Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might affect practice or services.

Principles of social work for adults with complex needs

For social workers

Recommendations 1.1.1 to 1.1.10

Why the committee made the recommendations

The committee looked at a range of evidence to inform the recommendations, which are intended to underpin all social work with adults with complex needs. They also took the Human Rights Act 1998, the Equality Act 2010, the Care Act 2014 and the UK General Data Protection Regulation (GDPR) and the Data Protection Act 2018 into account to address potential inequalities and data protection issues (for example, in access to services or in the services that people with complex needs receive). They also drew on the professional standards from Social Work England, the Professional Capabilities Framework from the British Association for Social Workers (BASW) and the Code of Ethics from BASW.

The committee discussed qualitative evidence related to supporting people to plan for the future that highlighted some of the barriers that could influence people's access to and participation with services (for example, poverty, which is associated with inadequate housing and limited access to support). Such barriers could, in turn, result in people who use services feeling shame about their health conditions or living circumstances. This could further isolate them and make it more challenging for providers to support them. The committee therefore made a recommendation to emphasise that social workers need to treat people with respect and dignity to prevent barriers developing, and to understand and take into account the different circumstances of people with complex needs and any of their past experiences of services. This is also in line with the Human Rights Act 1998 and the Equality Act 2010.

There was some qualitative evidence related to approaches to needs assessments that showed people were not always aware of what to expect from an assessment, and that language could be a barrier to communicating with social workers during the assessment. The committee agreed that meeting these needs are important principles that would apply to all aspects of social work, so they decided to broaden the recommendation beyond just the assessment process. They recommended that the social worker find out whether an advocate is needed to support the person and help with communication, information and understanding the legal framework. The committee discussed that some people (for example, people with learning disabilities) may also have particular sensory needs or impairments (for example noise level or brightness of light) and therefore added that this should also be taken into account. Based on the same evidence, the committee also emphasised the importance of ensuring that all the person's communication needs and preferences are addressed, to help them to actively participate in discussions. They noted that this was already covered in the section on overarching principles in the NICE guideline on people's experience in adult social care services so they included a cross reference to this.

There was also some qualitative evidence showing that people did not always understand the purpose of the needs assessment and what it would entail. The committee used this evidence to recommend that sufficient information is provided for all activities and processes so that the person can understand what is going to happen and why. This will mean they can make informed choices and actively participate in the assessment.

The committee discussed the support that people may need to be actively involved in social work processes:

  • qualitative evidence showed that cultural differences created challenges for practitioners

  • qualitative evidence showed that not having family support can be detrimental to the person's wellbeing

  • quantitative evidence showed that differences in perspective because of culture lead to care needs not being raised or recognised by social workers

  • in the committee's own experience, people's life experiences, expectations and emotional state can have an impact on their care experiences, and consequently lead to inequalities and poorer outcomes.

The committee made recommendations to address these problems. They also highlighted the positive impact of family support (if needed and wanted) which can help the person to be actively involved.

The committee drew on both quantitative and qualitative evidence from the review of individual and family casework. They discussed the qualitative evidence that suggested people's cultural experiences and perspectives can differ from those of the practitioner, and that this may result in the practitioner making assumptions. Based on experience and expertise, the committee emphasised that the starting point would be relationship building to identify a person's characteristics that might predispose them to inequality in healthcare provision, by actively listening to the person. They highlighted that forming trusting relationships is the cornerstone of social work and that looking at all aspects of the person's life would ensure that the social work approach has the person with complex needs at its centre, and that any reasonable adjustments are being made in relation to those needs. They discussed that a record of reasonable adjustment decisions should be made to ensure that this was given due consideration. The committee noted that there was only a small amount of evidence, but acknowledged that this was a key area of social work that could lead to inequalities in access to care and care provision, if not addressed. In the absence of evidence for other experiences and circumstances that may lead to inequalities and discrimination, which may be multiple (see the definition of intersectionality), the committee applied the evidence about the challenges of cultural differences and assumption as well as their knowledge from the Equality Act to cover the protected characteristics as well as other life circumstances and experiences (see box 1).

The committee noted that a lot of qualitative evidence on the social worker's role in multidisciplinary teams referred to information sharing as a potential facilitator to integrated working, as it provides continuity (and conversely, acts as a barrier if not present). They discussed, based on their experience, that information gets shared more about people with complex needs and between more agencies. There were concerns about the extent of information sharing, however. In the committee's experience, people with complex needs value continuity and consistency and generally think that it is a positive idea to share information, but they want to be informed when and what information is shared and with whom (whenever this is possible and appropriate, in line with UK GDPR and the Data Protection Act 2018). The committee decided that this is a principle that should not be restricted to multidisciplinary team working but applies to all social work practice. The committee agreed that people need to be reassured that there are legal limits on information sharing and that their data is protected, but also that sharing where possible would mean that they would not have to repeatedly tell their life stories.

The committee discussed that there are a wide range of conditions, impairments or fluctuating health conditions that lead to complex needs. They discussed that the guideline should be viewed in the context of such needs and that social workers when meeting a person with a particular condition should be aware of the relevant condition-specific guidance associated with this. The committee decided to give some examples of the range of conditions that may be applicable.

How the recommendations might affect practice

The committee noted that most of these recommendations would standardise practice, as they are actions that are mandated by legislation (particularly the Equality Act 2010, the Care Act 2014), and supported by Social Work England's professional standards or BASW's Professional Capabilities Framework. This is particularly in relation to information sharing, and active listening and relationship building.

