Eliminating Health Care Disparities
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The Contribution of Social Work and Social Interventions Across the Life Course to the Reduction of Health Inequalities: A New Agenda for Social Work Education? Esther Coren, Wendy Iredale, Deborah Rutter & Paul Bywaters
Inequalities in health and well-being are wide and widening and reflect the disadvantaged circumstances in which many people live. Users of personal social services in many cases
already experience disadvantaged health and well-being. Social work has established experience of working with marginalised groups, and may play a role in promoting
individual and community health and well-being. The value base for social work includes a focus on social justice, which may directly impact on the social determinants of health.
Using four examples of social interventions across the life span, this paper considers the role that social work can play in improving the health and well-being of disadvantaged
people across the life course, and the implications of this for evidence based social work practice and education.
Keywords: Inequalities; Health and Well-being; Interventions; Evidence; Social Work;
Education
Since the 1990s, a preoccupation with risk and its management has become central to
social interventions (Bornat and Bytheway, 2010), detracting from a more holistic
approach to social work practice and education (France et al., 2010). Macdonald
ISSN 0261-5479 print/1470-1227 online q 2011 Taylor & Francis DOI: 10.1080/02615479.2011.586556
Correspondence to: Esther Coren, Department of Social Work, Community and Mental Health/Centre for Research in
Children, Families and Communities, Canterbury Christ Church University, North Holmes Road, Canterbury CT1 1QU,
UK. Email: [email protected]
Esther Coren, Canterbury Christ Church University, UK; Wendy Iredale, Sheffield Hallam University, UK; Deborah
Rutter, Social Care Institute for Excellence, UK; Paul Bywaters, Coventry University, UK.
Social Work Education Vol. 30, No. 6, September 2011, pp. 594–609
and Macdonald (2010) suggest that social work concentrates too heavily on low-
probability, high-cost outcomes. Thus, social care efforts would be better placed in
identifying those whose welfare is seriously compromised and seeking to address the
underlying causes, rather than minimising unquantifiable risks (Gordon and Gibbons,
1998). The key challenge for social workers is to address underlying threats to well-
being that may develop into risk. Thus, social work education optimally needs more
focus on the range of interacting factors which contribute to an individual’s health,
well-being and resources, where there may be no obvious risk of immediate harm but
where well-being and quality of life is threatened.
One way in which social work and social interventions might impact on the
underlying causes that lead to risk is to address factors which underlie inequalities in
health and well-being: the social determinants of health [Commission on the Social
Determinants of Health (CSDH), 2008]. Despite continuing overall improvements in
life expectancy, inequalities in UK health outcomes, for example, are wide and
widening (Boyle et al., 2009), reflecting international patterns. Differences in average
life expectancy between the most and least disadvantaged UK local areas increased
from 9 to 11 years for men over the decade to 2001 (CSDH, 2008). Crucially, however,
inequalities do not impact only on the most disadvantaged, but are reflected in a
gradient across the population: ‘Put simply, the higher one’s social position, the better
one’s health is likely to be’ (Marmot, 2010, p. 4), and this association is a global
phenomenon (CSDH, 2008). Social services are mainly delivered to people with social
and health disadvantages, a large proportion of whom are already ill and/or disabled.
