The social worker has been a key part of community mental health teams (CMHTs), in secondary mental health care, since their inception. They bring a social perspective within the bio-psycho-social model of mental health care which situates mental distress as a function of interacting biological, psychological and social factors. They also represent a core aspect of the integration of health and social care which has been a longstanding policy objective for providing care for people with complex needs within mental health services (Heenan & Birrell, 2017).
The role has historically been hard to clearly define (Morriss, 2017), partly mirroring a poor (but growing) appreciation of the impact of social factors on mental health. Broadly, mental health social work responsibilities in England encompass the promotion of social inclusion, discharging statutory duties around needs assessments and safeguarding under the Care Act 2014, and leadership in the Approved Mental Health Professional (AMHP) role under the Mental Health Act 1983/2007. Taking a holistic, person-centred approach to care is often cited as central to social work practice (BASW 2017) and something which service users in particular have been found to value (Wilberforce et al., 2019). More detail can be found in the Department of Health’s strategic statement about the role (DH, 2016).
A recent study by Michele Abendstern et al (2021) looked to review the current position of social workers within CMHTs using a survey for managers. The authors suggest that the role may be under threat (ADASS, 2018), and sought to answer the nature and extent of social work membership within CMHTs, to what extent it is changing and what the implications of this might be for mental health care.
This study was part of a larger project which looked at similar questions from different angles.
The larger study … examined the responsibilities, roles and tasks of social workers in CMHTs through a national survey (reported on here) as well as focus groups with team members (Abendstern et al., 2020); the characteristics of people supported by social workers in CMHTs via a caseload audit; and aspects of CMHT social work practice most valued by service users through face-to-face interviews using a Best-Worst Scaling tool (Wilberforce et al., 2019). Finally, service user and staff experiences were captured via postal surveys.
The authors compiled a list of CMHTs in England (421 teams were identified across 54 mental health trusts). They were unable to contact two trusts and two others withdrew. A questionnaire was sent to team managers about team structures and processes, focusing on the social work role. It consisted of both closed and open ended questions, allowing for quantitative and qualitative analysis.
The study received responses from 188 team managers (44%).
Team size and membership
Just over 80% of teams included social workers, and there was an average of four social workers per team which meant they comprised the second largest group of workers behind nurses. Just over half (55%) of managers reported gaining social workers in the last 12 months, and just under half (47%) reported losing social workers.
The contribution of social workers to the team, rated from ‘very poor’ to ‘very good’, was more favourable the higher the number of social workers in the team.
Team roles and tasks
Various professionals, including nurses, occupational therapists (OTs) and social workers, were found to undertake a range of roles within the CMHT. Social workers were reported to be undertaking a high level of ‘generic’ roles and tasks (partly understood as roles which other professionals undertook as well), including acting as care coordinators (69%), duty workers (65%), conducting initial assessments (62%) and undertaking psychosocial interventions with service users (63%). Social workers were also involved in crisis response (60%). On average, however, a proportionally higher number of nurses undertook these roles and tasks.
Social workers proportionally undertook most of the tasks related to the Approved Mental Health Professional (AMHP) role and authorising local authority services.
A substantial number of social workers (43%) were involved in monitoring medication.
Over half (59%) of the team managers reported undergoing major changes in the last 12 months, mainly around integration of health and social care and general restructuring of staff, including social workers.
The ending of integration arrangements between health and social care (‘Section 75 agreements’) and additional duties through the Care Act 2014 were described as changing the role of social workers in the team. Some managers commented on an associated loss of social workers or curtailment of their role away from generic tasks (e.g. care coordination) to focus on statutory duties. The impacts of these changes included more limited collaboration following reduced integration, greater load on other staff in the CMHT, a loss of knowledge and skills within the team, and negative effects on holistic care offered with the service.