Return to recommendations

For organisations

Recommendations 1.1.11 to 1.1.16

Why the committee made the recommendations

The committee looked at a range of evidence to inform the recommendations, which are intended to underpin all social work with adults with complex needs. They also took into account the Human Rights Act 1998, the Equality Act 2010 (for example, to address inequalities in access to services or in the services that people with complex needs receive), the Care Act 2014, the UK GDPR and the Data Protection Act 2018 and the professional standards from Social Work England.

The committee used qualitative evidence from the reviews on individual and family casework, and helping people to connect with local communities and reduce isolation. This showed that the social work approach that people received was not sufficiently long or in-depth enough to address their complex needs. Based on this evidence, the committee recommended organisations provide sufficient time to social workers to build relationships in order to reduce inequalities.

The committee discussed that people's life experiences may have an impact on their care experiences, and consequently lead to inequalities in access to care and care provision and poorer outcomes. They recommended organisations support and train social workers to discuss people's personal and social identities, and life experiences. This is in line with professional standard 1.6 from Social Work England that outlines the role of the social worker to promote social justice, helping to confront and resolve issues of equality and inclusion. This would enable social workers to feel confident that they are providing an environment where people feel that they are free of discrimination, and emotional or physical harm, and feel safe in discussing the complex needs that they have. The committee highlighted that this would also improve wellbeing of people, but they discussed that the term wellbeing is sometimes interpreted only in physical health terms. They therefore decided to adopt the definition of wellbeing provided within regulation 1(2) of Care Act 2014.

There was qualitative evidence that social workers value support, supervision and training. The committee discussed that being up to date with relevant legal frameworks was particularly important to their work. They recommended that organisations should support this with continuous professional development so that social workers continue to develop legal knowledge and therefore act in accordance to the law when carrying out their duties.

Qualitative evidence showed that people felt existing services and interventions did not sufficiently address all their needs. This was also consistent with the committee's experience of current practice, and they emphasised that planning of services (commissioning and configuring) should take this into account to address potential inequalities in access to care and care provision.

The committee discussed evidence related to responding to an escalation of need, and concluded as a general principle that organisations should ensure social workers be given appropriate training and support during and after response to an escalation of need. However, the committee also agreed this would benefit all areas of their work, so expanded the recommendation to be one for development of an overall framework for an open learning culture. The committee discussed that this was in line with Social Work England's professional standards which also emphasise that families and communities should be taken into consideration. This will support social workers in learning from each other, and make them better able to appraise situations generally, but also specifically assess appropriate levels of risks that can be taken.

How the recommendations might affect practice

The committee noted that most of these recommendations would standardise practice. The recommendation that organisations should consider making time allowances to build relationships may lead to longer contact times than currently, but this would be balanced against better, individualised services and this was supported by the economic analysis. The recommendation on continuous professional development would address a current variation in practice in getting access and time for such training opportunities.

Return to recommendations

Assessment – needs assessment

Providing information

Recommendations 1.2.1 to 1.2.3

Why the committee made the recommendations

As there was no quantitative evidence on the effectiveness of different approaches to social work needs assessments, the committee used the qualitative evidence supported by their own knowledge and experience to make recommendations. They also took into account the legal framework underpinning social work assessments (particularly the Care Act 2014) and standards of practice (according to Social Work England's professional standards or BASW's Professional Capabilities Framework).

There was some evidence showing that people did not always understand the purpose of the needs assessment and what it would involve, so the committee recommended giving people accessible information on why it is needed, the objectives, and how it will be done so that they have time to prepare. This also included raising awareness with carers about their right to have a carer's assessment in line with regulation 10 of the Care Act 2014.

They also discussed that better understanding and knowledge (including of statutory rights) about social work assessments, both in terms of what is involved and the likely outcome, would reduce anxiety and stress for the person with complex needs. They noted that the social work can play an important part in addressing this by signposting to relevant resources.

How the recommendations might affect practice

Most of the recommendations will standardise rather than change practice, as they are actions that are mandated by the Care Act (such as giving sufficient information).

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Planning the assessment

Recommendations 1.2.4 to 1.2.9

Why the committee made the recommendations

As there was no quantitative evidence on the effectiveness of different approaches to social work needs assessments, the committee used the qualitative evidence supported by their own knowledge and experience to make recommendations. They also took into account the legal framework underpinning social work assessments (particularly the Care Act 2014) and standards of practice (according to Social Work England's professional standards or BASW's Professional Capabilities Framework).

Based on their experience, the committee emphasised that social workers should conduct assessments in a way that would minimise stress for the person noting that this would lead to better relationships and engagement and would therefore impact positively on outcomes.

The committee discussed the review findings which suggested people were not always able to express their preferences during assessment. Based on this the committee recommended that there could, in some circumstances, be a preparatory initial contact before the assessment as a way of overcoming these issues. The committee agreed that this can be particularly important if the person may have difficulties being actively involved in the assessment. To address such difficulties, support may be needed from an independent advocate in the assessment. A preparatory meeting could provide the opportunity to assess whether there are any adjustments that can be made or family members who can get involved and could help and support the person with complex needs throughout the process. However, regardless of whether a preparatory meeting is held or not, the committee highlighted that the practical arrangements for the assessments always need to be established before the assessment takes place. They discussed the benefits and challenges of remote (for example virtual) compared to in-person assessments. While there are some advantages of remote assessment (such as when an urgent assessment is needed) there are also disadvantages (such as not being able to get cues from the person's environment). While they could not categorically recommend 1 over the other, they highlighted that in cases of potential safeguarding concerns an in-person assessment would most likely be needed because missing any needs in these circumstances could have serious consequences.