Social work has established experience of working with marginalised groups, and may
play an important role in promoting individual and community health and well-
being. Social work values include a focus on social justice, human rights and
empowerment which may directly impact on the social determinants of health
(Bywaters, 2009). By interrogating the role that social work can play in the health and
well-being of disadvantaged people across the life course, important evidence-based
recommendations for social work education can be developed. The social determinants of health—‘the circumstances in which people grow, live,
work, and age, (and how they are) shaped by political, social, and economic forces’—
impact on health status throughout the life span (Marmot, 2010, Preface). These
determinants reflect the conditions of social life which contribute to social inequality
and well-being: access to material resources and services, locality factors, education,
training and employment, and individual factors such as access to social capital and
the confidence or esteem to benefit from opportunities. Many users of personal social
services have a lifetime history of such disadvantaged circumstances (McLeod and
Bywaters, 2000; CSDH, 2008) and this may be central to their involvement with
personal social services. Implicit within this complex understanding of health, and disadvantages in health
and well-being, is the acknowledgement that health cannot be reduced to physical
pathology. According to the WHO (1948), health is not only the absence of disease,
but a state of complete physical, mental and social well-being. Our focus is therefore
Social Work Education 595
the social determinants and physical, mental and social outcomes of a healthy life, and
how these might be influenced by social interventions. Poor health and well-being should be seen in terms of cumulative disadvantages
across the life course (Bywaters, 2007) and the effects of early disadvantage on health and well-being may only be apparent in later life. For example, children and young
people who have experienced abuse or neglect, who are disabled, or in local authority care, and their parents, are among those most likely to die prematurely as a result of
poor health and unhealthy lifestyles (Davey-Smith, 2003). The health disadvantage of people with mental illnesses, who have learning disabilities or are disabled, or who are addicted to drugs or alcohol, is exacerbated because these circumstances create
barriers to economic, environmental and social success, and because their physical health needs may be neglected (Michael and Richardson, 2008). As the Marmot
Review (2010) argues, investment during the early years of life may be the most important priority for reducing health inequalities within a generation.
This paper discusses evidence that social work can contribute to reducing health disadvantage across the life course. Based on a preliminary synthesis of selected
published research—a SCIE research briefing (Coren et al., 2010)—we demonstrate how social work and social care can impact on factors that contribute to health
disadvantage and how these findings might inform social work education. We use the framework provided by the UK General Social Care Council’s Codes of Practice for Social Care Workers (2010) to highlight the correspondence between social work
practice and values and the promotion of health and well-being.
Review of Literature
The literature below illustrates the impact of social care and social work-led interventions on health. No studies were found which attempted to show that
inequalities in health across the population as a whole were reduced. Therefore the studies reported were included because they evidenced attempts to improve the health
of service users, through impact upon the social determinants of health. Four examples of social interventions across the life span were identified: early
years programmes, kinship care for children in out-of-home care, parenting programmes for parents with learning disabilities and extra care housing for older
people. The literature included was international research on interventions in the developed world published in English. For further details on search methods please see SCIE (2009).
Findings
The UK General Social Care Council Codes of Practice (2010) for social care workers and employers in the UK describe expected standards of conduct and practice. We use these in the absence of a more international code of practice. However, the
International Federation of Social Workers (2010) has as its priorities ‘social justice, human rights and social development through the development of social work, best
596 E. Coren et al.
practices and international cooperation between social workers and their professional
organisations’, consistent with the UK codes. The codes state that social workers must:
. protect the rights and promote the interests of service users and carers;
. strive to establish and maintain the trust and confidence of service users and carers;
. promote the independence of service users while protecting them as far as possible from danger or harm;
. respect the rights of service users whilst seeking to ensure that their behaviour does not harm themselves or other people;
. uphold public trust and confidence in social care services; and
. be accountable for the quality of their work and take responsibility for maintaining and improving their knowledge and skills.
We use these six key obligations as a framework for reporting evidence of the actual or
potential impact of social work and social care on health disadvantage. Evidence is presented according to the four intervention types discussed above, with a table
presented for each code, separated into findings and recommendations for practice development as supported in the literature.
Protect the Rights and Promote the Interests of Service Users and Carers
The research discussed in Table 1 suggests that by protecting the rights and promoting
the interests of service users and carers, social care workers may impact on the social determinants of health across the life course.
Strive to Establish and Maintain the Trust and Confidence of Service Users and Carers
If service users are to benefit from services, they must have trust and confidence in
services and staff. This may be particularly important for service users from minority or marginalised groups (see Table 2).
Promote the Independence of Service Users while Protecting Them as Far as Possible from Danger or Harm
The research discussed in Table 3 suggests that social care-led interventions can impact on determinants of health by promoting independence, skills, competencies and
resilience across the life course.
