International Journal of Integrated Care, 1 June 2001 - ISSN 1568-4156
Book review
Critical practice in health and social care
Edited by A Brechin, H Brown, MA Eby
London: Sage Publications in association with The Open University, 2000, pp 352,
ISBN 0761964932
Ruth Young

This book is one of a series of core texts for an Open University course of the same title aimed primarily at students, practitioners, and educators in social work, nursing and associated health and social care professions. It sets out to take “a fresh look at professions and professionalism—what these terms mean and what they need to mean in the future in the health and social care field”. In doing this, its stated major intention is to support a new kind of reflexive practice—to help practitioners develop a much more “collaborative, negotiated and power-sharing approach to their work” which is both strategic and flexible to on-going change. However, because Critical Practice in Health and Social Care brings together the wide range of ever changing influences—both historical and contemporary—on decision-making by professionals in the health and social care arena, it is a useful reference text not only for its main professional audiences, but also for others interested in this key issue for the future of care services.

Critical Practice in Health and Social Care is based on contributions from a range of academic and practitioner disciplines—covering research, education and direct service management and development experience across social work, nursing, occupational therapy, clinical psychology, sociology, social policy and health services research. One of the key challenges for such a book is that the whole has to be greater than the sum of its parts. To be truly successful, it must present a coherent, overall argument rather than being a series of separate, if interesting, individual pieces. Critical Practice in Health and Social Care succeeds in doing just that. Each chapter can be seen as free-standing, providing insights into particular topics such as the differential development of ‘professional’ versus ‘worker’ power (Chapter 3), the views of service users (Chapter 5), the nature of caring relationships (Chapter 7), and the challenges of team-working (Chapter 8) and inter-agency collaboration (Chapter 12). Although it provides an accessible introduction to a number of the important detailed issues, however, the book also gives ‘value added’. It presents alternative perspectives—of multi-professional groups, service users and carers, the public, governments and other bodies—against each other in a manner that stimulates readers to think more broadly than perhaps they would otherwise. The book as a whole is, therefore, a useful resource both for thoughtful, joined-up practice, and for more comprehensive and sophisticated analytical study of on-going change in health and social care.

It is also timely because the role and contribution to change of professions in general and of different professional and non-professional occupational groups in the two sectors is currently an area of considerable interest and debate in both academic and policy fields. In the UK, for example, recent policies (e.g. Health Improvement Programmes, Joint Investment Plans, National Service Frameworks, the 1999 Health Act Flexibilities of lead commissioning, pooled budgets and integrated provision, the introduction of Primary Care Groups/Trusts, and the announcement in the NHS Plan [2] of Care Trusts to commission and provide both community health and social care) are encouraging much more innovative working arrangements between the NHS, local authorities and employees of other agencies at all levels. At the same time as policy frameworks are raising the issue of integrating services, there are also bottom-up pressures for adjustments in front-line assessment and service delivery. Modernising Social Services [1] noted, for example, that users and family carers themselves are increasingly carrying out complicated clinical procedures (e.g. self-injection) and using medical equipment (e.g. dialysis machines, nebulizers etc.). As with all new technologies, the boundaries are altering between knowledge only possessed by highly trained nursing and medical professionals and what lay people and others, including local authority social carers, can do if appropriately instructed in specific clinical techniques. As another example, the 1996 introduction of Direct Payments for disabled adults and their subsequent extension to older people, has seen the emergence of an entirely new ‘occupational’ group. Personal Assistants (PAs) are directly employed and often trained to their own individual care and support needs by service users themselves. This means that, even though Direct Payments were not originally intended to have a formal health remit (and NHS funding is rare), many PAs are ‘generic’ workers providing a combination of ‘traditionally’ health and social care services [3].

All of this has significant implications for the day-to-day working of practitioners in both health and social care. As the House of Commons Health Select Committee (1999) and the Royal Commission on Long-term Care (1999) spelt out, there is a need for much more than strategic-level understanding and middle-management commitment [5], for example, to shared commissioning objectives. Not only is joint working by employees of separate organisations a skill requiring specific training in itself, but, more importantly, moving towards integrated health and social care demands an increasingly unified workforce with a common culture and shared views of the aims and objectives of needs assessment and service delivery. What Critical Practice in Health and Social Care helps readers to understand is just how difficult—but not impossible—it could be to achieve a ‘unified’ workforce delivering ‘integrated’, even ‘generic’ care services given the historically derived circumstances which currently exist—i.e. circumstances that are complex both in terms of the range of institutions and the different types of professionals and other worker groups involved in delivering services.

More specifically, the book covers the following key areas:

  1. evidence on team and inter professional working, with a particular focus on the new ways of thinking and skills required in the health and social care sectors;

  2. an examination of what professional development entails in this context and what it will mean amongst different practitioner groups;

  3. an exploration of the ethical dilemmas of practice looked at against changing notions of accountability;

  4. the current debates about how professionals can be supported in their practice and how their performance is best regulated in light of new perspectives; and

  5. the potential contribution the range of professionals and other interested parties can make to the development of health and social care services on the ground.

  6. evidence on team and inter professional working, with a particular focus on the new ways of thinking and skills required in the health and social care sectors;

  7. an examination of what professional development entails in this context and what it will mean amongst different practitioner groups;

  8. an exploration of the ethical dilemmas of practice looked at against changing notions of accountability;

  9. the current debates about how professionals can be supported in their practice and how their performance is best regulated in light of new perspectives; and

  10. the potential contribution the range of professionals and other interested parties can make to the development of health and social care services on the ground.

Overall, the book is readable, well-structured and thought provoking. It raises a range of issues that deserve wider debate, not least in the context of rapid policy moves, and bottom-up changes, which potentially could bring about radical change in health and social care. In particular, Critical Practice in Health and Social Care illustrates the need for research that unpacks the workings of health and social care labour markets to aid the development of appropriate practice. What, for example, are the opportunities and constraints on developing more integrated services inherent in the current configuration of care delivery? How can the various existing and emerging professional and non-professional groups be most effectively developed and managed to bring about more user-responsive service provision? What are the lessons from innovative projects, such as the early sites using the Health Act flexibilities [4], which need to be shared more widely? Exploring such questions is a matter of some urgency, not least because of the potential impact on long-term quality and continuity of care for service users and their informal carers.

References
1.
Department of Health. Modernising Social Services. London: HMSO; 1998.
2.
Department of Health. The NHS Plan. London: HMSO; 2000.
3.
Glendinning C, Halliwell S, Jacobs S, Rummery K, Tyrer J. Health & Social Care in the Community. 8. 2000. Bridging the gap: using direct payments to purchase integrated care(3). p. 192-200.
4.
Hudson B, Young R, Hardy B, Glendinning C. National Evaluation of Notifications for Use of the Section 31 Partnership Flexibilities of the Health Act 1999: Interim Report. National Primary Care Research and Development Centre, University of Manchester and Nuffield Institute for Health, University of Leeds; 2001. Available from: URL: http://www.npcrdc.man.ac.uk/.
5.
House of Commons Health Select Committee. The Relationship between Health and Social Services. London: HMSO; 1999.
6.
Royal Commission on Long-Term Care. With Respect to Old Age: Long Term Care: Rights and Responsibilities. London: The Stationery Office; 1999.