The committee discussed qualitative evidence of possible challenges with self-assessment; for example, participants in a study reported that the self-assessment format was not always adequate or appropriate for people with multiple needs. Based on this, the committee emphasised that discussions should take place with the person about the advantages and disadvantages of this option so that they can make an informed choice, and that the person should be reassured that they will be supported and can change their mind and have an in-person assessment instead.

How the recommendations might affect practice

Most of the recommendations will standardise rather than change practice, as they are actions that are mandated by legislation such as the Care Act or based on Social Work England's professional standards or BASW's Professional Capabilities Framework. The recommendation for a preparatory initial contact is a change to current practice since this is not uniformly done across the country. This may lead to an increase in the number of contacts, which may cause a potential resource impact and increase demands on social worker time. However, the committee noted that a preparatory visit is an option rather than a mandatory requirement and could be a virtual contact or a phone call. The additional resources needed to have some such preparatory visits may be offset by improved outcomes from the person-centred approach, potentially improving quality of life and preventing expensive interventions later on, such as hospitalisation. Also, as it is only an option that services could use rather than something that should be implemented for everyone, the impact may be limited.

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Conducting the assessment

Recommendations 1.2.10 and 1.2.11

Why the committee made the recommendations

The committee used the Care and support statutory guidance and regulation 2(1) of the Care Act 2014 to make these recommendations.

The committee noted that if self-assessment is chosen, the Care Act 2014 requires social workers to check that the information that is provided in the assessment is accurate, so they emphasised this in a recommendation. This could be achieved by gathering information from multidisciplinary team members or family and carers, where appropriate.

Based on the committee's experience and expertise of the statutory guidance in relation to needs assessment, they discussed the content of the assessment and the related eligibility criteria. They agreed that it is important to highlight the questions that the social worker should take into account when deciding on the level of support that is needed in compliance with statutory guidance (eligibility outcomes of regulation 2(2) of the Care Act 2014). The committee discussed that some of the person's needs may be outside of the expertise of the social worker, for example communication or mental health needs, and it is important that specialist input is sought to address these needs.

How the recommendations might affect practice

Most of the recommendations will standardise rather than change practice, as they are actions that are mandated by either the Care and Support Statutory Guidance or the Care Act.

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Recording and reviewing the assessment

Recommendations 1.2.12 to 1.2.15

Why the committee made the recommendations

As there was no quantitative evidence on the effectiveness of different approaches to social work needs assessments, the committee used the qualitative evidence supported by their own knowledge and experience to make recommendations. They also took into account the legal framework underpinning social work assessments (particularly the Care Act 2014) and standards of practice (according to Social Work England's professional standards or BASW's Professional Capabilities Framework).

Evidence showed that people were not always given the opportunity to review their assessment details, so the committee made a recommendation to ensure that people have the opportunity to check the draft documents are accurate.

The evidence also suggested that needs can be interpreted differently by the person with complex needs and the social worker, which can lead to misunderstandings about the support that is expected. The committee acknowledged that differences of opinion could arise between a range of individuals, such as professionals and family members or others involved. They therefore recommended that a record of such differences should be kept in case any future issues arise. The committee noted that this could lead to tensions between the person with complex needs and the social worker, and could sometimes lead to complaints being made. They therefore emphasised that not only is good record keeping important when differences arise, but also that people should be given information about the complaints procedure, so they know what to do if they feel the correct processes have not been followed or they disagree with the outcome of the assessment.

In the context of self-assessment, the committee noted, based on their knowledge of legislation, that organisations have an obligation to provide the person who self-assesses with relevant information that they hold to help them in the process. The committee agreed that this was not always known by social workers and made a recommendation that this must be done to comply with legislation.

There is a lack of quantitative evidence addressing approaches to needs assessment and their potential impact on wellbeing. Because of this, the committee prioritised this topic for a research recommendation on needs assessment.

How the recommendations might affect practice

Most of the recommendations will standardise rather than change practice, as they are actions that are either mandated by the Care Act (such as giving sufficient information and support, or issues related to self-assessment) or extrapolated from it (such as preferences when arranging the assessment). The recommendation for a preparatory initial contact is a change to current practice, since this is not uniformly done across the country. This may lead to an increase in the number of contacts, with a potential resource impact and increasing demands on social worker time. However, the committee noted that it would not be routinely done and could be a virtual contact or a phone call. This may be offset by improved outcomes from the person-centred approach, potentially improving quality of life and preventing expensive interventions later on, such as hospitalisation. Also, as it is only an option that services could use rather than something that should be implemented for everyone, the impact may be limited.

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Assessment – risk assessment

Planning the risk assessment

Recommendations 1.2.16 to 1.2.19

Why the committee made the recommendations

The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the low number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations. They also took into account relevant legislation, including the Mental Capacity Act 2005 and the Mental Health Act 2007 as well as the Human Rights Act 1998 and the UK GDPR and the Data Protection Act 2018. The committee were also aware that decisions around risk can be influenced by culture, personal beliefs, and coping strategies. They therefore also took into consideration the Equality Act 2010.

The evidence highlighted that when people with complex needs, and their families and other people important to them were actively involved in the risk assessment process, it facilitated discussions with social workers around risks and helped them make decisions about care and support needs. The committee agreed that this was an essential component of social work and consistent with the legal framework. The committee agreed that for people with complex needs, and their families and other people important to them to be actively involved the process, it needs to be relevant to the person and therefore holistic, looking at the person's abilities and needs and taking their preferences into account.