Respect the Rights of Service Users whilst Seeking to Ensure that Their Behaviour Does
Not Harm Themselves or Other People
The research discussed in Table 4 suggests that social work values, including the
promotion of social justice and individual rights, are consistent with reducing the risk of harm to self and others arising from disadvantaged life circumstances.
Social Work Education 597
T a b le
1 P ro te ct
th e R ig h ts an d P ro m o te
th e In te re st s o f S er v ic e U se rs
an d C ar er s
E ar ly ye ar s (E Y )
K in sh ip
ca re
P ar en ts w it h le ar n in g
d is ab il it ie s (L D )
O ld er
ad u lt s
F in d in gs : E ar ly ye ar s (E Y ) in v es tm
en t ‘v it al ’ to
re d u ce
h ea lt h in eq u al it ie s (M
ar m o t R ev ie w ,
2 0 1 0 ).
E Y p ro g ra m m es
im p ro ve
m at er n al an d ch il d
h ea lt h . S u re
S ta rt im
p ro v ed
o u tc o m es
(b re as t
fe ed in g , b ab y m as sa g e, im
p ro v ed
ch il d co n fi -
d en ce ) (N
o rt h ro p et a l. , 2 0 0 8 ).
S u re
S ta rt h o m e v is it s im
p ro v ed
fa m il y h ea lt h
an d p ar en ta l co n fi d en ce
(N E S S , 2 0 0 1 , 2 0 0 6 ).
P ar en ts w it h L D
m ay
n o t re ac h lo ca l se rv ic e
th re sh o ld s, an d o n ly co m e to
se rv ic es ’ at te n ti o n
if ch il d re n p er ce iv ed
as in
n ee d /a t ri sk
(W ar d an d
T ar le to n , 2 0 0 7 ).
S u re
S ta rt ch il d re n h ad
im p ro v ed
le ar n in g
sk il ls /a tt it u d es ; b et te r so ci al d ev el o p m en t
(O fs te d , 2 0 0 9 ).
A d u lt s w h o re ce iv ed
p re -s ch o o l p ro g ra m m e
ac h ie v ed
h ig h er ac ad em
ic sc o re s (C
am p b el l et a l. ,
2 0 0 2 ; H il l et a l. , 2 0 0 3 ; M el h u is h an d O ffi ce , 2 0 0 4 ;
B lo k et a l. , 2 0 0 5 ).
S u re
S ta rt in cr ea se d co n fi d en ce , p ar en ti n g sk il ls ,
ch il d – p ar en t b o n d s, so ci al ca p it al an d em
p o w -
er m en t (N
E S S R es ea rc h T ea m , 2 0 0 1 , 2 0 0 6 , 2 0 0 8 ;
B ag le y an d A ck er le y, 2 0 0 6 ; A n n in g et a l. , 2 0 0 7 ;
A ll en , 2 0 0 8 ).
F in d in gs : F o r yo u n g p eo p le in
o u t
o f h o m e ca re , k in sh ip
ca re
m ay
p ro m o te
b et te r em
o ti o n al /m
en ta l
h ea lt h o u tc o m es
co m p ar ed
to o th er fo rm
s o f ca re (F ar m er , 2 0 0 9 ;
W in o k u r et a l. , 2 0 0 9 ).
S te in
(2 0 0 9 ) su g g es ts th at
p la ce -
m en t st ab il it y fo r ch il d re n ag ed
1 1 þ
is ce n tr al to
w el l- b ei n g ,
sc h o o l sa ti sf ac ti o n an d g en er al
h ap p in es s: k in sh ip
ca re
as so ci at ed
w it h g re at er
p la ce m en t st ab il it y.
F in d in gs : W o m en
w it h L D
h av e le ss
ac ce ss
to m at er n it y
ca re
ch o ic es
(C am
p io n ,
1 9 9 6 ).
P ar en ts w it h L D
m ay
ex p er i-
en ce
d if fi cu lt ie s ac ce ss in g
re so u rc es
(T ag g an d K en n y,
2 0 0 6 ).
