed to give carers a break. One study of consecutive referrals to social work teams in four areas found that people with cognitive impairment receiving home care remained at home for longer (Andrew et al., 2000). Accounts of specialist schemes have suggested that home care services specializing in supporting people with dementia can offer advantages in that they are more likely to offer a worker who can build up a good relationship with the person with dementia, and staff are more likely to have had access to specialist training (Rothera et al., 2008; Snayde and Moriarty, 2009). However, other work (Challis et al., 2010) has suggested that what matters is not so much whether a service is generic or specialist but that it conforms to good standards in dementia care and that both types of service can do this.


Good support for older people with mental health problems requires good partnership working between health and social care. This chapter has shown that the differing origins of health and social care and different ways in which services have been organized helps explain why there have often been barriers to more effective working. The government plans for greater integration between health and social care suggest that there will be opportunities to develop more ‘joined up’ services. At the same time, such approaches are very dependent upon finding solutions to the long-standing issues about funding for social care and the various and complicated pieces of legislation on which it is based.

Finally, it is important to recognize that much of the care that older people with mental health problems receive on a daily basis is delivered by social workers, many of whom have only limited training about older people’s mental health problems. There are clear opportunities for health professionals to play a part in delivering training on topics that care workers find relevant and useful for their work.

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