The committee noted that the evidence suggested that people found it useful when family members supported them. However, they cautioned against being prescriptive about this because not every person would want their families involved in the process. Therefore, the committee recommended that social workers discuss the person's views and preferences and that these be recorded and shared (in line with the UK GDPR and the Data Protection Act 2018) so that families are not inadvertently included in discussions if this would go against the wishes of the person with complex needs.

The committee discussed the evidence relating to contextual risk assessment that showed that people found the risk assessment approach worked better when their individual circumstances were fully understood. The recommendations emphasise the need for social workers to develop a rapport with, and engage with, the person at risk. When possible and practical, the committee recommended that ideally this should be done over several contacts so that the person's circumstances and environment is fully understood. While the committee wanted to emphasise the need to build relationships and understand the person's circumstances and environment, they also acknowledged that in some situations when a person is at urgent risk, immediate action needs to be taken which may not allow time for several contacts.

How the recommendations might affect practice

The recommendations reinforce current legislation and usual practice. While conducting risk assessments over several contacts (which could be a virtual contact or a phone call) is not consistently done across the country, and would add time to the assessment, this would improve outcomes through a better understanding of the person's situation and environment. However, rather than this being implemented for everyone the committee thought that this could be one of the considerations around the assessment and would therefore not significantly change practice.

Return to recommendations

Conducting the risk assessment

Recommendations 1.2.20 to 1.2.34

Why the committee made the recommendations

The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the small number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations. They also took into account relevant legislation, including the Mental Capacity Act 2005 and the Mental Health Act 2007 as well as the Human Rights Act 1998. The committee were also aware that decisions around risk can be influenced by culture, personal beliefs, and coping strategies. They therefore also took into consideration the Equality Act 2010.

The committee noted the evidence related to assessing risk when a person lacks capacity, and so highlighted that risk assessments would also involve planning for the future so that the person's wishes are known in advance and a plan is in place to manage risk. They agreed that this would lead to better outcomes, since any risky situation can be managed in line with the person's preferences even if they later lack capacity to make decisions.

The committee discussed that safeguarding issues can be noticed in the risk assessment process and that it is therefore a legal duty in line with the Care Act 2014 that the social worker adheres to local policies to keep the person safe.

There was a lack of evidence about what works well and what could be improved in relation to the content of risk assessments, but despite this the committee agreed that it was important to provide guidance about what should be taken into account when conducting a risk assessment. They also discussed a guide about risk assessments from the Social Care Institute of Excellence and took this into account. In line with this, the committee recommended that to be effective the social worker should individualise the risk assessment and consider not only harmful outcomes but also where there are low risks and potential for good outcomes (for example, if the risks of harm from others and harm to others is low, it could mean that there is a good support network that the social worker could get involved to help with other potential risks that are high). The committee agreed to highlight categories of risks that would affect the person's safety and the safety of other people, as well as risks to their independence and the independence of others who may depend on them so that plans can be made to minimise them.

The committee discussed their concerns that any risky decisions could lead the social worker to conclude that the person lacks capacity, and they therefore highlighted the legislation of the Mental Capacity Act 2005 which states that assessments of mental capacity should not be based on such assumptions. They discussed that such decisions can be challenging with some cognitive impairments, such as executive dysfunction, and therefore highlighted this in a cross reference to recommendation 1.4.19 of the NICE guideline on decision making and mental capacity.

The committee were aware that people who lack capacity to make decisions related to risk were particularly vulnerable, and that therefore the legislation in section 4(6) of the Mental Capacity Act 2005 needs to be followed so that their current wishes can be established if possible. Even though an assumption should not be made that someone is lacking capacity, the committee did not want to leave someone vulnerable to risk if they do lack capacity, so they recommended that a person who makes a decision that would put themselves at significant risk should be considered for an assessment of capacity. Getting the views of people close to the person and members of the multidisciplinary team may be helpful to determine whether an assessment may be necessary. This is to ensure their safety, and potentially the safety of their family members or carers.

The committee noted the qualitative evidence showing that people agreed that risk assessments work better when discussions take into account the words a person uses to describe risk and their understanding of risk. There was some evidence that checklists can help with this, but the committee was cautious to recommend these as a routine form of assessment as there are only a small number of validated checklists available, and so they would not address the range or complexities of risks for people with complex needs. They were also concerned that this could also be seen by the person as a tick box exercise, and so recommended that checklists be used as a starting point for a wider discussion including previous causes of an escalation of needs and what worked well before to minimise risk. Because of uncertainties with the evidence on the use of checklists and it being restricted to people with complex mental health needs, the committee also made a research recommendation on risk assessment.

When reviewing evidence indicating that risk assessments worked better if social workers fully understand the person's perspectives of risk (when they have capacity to do so), the committee noted that this was consistent with their own experience. They therefore wanted to ensure that this was taken into account when assessing risk, but also that this should not stop social workers from providing necessary support if needed. The committee noted that this was in line with Social Work England's professional standards which advise social workers not to prejudge the person's state and also reflect on their own interpretations (which can be based on their own values), so as to avoid their own feelings around risk influencing their assessment.

The committee discussed evidence highlighting that a risk assessment works well for people who have capacity when it balances a person's risk with their autonomy, and other evidence that showed understanding the person's perception of risk facilitates the process. They therefore highlighted that people can make their own decisions about risks or decline interventions (for example, keeping many personal belongings if they are hoarding items even if it makes it difficult to move around their home). However, such choices should not be a reason to stop working with them or providing care even if the social worker perceives these decisions to be risky or unwise.