F in d in gs : S o ci al ca re
m ay
im p ac t o n
h ea lt h o u tc o m es
b y im
p ro v in g
li v in g co n d it io n s. E x tr a ca re
h o u s-
in g (E C H ) m ay
o ff er
b et te r q u al it y
o f li fe
th an
el se w h er e (C
ro u ch er
et a l. , 2 0 0 6 ; B ro o k er
an d W o o le y,
2 0 0 6 ).
E C H
fo u n d to
re d u ce
re si d en ts ’
h o sp it al st ay s an d se v er it y o f
d ia g n o se d m en ta l il ln es se s (C
ro u -
ch er , 2 0 0 7 ; B ro o k er
et a l. , 2 0 0 9 ).
T en an ts w h o en g ag ed
w it h co m -
m u n it y ac ti v it ie s in
E C H
fo u n d li fe
m o re
st im
u la ti n g (E v an s an d V al -
le ll y, 2 0 0 7 ; E v an s, 2 0 0 8 ).
L es s k n o w n ab o u t m ee ti n g n ee d s o f
sp ec ifi c g ro u p s, e. g . th o se
w it h
se n so ry
im p ai rm
en ts /d em
en ti a
(B er n ar d et a l. ,2 0 0 7 ; D u tt o n ,2 0 0 9 ).
598 E. Coren et al.
T a b le
2 S tr iv e to
E st ab li sh
an d M ai n ta in
T ru st an d C o n fi d en ce
o f S er v ic e U se rs
an d C ar er s
E ar ly ye ar s
K in sh ip
ca re
P ar en ts w it h le ar n in g d is ab il it ie s
O ld er
ad u lt s
F in d in gs : P ar en ts o f d is ab le d ch il d re n
m ay
fi n d ac ce ss in g S u re S ta rt d if fi cu lt
(P in n ey , 2 0 0 7 ). M ai n ly
m o th er s as
m en
m ay
fe el u n co m fo rt ab le (P ea r-
so n an d T h u rs to n , 2 0 0 6 ).
F in d in gs : K in sh ip
ca re rs
o ft en
p ai d
fa r le ss th an
n o n -k in sh ip
fo st er ca re rs
an d o ff er ed
m in im
al su p p o rt ; le v el /-
ty p e o f su p p o rt fo r k in sh ip
ca re
p la ce m en ts v ar ie s g eo g ra p h ic al ly
(A ld g at e an d M cI n to sh , 2 0 0 6 ).
F in d in gs : D es p it e p o li cy , p ar en ts w it h
L D
fe el ju d g ed
b y p ro fe ss io n al s n o t
su p p o rt ed
(O ls en
an d W at es , 2 0 0 3 ;
T ag g an d K en n y, 2 0 0 6 ) an d fe ar
re m o v al o f ch il d re n .
P ar en ts o ft en
so ci al ly ex cl u d ed
an d
m ay
d ep en d o n st at u to ry
ag en ci es fo r
su p p o rt (M
cG ra w et a l. , 2 0 0 2 ). T o
av o id
la b el li n g as
‘i n n ee d ’, p ar en ts
m ay
re je ct
n o t se ek
h el p (W
ar d an d
T ar le to n , 2 0 0 7 ).
F in d in gs : S u p p o rt v ar ie s b et w ee n
p ro v id er s. D if fe re n ce s in
sc h em
e su cc es s m ay
d ep en d o n ru ra l/ u rb an
lo ca ti o n (E as te rb ro o k an d V al le ll y,
2 0 0 8 ).
R ec o m m en d a ti o n s: C re at in g st af f
te am
s fr o m
v ar ie d so ci al g ro u p s an d
st ri v in g to
re ac h al l el ig ib le fa m il ie s
re q u ir es
im p ro v ed
in te r- ag en cy
w o rk in g (N
E S S , 2 0 0 5 ).
R ec o m m en d a ti o n s: G re at er
eq u it y in
su p p o rt re q u ir ed
to im
p ro v e k in
co n fi d en ce
to ta k e o n fo st er
ca re
an d
av o id
fi n an ci al h ar d sh ip .
