I welcome Ms Ineke Durville and Ms Mary McNutt and thank them for coming before the committee to assist it in its examination of the primary care area. I draw their attention to the fact that while members of the committee have absolute privilege, the same privilege does not extend to witnesses. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. Perhaps our guests will provide a brief synopsis of their presentation which members have read. We will then take questions from individual members.
Irish Association of Social Workers.
Ms Ineke Durville
I am president of the Irish Association of Social Workers. We are very pleased that the primary care system is being rolled out and support the concept. The issue of generic social work has always been on our agenda. In the early days when social work was introduced into community care and the health system, we were very much involved in a broad, generic base. Social workers have become more concentrated in the child care area because of the emphasis placed on child care issues during the years. We are delighted this aspect of social work is coming back into focus and being developed in a more generic way.
Ms McNutt is a primary care practitioner and will address the role of the social worker in primary care and the cases with which he or she deals.
Ms Mary McNutt
Social workers in primary care provide a service for everybody from the cradle to the grave. We focus on supporting people within their communities and families. We examine all aspects of the family and social concerns people may have. Some of the issues at which we look are abuse and neglect, physical or mental deterioration of those who acquire a disability, care and network collapse where people are cared for in the home and the stress of caring proves too much for the family, even with improved and increased community supports. We also help people to make life choices, as they move along the continuum of life where they have to make decisions about their long-term needs such as entering a nursing home. We are also engaged in child welfare where families have difficulties with parenting. If, however, they are identified as coming within the realm of child protection, they are referred to the child and family social work service for follow-up and intervention. In general, we address health and welfare issues.
Sometimes, because we are in the local community, perhaps based in the health centre, people come in with a general query about welfare benefits when they visit their general practitioner or the GP might ask us to have a word with them. That is the type of service we are trying to provide as social workers. It should be immediate and available. We try to address the needs of people as they are identified by the GP, occupational therapist or public health nurse.
Concern has been expressed about the way services are delivered. How many children are on a waiting list for a social worker in south Tipperary, even for a first visit? Is an adequate number of social workers available to deal with referrals? With regard to maternity leave and so on, is the embargo affecting the services that can be delivered?
I welcome the delegation. I was a GP before I entered the House. The IASW has a major job to explain the role of social workers. The submission lists all the areas in which the association considers it can make a contribution and there is a significant overlap with other professionals. My question concerns the availability of social workers, how they see themselves fitting in to the new structure in dealing with clients, given the limited resources available, and how they interact with counsellors and the psychiatric service. Do they have a co-ordinating role? What happens after 5 p.m.? All these issues need to be resolved. Manpower is a major issue in social work. My experience is social workers are not accessible. That is the reality and not a criticism of them. What happens after 5 p.m. on a Friday? We have all heard about the tragedies involving people who sought help and were unable to obtain it. I am attacking the system that does not allow the service to be available, not social workers. How can this be addressed? The advantage of the primary care team is social workers are able to discuss their role with medical and nursing colleagues and how they can help in various areas. There is confusion among medical and paramedical professionals about the role of social workers because there is a disparity in the service in different areas. In other words, where they experience a good service, they see a complete role for social workers but where there is not such a good service because of personnel problems, the role is different and limited to a certain area. Where there is only one social worker to cover a huge area, there is no way the list outlined in the submission can be met
I thank the delegation for the presentation and useful documentation forwarded to the committee. The submission refers to 21 areas of need in which social workers are involved. I refer to co-ordination with other services, as many other disciplines are involved in the same areas. The more disciplines involved, the more fragmentation that results and the issue is ensuring no client slips through the net because one service may be aware of something while another with a critical role to play may not be so aware.
I refer to the question of prevention. There is a need to work much harder to minimise risk. How might this be approached? Is there anything the committee should examine and recommend?
I thank the delegates for their attendance and the information they have given us. I share the concern about the difficulties relating to the out-of-hours service. That is not a reflection on social workers but when someone is desperate and he or she is put through to an answering machine when seeking help, the cry for help may not be heard. This must be examined in the reconfiguration of services.
I refer to prevention. More parents are finding it difficult to parent. It is the one job in this life for which one does not receive training. One is handed one's baby and goes home. How one rears him or her is largely left up to oneself. Prevention is better than cure for parents who face difficulties. Something should be incorporated in the reconfiguration of services to help and assist people before problems begin in order that they develop coping mechanisms and know that somebody is available to whom they can turn if they have a query or are concerned about something. Abuse and neglect may then be highlighted at an earlier stage and there would not be a repetition of cases that have been brought to our attention.
It is stated in the documentation that every primary care team should have at least one social worker on the team. However, the HSE stated in its outline that a typical primary care team consisted of general practitioners, nurses, home helps, physiotherapists and occupational therapists, and did not mention social workers. Has the association had discussions with the HSE and are social workers to be included in the teams?
Following on Deputy Conlon's question, we are all aware of the case in the news last week. I realise the Irish Association of Social Workers is here to represent not the interventionist social worker in the child care team so much as primary care team social workers. However, in terms of the balance between the family and the welfare of the child, to what extent are social workers, in the training and guidance given to them, told the rights of the child are paramount? This is the nub of the moral issue with regard to when to intervene, but to what extent is it part of a social worker's training?