There was evidence related to detention under the Mental Capacity Act for people assessed as lacking capacity, and the committee used the principles of the Mental Capacity Act to highlight that the circumstances where potential risks for people who lack capacity could occur need to be carefully considered, including ascertaining the person's best interests, so that any restrictions made are proportionate and justified.

There was evidence highlighting that it is difficult to define the seriousness of risk, which was consistent with the committee's experience that risk would vary from person to person. The committee discussed that in the absence of such definitions, risk assessments can potentially place too much emphasis on the use of generic risk categories such as 'high' and 'low' risk – these do not distinguish the severity of potential harms from their likelihood, and do not take into account the different circumstances and choices of the person at risk. Based on these discussions, the committee made recommendations which emphasised that when recording risks social workers need to assess the severity and likelihood of identified potential harms to inform a risk management plan. This should weigh potential harms against potential benefits of risk taking, and a person's needs and wishes.

The committee acknowledged that the person at risk may not always give consent for their information to be shared. The committee identified the Human Rights Act 1998 underpins such decisions, and this was stated in the recommendations.

How the recommendations might affect practice

The recommendations reinforce current legislation and usual practice. For advance decision making, while this is not a mandatory part of risk assessment it is commonly done, so the recommendation is likely to lead to standardised practice.

Return to recommendations

Recording and reviewing the risk assessment

Recommendations 1.2.35 to 1.2.39

Why the committee made the recommendations

The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the limited number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations. They also took into account legislation, under the UK GDPR and the Data Protection Act 2018.

Based on their experience, the committee were keen to emphasise the need to balance any competing demands and perspectives of different organisations, and for different practitioners to be able to exercise their professional judgement. To achieve this, they recommended that, in complex situations involving potential risks of serious harm (for example these could be situations where there are many different opinions in the multidisciplinary team, potentially different complex harms or where 1 action to avoid 1 risk might bring about a further risk), social workers coordinate a case conference. Usually this would include the person and their family or carers but the committee decided that there are situations where a case conference could be a cause of distress for the person or may put a family member at risk. They therefore made a recommendation to highlight both that the person's and their family's involvement is important as well as situations when this may not be advisable.

Also based on their experience, the committee discussed that, when there are significant concerns about risks, information ought to be shared between agencies to ensure the safety of the person with complex needs. However, they emphasised that this can only be done within the constraints of the legal framework within the UK GDPR and the Data Protection Act 2018.

Evidence showed that people were not always given the opportunity to review their risk assessment, so the committee made a recommendation to ensure that people have the opportunity to check the draft documents are accurate.

The evidence also suggested that disagreements could arise across different organisations and among different practitioners because of the varying ways in which risk is conceptualised and decisions on managing risk are made. The committee also noted that differences of opinion could arise among professionals, the person with complex needs, family members or others involved. They therefore recommended that a record of such differences should be kept in case any future issues arise from disagreements.

The committee also noted that risk assessments need to be relevant, up to date and responsive to change and therefore, based on their experience, recommended that they are reviewed at least annually, or when circumstances change and a new review is needed.

How the recommendations might affect practice

The recommendations reinforce current legislation and usual practice.

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Organisational support

Recommendations 1.2.40 to 1.2.45

Why the committee made the recommendations

The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the limited number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations.

The evidence showed that social workers valued support, particularly when they have experienced abuse, and ongoing training (including legal literacy). Based on the evidence and potential for high-risk situations, advice for social workers should be available whenever they are working, including outside normal office hours. The evidence showed that positive organisational cultures give social workers confidence in making risk assessments, and the committee drew on this to recommend a written strategy for training and support.

How the recommendations might affect practice

The recommendations reinforce current legislation and usual practice. The availability of training on risk assessment for social workers varies, so there may be a resource impact where it is currently not available. However, this would lead to better outcomes by improving the knowledge and awareness of processes and approaches to assess risks. Having out-of-hours access to advice in relation to risk for social workers who do not work during office hours is common practice (such as using an on-call system), so should not be an additional resource impact in most cases.

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Individual or family casework

Recommendations 1.3.1 to 1.3.4

Why the committee made the recommendations

The committee drew on both quantitative and qualitative evidence to make recommendations.

The committee discussed the quantitative evidence, which showed mixed results for social work approaches to individual and family casework. They discussed the evidence that showed that a stepped care intervention had an important benefit in terms of morbidity outcomes. This intervention had a number of components including guided self-help and problem solving. The qualitative evidence suggested that social work approaches, in particular goal setting, helped people to identify their priorities and think about ways to achieve these goals. Based on experience, the committee discussed the benefits of such approaches – in particular, those with components that seek solutions to defined areas and working to agreed goals to solve problems. They decided that they could not recommend the specific stepped care approach described in the study, as it was done in a different health and social care setting (Belgium and the Netherlands) and had many components that would make it difficult to implement. However, they noted that some of the components would fall into the category of task-focused approaches which are already used by social workers in the UK. Although the evidence showed benefit for a specific group, the committee agreed that the importance of identifying goals and outcomes (as is done in task-focused approaches) could be extrapolated to the wider population of adults with complex needs and recommended that people should be supported in this process.

The committee highlighted legal frameworks that were in place to support the rights of the person as well as the rights of the family. They agreed that by doing this, social workers would better understand that their role is not necessarily to resolve conflict, but to uphold the rights of the person being supported.