R ec o m m en d a ti o n s: T o p ro m o te
co n -
fi d en ce , se rv ic e fo cu s sh o u ld
ac ti v el y
sh if t fr o m
ju d g em
en t to
su p p o rt .
R ec o m m en d a ti o n s: O ld er
p eo p le ’s
ca re
sh o u ld
n o t b e g eo g ra p h ic al ly
d ep en d en t; ac ce ss
to so ci al /l ei su re
fa ci li ti es
m ay
b e es p ec ia ll y im
p o rt an t
in ru ra l ar ea s (A
ll ar d ic e, 2 0 0 5 ).
In v o lv in g m in o ri ty
st af f in
d es ig n in g
se rv ic es
m ay
p ro m o te
m in o ri ty
g ro u p s’ ac ce ss
(C ra ig , 2 0 0 7 ).
Social Work Education 599
T a b le
3 P ro m o te
In d ep en d en ce
o f S er v ic e U se rs
w h il e P ro te ct in g T h em
as F ar
as P o ss ib le fr o m
D an g er
o r H ar m
E ar ly ye ar s
K in sh ip
ca re
P ar en ts w it h le ar n in g d is ab il it ie s
O ld er
ad u lt s
F in d in gs : E v al u at io n li te ra tu re
su p -
p o rt s co m m u n it y d ev el o p m en t as
‘a d d ed
v al u e’ . S u p p o rt iv e p ar tn er -
sh ip s, so ci al an d lo ca l co m m u n it y
n et w o rk s ca n b e p ro te ct iv e an d h el p
p ar en ts w it h ch il d -r ea ri n g (C
o w le y,
1 9 9 9 ).
E v id en ce
o f in cr ea se d ‘c o m m u n it y
sp ir it ’ w it h S u re
S ta rt p ar en ts w o rk -
in g to g et h er
to im
p ro v e lo ca l
co m m u n it ie s (N
E S S , 2 0 0 1 ).
L o ca l v ar ia ti o n in
d eg re e to
w h ic h
p ar en ts ’ m u tu al su p p o rt an d v o lu n -
te er in g g en er at ed
co m m u n it y
em p o w er m en t (N
E S S , 2 0 0 1 ).
F in d in gs : K in sh ip
ca re rs
ap p ea r
fi n an ci al ly d is ad v an ta g ed
(A ld g at e
an d M cI n to sh , 2 0 0 6 ). U n d er -r es o u r-
ci n g m ay
ex ac er b at e h ea lt h in eq u al -
it ie s: w it h o u t ad eq u at e su p p o rt ,
k in sh ip
ca re rs
(o ft en
g ra n d p ar en ts )
an d yo u n g p eo p le h av e in cr ea se d ri sk
o f d is ad v an ta g ed
h ea lt h /w el l- b ei n g
o u tc o m es . (A
ld g at e an d M cI n to sh ,
2 0 0 6 ).
F in d in gs : P ar en ts w it h L D
m ay
d ev el o p in d ep en d en ce
th ro u g h sk il ls
tr ai n in g (S h ee ri n , 1 9 9 8 ; T ag g an d
K en n y, 2 0 0 6 ). In d ic at io n s th at
p ar -
en ti n g sk il ls ca n im
p ro v e th ro u g h
se lf -i n st ru ct io n al p ic to ri al ch il d -c ar e
ca rd s (F el d m an
et a l. , 1 9 9 7 ; F el d m an
an d C as e, 1 9 9 9 ); n u tr it io n an d
fe ed in g tr ai n in g (F el d m an
et a l. ,
1 9 9 7 ); g ro u p le ar n in g (H
ei n z an d
G ra n t, 2 0 0 3 ), an d h o m e- b as ed
tr ai n in g (L le w el ly n an d M cC
o n n el l,
2 0 0 2 ; M il d o n et a l. , 2 0 0 8 ; W ad e et a l. ,
2 0 0 8 ).
P ar en ts w it h L D
m ay
h av e fe w
su p p o rt iv e fr ie n d s/ n ei g h b o u rs
re la ti o n sh ip s (L le w el ly n , 2 0 0 2 ).