To follow on from that, on what basis does the HSE distribute its social worker staff throughout the country? The sense one gets, irrespective of what was stated in the document, is that it was envisaged that all professionals in an area would become part of the primary care team. There seems to be an issue with regard to communication, which should be the cornerstone of the system. While the team may be co-located, there must be communication and information must be shared so that the patient benefits. Can the delegates comment on that?
Ms Ineke Durville
I will address first the issue of the HSE view of what is possible and its methodology of allocation. We are very aware that primary care is still a changing concept and is something that is evolving rather than already fixed. What was envisaged initially is slowly becoming reality, but with practice people have had to change direction in some areas. They have realised that all that was initially envisaged may be difficult to achieve because of issues such as logistics. For example, does a person stay with the same general practitioner or do people have a choice? Various matters that have arisen have created issues to be addressed and we are aware of that.
We are not party to the full allocation of social workers. It is our aim that each primary care team has a social worker, because it is important to any service that there is a social work presence. We would like to be part of the discussion with the HSE on how social work roles will progress in that regard and have had contact with it and hope to make further submissions to the HSE on how we see our role develop. However, our submissions have not been finalised or submitted yet. When we addressed the issue, we did not see the whole child care area as integrated as envisaged by the HSE and that is still part of the discussion. Much work done by the child care and child welfare sector does not necessarily fit into primary care team tasks, because it is broader than that.
On the issue of resources and the lack of social workers on some primary care teams, there is a resource issue. Some social workers have had to prioritise child welfare needs, because there is a statutory responsibility for child welfare needs to be met in order to keep children safe. As a result, we end up with a service that is concentrated on crisis type intervention rather than prevention through early intervention. This has to do not just with lack of additional staff, but with insufficient staff and sometimes a lack of local resources. This leads to difficulty in properly staffing primary care teams. However, I am not involved in allocation of staff and am unsure what exact measures and methods are in place to try and address those issues. The association would not be aware of those issues. It just tries to highlight professional issues that arise for social workers in the sector.
Senator Prendergast asked about the number of children on waiting lists in south Tipperary. I do not have the answer to such a specific question. I know there are waiting lists for many services, but I am not aware of how many are on the waiting list for specific services. That is not an issue brought to our attention.
Deputy Jan O'Sullivan asked about training with regard to child welfare and whether we are trained to put the child paramount. All social workers are bound by the overall legislative framework within which they work. Although people are clearly told about the necessity to keep the needs of children central in their work, they are still bound by the Constitution, which does not have separate and clear rights for children enshrined in it. We have issued a number of statements with regard for these to be introduced and for a referendum to be held to include the rights of the child in the Constitution.
Is the association in favour of an amendment to the Constitution?
Ms Ineke Durville
Absolutely, yes. We understand that it will not be possible to address all the areas of work until we have properly functioning well running primary care teams. We are at the very early stages of the development of primary care, and we are only a small player in that and are trying to work with what we have. Perhaps Ms McNutt will develop that further.
What level of referrals are made to the service? By their nature, the areas in which social workers specialise are time consuming. The concern is there may be so many referrals, but social workers will only be able to deal with a tiny proportion of the problems. For example, if we consider the primary care team in the areas we expect to be included, while a general practitioner could deal with many of the issues that are dealt with by social workers, he would never have the time to focus on the issues as specifically as them. The concern, therefore, is that the social care part of the team must have a massive waiting list. As a result, it could end up focusing on child care and never get to touch the other areas. How do social workers deal with that and how do they prioritise the waiting lists?
Ms Ineke Durville
The social work service must try to prioritise the areas in most crisis. If people are seriously at risk, those issues must be addressed. This is how the priorities are decided. Over the years, social workers have consistently sought resources to try to help them to become involved earlier. They want to be involved in prevention and have family support services available in the community. They want family support workers who can work with families to try and alleviate some of the stress that exists for certain families. On a short-term basis, they want to help families over the difficult period so they can function on their own again.
Early intervention needs people with time and energy to come in and work intensively with groups and families, as part of an overall team. These could include family support workers from other services that are available, such as psychiatric mental health services, child guidance support services. Many different services may be needed for certain families to try to prevent family breakdown. The difficulty is the level of staffing available to each area. This is the reason the whole social work profession ended up concentrating on the child care part. We are now trying to arrive at a situation where the primary care is isolated from that and we will try to deal with some of the other pieces so that primary care is not dragged in. This still puts additional pressure on child care and the child care professionals still have to deal with the crisis that arises in their areas.
Ms Mary McNutt
I wish to comment on the query about the communication element. The primary care team tries to focus on two meetings, one being the operational meeting where we sit down and look at the issues from a team perspective and the other meeting is the clinical meeting where the team tries to get together to discuss particular families or individuals in crisis. This meeting would hopefully include the GP, the occupational therapist, the physiotherapist, the public health nurse, whichever professionals are involved with the particular care plan for that particular individual. Sometimes I may not have a role or sometimes I may be the key person in that family case but that is decided at a clinical meeting and that is where communication is so important. We try to have those meetings as often as possible within the primary care team structure. That is what we are trying to change about how we work in the community. We have always had communication between our GPs, our public health nurses and community welfare officers but this will be on a more focused basis where we will be able to get together on a more regular basis. We need the agreement of the individual to get together and share that information in the individual's best interests. Very often they themselves will come along to the meeting or a family representative will do so and it means everyone is involved in the care, in terms of communication and that is the hope.
I thank the members of the delegation for their assistance. If the committee requires any further clarification we will request same by correspondence.