The committee looked at evidence around the challenges of involving family members in social work approaches to casework, and potential conflicts which may exist between family members and how safeguarding concerns may arise in some situations. They discussed the difficulties, as highlighted in the evidence, of ensuring family members participate and engage in interventions. However, they noted that there was little quantitative evidence on the effectiveness of any particular family intervention that had been carried out specifically by social workers to address these challenges. The committee was aware that there is a benefit from family interventions (for example, improving communication between family members), but that the evidence originates from other disciplines (for example, research in clinical psychology) and it is therefore unclear what the role of these interventions is in social work. However, to promote the rights and wellbeing of people and families (in line with Social Work England's professional standards) they felt such interventions could be considered with sufficient training, because the benefits of positive family relations and the social support that this could provide to the person with complex needs could lead to positive outcomes.

How the recommendations might affect practice

The recommendations aim to standardise practice rather than change it.

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Helping people to connect with local communities and reduce isolation

Recommendations 1.4.1 to 1.4.7

Why the committee made the recommendations

The committee discussed the quantitative evidence, which showed benefits for some outcomes but no differences for other outcomes. However, because of methodological biases, as well as uncertainty around the magnitude of the findings, the committee were less confident in relying completely on the quantitative evidence to support recommendations. There were some themes of the qualitative evidence that supplemented or provided an explanation for the lack of clear results in the quantitative evidence. This combination of quantitative outcomes and qualitative themes suggested that the relative lack of improvement in the quantitative outcomes could be explained by the qualitative evidence that social workers place importance on taking an individualised approach to achieve positive outcomes. The committee agreed that this was a reflection of their experience of practice and was therefore important to take into account.

The committee made a recommendation based on the quantitative evidence that showed social work approaches to social inclusion had an important benefit over usual practice that mainly focused on the person's existing networks, as there was an improvement in perceived social support. The qualitative findings also highlighted the importance of thinking about the different levels of support a person may need. Based on the combination of the quantitative and qualitative evidence and drawing on their experience, the committee were confident to make a recommendation for the social worker to use a strengths-based, person-centred approach to help the person to develop connections with their local communities. The committee emphasised that approaches that do not solely focus on the person's needs would improve their confidence and contribute to their overall wellbeing by helping them to take steps to reduce isolation.

The committee also made a recommendation for social workers to support access to a range of activities in the community. A number of qualitative themes supported this recommendation, including the benefits of taking an individualised approach to social inclusion activities (as people's preferences and needs will vary greatly). The findings also highlighted that participants felt community-based groups and resources could be more beneficial in matching people's needs than those provided by health and care services.

The committee discussed the qualitative evidence around practitioners' views of social work approaches to social inclusion, which highlighted that the range of available groups and resources for people were not always adequate. As reducing isolation is beneficial to the person, the committee recommended social workers use creative approaches to see whether new resources could be developed. This also include the flexible use of personal budgets to support an activity. Support should also be given at an organisational level to help social workers find activities and groups that might match a person's interests. This relies on information being up to date, so the committee gave some examples of how this could be achieved.

The committee discussed evidence that highlighted that it was important to take into account that the level of support needed varied depending on peoples' needs. They agreed that the support of the social worker should not end once a person has made contact with a group, but that this should be followed up with the person after they have joined a group to ensure that they benefitted from it.

Based on experience, the committee agreed that it was important for organisations to provide information that is up to date about available community resources, as this would minimise barriers to accessing services (such as frustrations around contact details no longer being active, or activities no longer being available).

The committee discussed the evidence around the barriers to connecting with communities or groups, that showed that an NHS trust's catchment area could be a barrier to this because it is assumed by practitioners and the person that people do not have the right to access groups that are outside the catchment area. The committee recognised that it was not within the scope of the guideline to make a recommendation about local authority catchment areas, but agreed to recommend that people are informed about their rights to receive services outside of their catchment areas to help address this. Based on their experience and knowledge, they expanded on this to alleviate other barriers to access, such as eligibility criteria and referral processes.

Even though there was both quantitative and qualitative evidence to draw on, the committee felt that further evidence to clarify the best approach that social workers could take to help people connect with their local community is needed and so made a research recommendation on social and community support approaches to address this.

How the recommendations might affect practice

There is variation in practice in how much time is spent by social workers helping people connect to local communities. The recommendations will increase the time social workers spend researching, supporting and helping people to make connections in their communities. However, this potential change in practice could lead to improved outcomes by reducing the detrimental effects that loneliness can have on the person's health and wellbeing.

Return to recommendations

Supporting people to plan for the future, including considering changing needs, wishes and capabilities

Recommendations 1.5.1 to 1.5.13

Why the committee made the recommendations

The committee discussed both quantitative and qualitative evidence. The quantitative evidence was of limited value because of the quality of the studies and applicability, as most of the included studies were not conducted in the UK so the care provision and legislation were different. They therefore focused on the qualitative evidence as it was of better quality, with themes that the committee agreed were more generalisable to the wider population (with more UK evidence and a wider range of complex needs included).

The evidence suggested that when people have information and support in advance and understand the care planning process, this helps them to participate in planning for the future with their social worker. The committee highlighted the key role social workers play in communicating relevant information to people with complex needs, as well as to their support network, in a timely manner throughout the whole process. The committee emphasised that this would also include information and support for carers, which would have a positive impact on their own wellbeing as well as that of the person that they are providing care for.

There was evidence that highlighted that the environment and service location can be an important facilitator to help the person feel safe and relaxed, and there was also benefit in having a location that provides easy access to case management services (this included visits to the person's home). The committee drew on this to recommend that care planning take place in the person's preferred location whenever possible.

There was some limited evidence about the importance of building relationships and trust. This was consistent with the committee's experience that good relationships that include meaningful conversations to engage individuals are an important aspect of case management and care planning. Drawing on their own expertise, the committee recommended a rights-based approach to case management and care planning, focusing on the individual's rights according to the principles of the Human Rights Act 1998. This would improve people's outcomes by promoting their dignity and wellbeing, building on their strengths and supporting both their participation in the community and engagement with services.