F in d in gs : E x tr a ca re
h o u si n g m ay
in cr ea se
fe el in g s o f sa fe ty
an d
p ro te ct io n w h il st m ai n ta in in g in d e-
p en d en ce , o ff er in g so ci al , re c-
re at io n al an d m ed ic al p ro v is io n s ‘i n -
h o u se ’, im
p ro v in g sa fe ty
an d se n se
o f
co m m u n it y. T h u s, re ti re m en t v il la g es
ca n im
p ro v e b o th
in d ep en d en ce
an d
se cu ri ty
(B er n ar d et a l. , 2 0 0 7 ;
C ro u ch er , 2 0 0 7 ; B ro o k er et a l. , 2 0 0 9 ).
R ec o m m en d a ti o n s: R es ea rc h sh o u ld
as se ss th e ro le o f p ro ce ss
fa ct o rs , e. g .
st y le o r m an ag em
en t o f se rv ic e
d el iv er y, in
ac h ie v in g su ch
o u tc o m es ,
to en ab le se rv ic e d ev el o p m en t to
o p ti m iz e p o te n ti al .
600 E. Coren et al.
T a b le
4 R es p ec t th e R ig h ts o f S er v ic e U se rs
w h il st S ee k in g to
E n su re
th at
T h ei r B eh av io u r D o es
N o t H ar m
T h em
se lv es
o r O th er
P eo p le
E ar ly ye ar s
K in sh ip
ca re
P ar en ts w it h le ar n in g d is ab il it ie s
O ld er
ad u lt s
F in d in gs : E Y ca re
m ay
n o t re ac h
g ro u p s m o st at
ri sk : m o st v u ln er ab le
m ay
b e h ar d es t to
re ac h (B ar lo w et a l. ,
2 0 0 5 ).
F in d in gs : K in sh ip
ca re rs
d is ad v an -
ta g ed
co m p ar ed
to o th er s, in cl u d in g
li m it at io n s to
fr ee d o m
fo r ch il d re n /-
ca re rs ; is su es
fo r o ld er
ca re rs
co p in g
w it h b eh av io u r o f yo u n g p eo p le ; la ck
o f ag en cy
su p p o rt ; o v er cr o w d in g ;
ca re r il l h ea lt h ; le ss
th o ro u g h as se ss -
m en ts th an
fo r n o n -f am
il ia l ca re rs ;
le ss
st ri ct
m o n it o ri n g , lo w er
re u n ifi -
ca ti o n (A
ld g at e an d M cI n to sh , 2 0 0 6 ).
F in d in gs : P ar en ts m ay
la ck
sk il ls /-
k n o w le d g e re : se x ed u ca ti o n , ch il d
h ea lt h , sa fe ty
an d d ev el o p m en t
(C am
p io n , 1 9 9 6 ; Ja m es , 2 0 0 4 ) so
m ay
en g ag e in
b eh av io u r w h ic h
co u ld
im p ac t o n p ar en t/ ch il d .
P ar en ts ca n im
p ro v e ch il d ca re
an d
sa fe ty
th ro u g h au d io v is u al
se lf -
in st ru ct io n al h an d b o o k s (F el d m an
et a l. ,1 9 9 7 ;F el d m an
an d C as e, 1 9 9 9 )
o r h o m e- b as ed
in te rv en ti o n s (L le -
w el ly n et a l. , 2 0 0 3 ).
P ar en ti n g p ro g ra m m es
m ay
o n ly
b e
o ff er ed
in ex tr em
e ca se s w h er e
ch il d re n ar e at
ri sk
(S h ee ri n , 1 9 9 8 ).
F in d in gs : E C H
re si d en ts m ay
ex p er ie n ce
lo w er
h ea lt h ri sk s th an
th o se
el se w h er e, e. g . V al le ll y et a l.
(2 0 0 6 ) fo u n d th at
re si d en ts h av e
m o st h ea lt h ca re
n ee d s m et
in -
h o u se , w it h m o re
o p p o rt u n it y to
ac ce ss
G P h o m e v is it s/ p re ve n ti v e
se rv ic es , e. g . p h y si o th er ap is ts o r
ch ir o p o d is ts .