Although there is an upward trend in the number of social workers, this may be linked to growth in the size of CMHTs in general, and proportionally the number of social workers seems to have actually gone down (previously 17% in 2007 and currently 14%). The authors suggest that the gap in the ratio of social workers to nurses is likely to continue widening, given a recent NHS England (2019) commitment to recruit an additional 1,540 nurses and just 360 social workers to CMHTs over the next five years. The number of psychologists also seems to be rising, however it is unclear the effect this will have on social workers given the different nature of their roles.
A declining presence of social workers in CMHTs may be particularly concerning given that just over one fifth (22%) of responding managers felt the social work contribution to the team was already insufficient (rated ‘poor’ or ‘very poor’ as opposed to ‘adequate’). Fewer numbers of social workers is likely to exacerbate this shortfall.
It can be hard to unpack the relative value of ‘generic’ vs ‘specialist’ social work contributions in CMHTs. This study supports previous evidence (Abendstern et al, 2014) which suggests that social workers undertake both generic and specialist tasks. However, social workers seem to be undertaking less of the range of roles expected within a generic CMHT workforce; especially when compared to other professions, such as nurses. This may be due to changes in Care Act 2014 legislature, which brought in more statutory duties for social workers, and presents a move away from the ‘creeping genericism’ that has previously been expressed regarding the role (Brown et al., 2000). Social workers still undertake the majority of AMHP duties within CMHTs, despite the role being open to other professions. However, in combination with other data on the AMHP role (ADASS, 2018), this study also suggests that a substantial portion of AMHP work is likely to be undertaken by social workers outside the CMHT.
The authors suggest that given the substantial minority of social workers involved in monitoring medication, this may need to be included as part of social work education. Although some may see this as undermining the social model of mental health, it could help promote viewing the prescribing of medication within its broader social and cultural context (Hughes et al., 2017).
Qualitative data suggested that where the social work contribution has diminished in teams, it had a “negative impact on other staff and service users alike, resulting in a less collaborative, coordinated and holistic service.” This aligns with other research that points to the valued perspective of social workers in promoting the social model of mental health, least restrictive practice and person-centred care (Penhale & Young, 2015; Abendstern et al., 2020). Any loss in the social work contribution may run counter to the policy context, such as the independent review of the Mental Health Act (Department of Health and Social Care, 2018), which advocated that social workers play a leadership role in mental health care.
Strengths and limitations
The study received a reasonable response rate although this was lower than in studies of a similar nature. The wording of the questionnaire may have biased responses to health care practice and there was also potential confusion around the interpretation of ‘sufficiency’ of social work contribution. It is unlikely this will have been interpreted uniformly by all respondents.
Implications for practice
In my view, this study is consistent with the sentiment that social workers are valued members of CMHTs, and central to the biopsychosocial model of care, whilst it can also be difficult to clearly delineate their role and contribution. In terms of the policy context, and the potential restriction of the role in line with the Care Act 2014, this may leave mental health social workers particularly vulnerable to future changes; for example, if the relevance of the Care Act 2014 within mental health care diminishes, then so too may the social worker role tied to it.
More broadly, it seems that social workers continue to distinctively lead on promoting social perspectives within mental health care (even if the connection to specific interventions can sometimes be less clear). Unless the rationale of the biopsychosocial model of mental health is taken up differently by other professions, then this is likely to remain the case and to be a critical part of ensuring that mental health service users have their needs met in a holistic way.
Statements of interest
I have no involvement with the research. I am a recently qualified mental health social worker.
Abendstern, M., Wilberforce, M., Hughes, J., Arandelovic, A., Batool, S., Boland, J., Pitts, R., & Challis, D. (2021). The social worker in community mental health teams: Findings from a national survey. Journal of Social Work. https://doi.org/10.1177/1468017320979932
Abendstern, M., Hughes, J., Wilberforce, M., Davies, K., Pitts, R., Batool, S., Robinson, C., & Challis, D. (2020). Perceptions of the social worker role in adult community mental health teams in England. Journal of Qualitative Social Work. https://doi.org/10.1177/1473325020924085.
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