The committee discussed the qualitative evidence that highlighted the importance of existing relationships between adults with complex needs and their family members and carers, and also the wider community. Promoting such relationships may enhance the support networks available to adults with complex needs, which may in turn help minimise the potential for isolation. They discussed the importance of both paid and unpaid support networks (for example, family and personal assistants), and agreed that their input should be reflected in the care plan where appropriate.

Based on evidence that highlighted that a barrier to successful planning for the future was not recognising quickly enough when needs change, the committee highlighted the benefits of a flexible and responsive approach. This should include regular reviews so that plans can be adjusted to ensure the person's safety and wellbeing.

Based on the evidence about the challenges of planning and addressing all the person's needs, and supported by their own knowledge and experience, the committee were aware that services may not always successfully address the whole range of identified, eligible needs. The committee therefore agreed to acknowledge this in a recommendation, stating that the agreed care plan should be delivered while also highlighting any eligible needs which appear unlikely to be met or only partially met, with the aim of exploring why some needs have not been met through review and looking to meet these needs in future.

In relation to this, the committee cited section 13.13 of the Care and support statutory guidance which describes the routes to reviewing care and support plans. While, based on their experience, a review should be planned with the person and take place at least once a year, the statutory guidance highlights that there can be situations where an unplanned review is necessary (for example, if needs change or if it is requested by the person or other people important to them).

The committee discussed findings around working arrangements which identified certain conditions that enabled social workers to fulfil their roles more successfully, including autonomy, training, support and supervision. However, the evidence suggested that most social workers reported a lack of support from managers from their own organisations. The committee were keen to emphasise the importance of supporting social workers in their role so that in turn, adults with complex needs would be effectively supported. This was reflected in the committee's recommendation that organisations provide social workers with regular, practice-based supervision and support so they can be responsive to people's complex and fluctuating needs, and keep their knowledge and practice up to date.

The committee discussed the evidence showing that continuity was valued in care planning, particularly because people with complex needs felt frustrated about having to tell their stories repeatedly. The committee noted that this was consistent with their experience that offering people access to a named social worker would benefit them in terms of providing such continuity of care, which would in turn enhance their health and wellbeing (where there are changes in social workers, continuity could be maintained by having clear handover processes in place).

The committee made a research recommendation on supporting people to plan for the future to inform future guidelines that would address the gap in the effectiveness evidence relating to the evaluation of specific models of social work case management.

How the recommendations might affect practice

The recommendations will mainly standardise practice. There is some variation nationally in provision of a 'named' social worker so increased provision may have some resource impact, but this is already common practice for many services so this may be limited.

Return to recommendations

Responding to an escalation of need, including urgent support

Recommendations 1.6.1 to 1.6.7

Why the committee made the recommendations

While some quantitative evidence was available, the committee decided not to make use of it when making recommendations, as only 1 small observational study with methodological limitations (such as lack of comparison group) was identified and the population was restricted to the specific needs of people with mental health conditions. Therefore, it was difficult to generalise to the wider population of people with complex needs. The committee drew on the more substantial qualitative evidence (from 8 studies) and supplemented this with their experience and knowledge to make advice applicable to the wider population of adults with complex needs.

The committee used their expertise and knowledge of BASW's Professional Capabilities Framework – which sets out the ethical principles and critical reflection practices that a social worker must apply to guide their decision making – to recommend social workers consider a person's wishes, preferences, social circumstances and cultural background when planning during an escalation of need. This would help ensure that any decisions that are made are not based on the social worker's assumptions.

The committee discussed the evidence that suggested practitioners who used the wider support network of friends and family to help with decision making during a Mental Health Act assessment facilitated the social worker's response to an escalation of needs. Based on this evidence and their experience, and statutory requirements, they decided to generalise this to the whole population for all situations of unplanned escalation of needs. They agreed that gathering information about the situation not only from the person's family and social networks, but also relevant practitioners would create a clearer picture of the situation (and any previous, similar situations) and would therefore likely lead to better solutions. The committee noted that usually this information could be gathered by phone or using virtual meetings (for example, virtual case conferences or Care and Treatment Reviews).

The evidence that showed there was a lack of time and resources for social workers to look at alternative options to detention under the Mental Health Act in response to an escalation of need. However, in accordance with the Mental Capacity Act 2005 other less restrictive options need to be considered which can take time. They discussed that social workers in such circumstances can feel under pressure and may make rushed decisions. They drew on 1 of the principles of the Mental Capacity Act that highlights that whenever possible, options must be explored that are less restrictive of the person's rights and freedom of action. To ensure that this principle is upheld and to ensure that people with complex needs can maintain their independence and autonomy as much as possible in the event of an unplanned escalation of need, the committee made a recommendation to reinforce this legislative requirement.

The committee used their knowledge, supported by legislation, to make recommendations on the use of a person's advance statements during decision making to ensure a personalised approach to care is taken. The committee noted that an advance statement could be any statement of a person's wishes and preferences which is not to be confused with a formal written document like an advanced directive related to medical treatment decisions. An advance statement should lead to better outcomes and satisfaction with services, as a person's wishes and preferences may have been informed by what has worked previously. However, the committee noted that individualised approaches are always needed, even if no advance statement has been made, to provide support in accordance with the person's wishes and preferences.