R ec o m m en d a ti o n s: C re at in g a te am
fr o m
a d iv er se
p o p u la ti o n , an d
st ri v in g to
re ac h al l el ig ib le fa m il ie s
re q u ir es
m o re
ef fe ct iv e in te r- ag en cy
w o rk in g (N
E S S , 2 0 0 6 ).
‘H ar d to
re ac h ’ g ro u p s, e. g . m in o ri ty
et h n ic co m m u n it ie s, d is ab le d p eo p le
an d ca re g iv er s, p eo p le w it h le ar n in g
d if fi cu lt ie s, y o u n g m o th er s an d n ew
se rv ic e u se rs
m o re
li k el y to
en g ag e if
th ey
re ce iv e h o m e v is it s (N
E S S , 2 0 0 6 ;
P ea rs o n an d T h u rs to n , 2 0 0 6 ).
R ec o m m en d a ti o n s: C h al le n g e is to
su p p o rt k in sh ip
p la ce m en ts , re d u ci n g
ri sk
fa ct o rs
to en ab le o p p o rt u n it ie s
th at
eq u ip
ch il d re n fo r su cc es sf u l
fu tu re
(A ld g at e an d M cI n to sh , 2 0 0 6 ).
R ec o m m en d a ti o n s: S er v ic es
sh o u ld
p ro v id e p re ve n ta ti v e ca re , su p p o rt -
in g p ar en ts w h er e ch il d re n n o t
id en ti fi ed
as ‘a t ri sk ’ (S h ee ri n , 1 9 9 8 ).
M u lt i- ag en cy
co ll ab o ra ti o n o p ti m al
(S h ee ri n , 1 9 9 8 ; T y m ch u k , 1 9 9 9 ).
R ec o m m en d a ti o n s: E C H
m u st b al -
an ce
q u al it y o f li fe
w it h ri sk
m an ag em
en t. O ve rc au ti o u s
ap p ro ac h es
ca n li m it o p p o rt u n it ie s
fo r so ci al in te ra ct io n , p ar ti cu la rl y
fo r re si d en ts w it h im
p ai re d m o b il it y
(E v an s an d V al le ll y, 2 0 0 7 ).
Social Work Education 601
Uphold Public Trust and Confidence in Social Care Services
The research discussed in Table 5 suggests that social care work can improve outcomes
for, and protect, marginalised and vulnerable groups, which is consistent with the public expectation of social welfare.
Be Accountable for the Quality of Their Work and Take Responsibility for Maintaining and Improving Their Knowledge and Skills
Social work and social care workers are expected to be accountable for improving knowledge and skills, which requires access to best possible evidence. However, there
are gaps in the literature that suggest more evidence is needed to understand the potential impact of social work on health inequalities. Table 6 outlines some gaps in literature identified by this overview.
Discussion
The Marmot Review of health inequalities policy in England (Marmot, 2010, p. 159) states that adult social care, ‘makes a significant contribution to health and to health
inequalities’, while also emphasising the importance of children’s services to health. The Review asserts that access to holistic social care services is a health inequalities issue and that sustained, adequate funding, ‘the greater integration of health and social
care, and joint action on health inequalities’ is required to underpin this. However, it cannot be assumed that well intentioned preventive action which benefits some groups
within the population will necessarily reduce inequalities in health (Capewell and Graham, 2010) and so evidence is needed of the impact of social interventions on the
distribution of health outcomes. The aims of this paper were to pilot a review of such evidence and consider the implications for social work and social care education,
research, and practice. The UK General Social Care Council’s Codes of Practice for Social Care Workers (2010) was adopted as a framework for reporting reviews covering
four examples of social work and social care practice across the life course. Four broad conclusions can be drawn from these reviews. Firstly, there is currently little or no conclusive evidence at the population level of
the impact of social work or social care interventions on health inequalities, because such research hardly exists. Although this may be partially due to methodological and
resourcing difficulties, we suspect it is largely due to a lack of focus on this aspect of practice. We therefore had to draw inferences from studies of the health impact
of interventions targeted at disadvantaged populations, or consider the impact of interventions on aspects of the social determinants of health. The development of an
epidemiological approach within social work and social care research could be valuable. Secondly, the reviews have demonstrated the relevance of social work and social care
interventions for promoting physical and mental health, preventing illness and helping people to build and maintain independence and life skills that improve outcomes
