Health: A prescription for more than pills: At one GP surgery a social worker is complementing medical diagnosis with broader advice and support. Christopher Mowbray reports
Tuesday 01 December 1992
The picturesque Georgian and Tudor town centre has escaped the attentions of the chain stores, and is dominated by small shops and public houses. The main landmark, a redundant church tower known affectionately as 'the Pepperpot', gives the town the air of a place where the clock stopped 40 years ago.
But the fact that this southern corner of Hereford and Worcester is such an ultra-traditional community is one reason why Upton, with a population of 9,000, has been chosen as a test bed for an interesting application of the NHS and Community Care Act 1990 (its community care provisions come into force in April).
Patients seeking an appointment at Upton's general practitioner surgery may now end up seeing the full-time resident social worker, as well as a doctor. The philosophy is that some social difficulties can be prevented from developing into medical problems, and vice versa.
The experiment has attracted the personal interest of Sir Roy Griffiths, one of the main architects of the Act, which envisages a closer working relationship between social services and health agencies. It is being evaluated by Dr Stuart Cumella, a senior research fellow at the Centre for Research and Information into Mental Disability at Birmingham University.
The scheme was formulated by Dr George Wilson, an Upton GP, and his three partners after they identified a gap in the provision of both social services and primary health care for people aged 16 to 64. The problem seemed to be not a shortage of resources, but more a lack of co-ordination between the two agencies.
The doctors therefore approached the Hereford and Worcester Family Health Services Authority with the idea that a social worker should work alongside them. The authority put forward pounds 25,000 to fund the project for a 12-month experimental period, while the Hereford and Worcester social services department agreed to manage the operation. Within eight months the scheme was so successful that it was extended for a second year.
A survey of the first 50 long-term patients to be referred to the social worker, seconded from the local authority, showed that 90 per cent would benefit from his expertise in some way.
'Total care plans' were drawn up for 82 per cent; and for 44 per cent there was a direct financial benefit for them or their families, because they were made aware of social security benefits that they had not been claiming. In 74 per cent of cases, friends or relatives caring for the patients at home were provided with social services support for the first time.
There was a smaller, but important, change in the type of medical treatment being given: a quarter of the patients in the survey were found to have unmet medical needs, and there was an alteration in drug supervision in 28 per cent of cases. One-third had changes made in the amount of medical input they had been receiving. In some instances, the doctors found themselves giving less treatmenEt rather than more.
The social worker chosen for the project was Jonathan Monks, who has been collaborating with Dr WilsTHER write erroron and a trainee GP, Dr Alison Wallace. Together they have gradually managed to bridge the traditional chasm between their professions.
Having a social worker under the same roof has presented the practice with few difficulties. Whenever one of the doctors encounters a case where there appears to be a relevant social problem, Mr Monks is introduced to the patient and starts assessing his or her needs. The patient is then invited back to the surgery to be seen by the appropriate professionals, and if necessary given a very thorough medical examination. There is then a team discussion and Mr Monks produces a total care plan.
Dr Wilson says: 'Having a social worker here has meant that we have had a fresh look at these patients, which has been invaluable and has helped us to give a better service. This was the whole point of the project. Health is not just about medical things - it is about housing, peace, warmth, sewers - a whole variety of factors.'
Typical of the cases that the team has tackled is a young woman with panic attacks who had been prescribed valium regularly and had been too scared to leave her home for several years. The prospect of a new approach to her problems revolutionised her life. Mr Monks talked to her over a relaxed pub lunch and formed the basis of a care plan. She was able to go to the doctor's surgery herself and to make decisions about the type of treatment she felt she needed.
The patient can now be seen regularly out and about in Upton, and her valium prescription has been reduced to a maintenance-only dose, which it is hoped will soon cease altogether.
In another case, a recently widowed middle-aged woman with a disabling and progressive disease is being helped to stay in her own home rather than move into residential care. In addition to her medical treatment, her care package makes use of such diverse agencies as 'twilight' nursing, physiotherapy, Meals on Wheels and an organised rota of friendly neighbours.
Mr Monks, who is involved with 65 patients at the moment, says: 'As 98 per cent of the population are on the doctors' books, I have access to a far greater range of clients who might need help than I would otherwise have.
'Because I am being introduced to people by a family practitioner who has been their trusted adviser for up to 30 years, any reserve they might have about social workers is broken down. I can also work more efficiently because I can see patients within three days of any referrals coming into the surgery.
'The doctors and I are learning more about how we work and this means we do not have unrealistic expectations of each other. They were very concerned that I should not go too far too quickly, and I have been on trial with the practice, but we have built up a good working relationship.'
That relationship has been helped by the fact that formal multi-agency case conferences are largely a thing of the past. They have been replaced by businesslike chats between colleagues who work in the same small building.
Dr Wilson says: 'Health is a combination of physical, emotional and environmental factors, and with a social worker and a GP working together we can move towards a state of total wellbeing for the patient. The employment of a social worker within a general practice has given the process enormous oomph. It may not be an easy thing to achieve in all cases because some social workers and GPs might find it rather daunting.'
The 'fortress' mentality between the professions - with doctors in one castle and social workers in another - can be overcome. 'We have proved that what we are doing is complementary. In general practice, there is a vacuum waiting to be filled by social work and, likewise, social work can benefit from close involvement with general practice.'
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