The committee discussed the review finding that showed there was dissatisfaction that out-of-hours services were not always available. The committee were aware of legislation that supports 24-hour services and made a recommendation in favour of them so that prompt support can be provided in situations of an unplanned escalation of need in the context of Mental Health Act assessments in accordance with legislation (section 14.35 of the Mental Health Act Code of Practice). They noted that availability of services out of hours may prevent some hospital admissions or presentations to accident and emergency departments. They noted that, in their experience, use of out-of-hours services was not always well communicated with daytime services, so recommended that timely and clear communication take place between services to enable better continuity of support.

To address the identified evidence being restricted to a narrow population, the committee made a research recommendation on responding to an escalation of need.

How the recommendations might affect practice

Most of the recommendations aim to standardise current practice and are supported by legislation. The recommendation for a joint assessment in some crisis situations would not have a significant resource impact or cause a change of practice, because this would usually be done by phone or virtually. The current availability of out-of-hours services is varied in the context of Mental Health Act assessments, but according to legislation (section 14.35 of the Mental Health Act Code of Practice) decisions on applications for the detention under the Mental Health Act should be covered over 24 hours so services should have such arrangement in place already.

Return to recommendations

Social workers and multidisciplinary teams: communication, support and collaboration

Recommendations 1.7.1 to 1.7.8

Why the committee made the recommendations

The committee agreed that the features of the integrated services covered in the quantitative evidence were not directly applicable to the whole population of people with complex needs. They also noted other limitations in the evidence, such as concerns about the way the studies were conducted and had mixed or contradictory findings, with uncertainties about the size of effects that decreased the confidence in this evidence. Therefore, the committee made recommendations using the qualitative evidence together with their experience and expertise and legislation (the UK GDPR and the Data Protection Act 2018) as well as drawing on BASW's Professional Capabilities Framework and BASW's Charter for integrated working. They agreed that the qualitative evidence highlighted specific aspects that were key to successful integrated working.

There was evidence indicating that having shared visions and aims helped to promote integrated working, because it led to an increased understanding between organisations and disciplines. The committee discussed the importance of this to help everyone in the team understand the context in which they work, even if they come from different disciplines. Having a clear strategy should improve team working because overall purposes and objectives can be defined, and everyone knows the part they play.

Most of the available evidence related to organisational matters that can help or hinder multidisciplinary team working, rather than focusing on actions taken by individual social workers. This was consistent with the committee's experience of team members' willingness to work together, that they felt could be better supported by the organisations members work for. Supporting information sharing (in line with the UK GDPR and the Data Protection Act 2018) and providing opportunities for clear communication should lead to better teamwork, because members would understand each other's expertise and roles and have opportunities to share knowledge and learn from each other. It would also help team members define what role they can play in providing support to the person with complex needs. The committee also decided that information sharing relies on clear communication within the multidisciplinary team and suggested some measures to increase efficiency.

The committee agreed that joint training opportunities would enable the sharing of skills and knowledge between professionals and help them understand each other's roles and responsibilities across different health and social care roles (as well as other relevant settings, for example voluntary sector organisations). This would enable team members to direct the person with complex needs to the practitioner who can provide the most relevant support. Based on the committee's experience, it was noted that training would need to include the views and perspectives of people with lived experience to give team members greater confidence in understanding the role that each of them can play in providing individualised care (as outlined in BASW's Professional Capabilities Framework). This would address addressing people's needs more effectively and in turn lead to improved outcomes. The committee agreed training should not only be about the theory, but also contain practical information with examples of best practice or lessons that have been learnt. This would mean training can be followed up and implemented to improve team working and to benefit people with lived experience (for example, using case studies that show how the principles of best practice of multidisciplinary team working could be applied).

There was evidence on barriers to integrated working related to a lack of clarity of roles within integrated teams. Using the evidence on facilitators of integrated working, and drawing on BASW's Charter for integrated working, the committee made recommendations to support social workers in retaining their professional identity when working in an integrated team. This can lead to better outcomes, as the person with complex needs knows what to expect and from which person, so that they are aware which needs can be specifically addressed by a social worker.

There was evidence that bureaucracy was often viewed as a barrier to effective integrated working within multidisciplinary teams, negatively impacting efficiency of referral within the team and causing delays. Simplifying referral processes and pathways (for example, with clear eligibility criteria) was seen as a solution for this and would likely improve outcomes by improving the speed and accuracy (in terms of going to the person most able to help) of referral.

The committee discussed the evidence related to potential benefits of co-location which was assessed as high-quality thematic evidence and was also supported by the mixed method analysis of qualitative and quantitative evidence. They acknowledged that this could have a positive impact on services but would not always be feasible, practical and could be costly (particularly if it involves new premises), and therefore cannot be routinely implemented. However, the committee recommended that organisations should think about whether this could be a beneficial and achievable option for their particular service (for example, having a social work team in a hospital co-located with healthcare staff may improve joined-up services and could have practical benefits).

The committee discussed evidence suggesting shared formal agreements help integrated working. This was in line with their experience, so they recommended such agreements should be used to support integrated teams, particularly in terms of shared decision making and accountability. The committee agreed this should also cover budgets, as the evidence showed that a lack of access to pooled budgets could create barriers to integrated working.

How the recommendations might affect practice

The recommendations largely reinforce current regulation and usual practice. There may be some short-term costs if office accommodation needs to be reconfigured to allow for co-location, although there should be no difference in costs once this has been achieved and potential cost savings through working efficiencies and economies of scale. If physical co-location is not feasible, measures to allow virtual co-location (such as diary sharing and virtual meetings) should involve negligible costs, if any, while allowing potential savings from more efficient and integrated working.

Return to recommendations

  • National Institute for Health and Care Excellence (NICE)