602 E. Coren et al.
T a b le
5 U p h o ld
P u b li c T ru st an d C o n fi d en ce
in S o ci al C ar e S er v ic es
E ar ly ye ar s
K in sh ip
ca re
P ar en ts w it h le ar n in g d is ab il it ie s
O ld er
ad u lt s
F in d in gs : F am
il ie s’ en g ag em
en t w it h
S u re
S ta rt n eg at iv el y as so ci at ed
w it h
d is ad v an ta g e an d ri sk , i. e. u n d er -
re p re se n ta ti o n o f te en
p ar en ts , lo n e
p ar en ts an d u n em
p lo ye d (S ir aj -
B la tc h fo rd
an d S ir aj -B la tc h fo rd ,
2 0 0 9 ). Id en ti fi ed
b ar ri er s to
u p ta k e
w er e: tr an sp o rt , co st , la n g u ag e an d
in ac cu ra te
p er ce p ti o n (e .g . th in k in g
S u re S ta rt w as
ju st fo r ‘d is ad v an ta g ed
p eo p le ’; C o e et a l. , 2 0 0 8 ).
F in d in gs : R es ea rc h sh o w s k in sh ip
ca re
to b e b en efi ci al , b u t ca re rs
m ay
b e in h ib it ed
d u e to
fi n an ci al h ar d -
sh ip
an d la ck
o f ag en cy
su p p o rt
(A ld g at e an d M cI n to sh , 2 0 0 6 ).
F in d in gs : D es p it e h ig h ra te s o f ch il d
re m o v al fr o m
L D p ar en ts , in v es tm
en t
in to
p ro m o te ef fe ct iv e p ar en ti n g lo w
(B o o th
an d B o o th , 1 9 9 9 ). E n v ir o n -
m en ta l fa ct o rs , e. g . p o v er ty , la ck
o f
su p p o rt to
u n d er st an d ea rl y d ev el -
o p m en t n ee d s, d is ad v an ta g e p ar en ts
w it h L D
(T ag g an d K en n y, 2 0 0 6 ).
F in d in gs : D aw
so n et a l. (2 0 0 6 ) fo u n d
th at
th e m o st in fl u en ti al fa ct o r
p ro m o ti n g d ev el o p m en t o f E C H
w as
g o o d p ar tn er sh ip s b et w ee n so ci al
se rv ic es , h o u si n g d ep ar tm
en ts an d
o ld er
p eo p le .
R ec o m m en d a ti o n s: Im
p li ca ti o n s fo r
p ro m o ti o n , fu n d in g an d st af fi n g (s ee
ea rl ie r se ct io n s)
R ec o m m en d a ti o n s: K in sh ip
ca re rs
n ee d st ro n g er
su p p o rt an d fu n d in g
to en ab le b et te r o p p o rt u n it y fo r
p la ce m en t st ab il it y (B ro ad , 2 0 0 7 ).
R ec o m m en d a ti o n s: A d v o ca cy
al o n e
w il l n o t re li ev e p re ss u re s th at
u n d er -
m in e p ar en ts ’ co p in g (T ag g an d
K en n y, 2 0 0 6 ). P re su m p ti o n o f
in co m p et en ce
b y p ro fe ss io n al s,
in cl u d in g fi x ed
id ea s ab o u t o p ti o n s
fo r ch il d re n ; te n si o n b et w ee n p o li -
ci n g an d en ab li n g ro le s; se rv ic es
d e-
sk il li n g p ar en ts b y ta k in g o v er
re sp o n si b il it ie s; b la m in g v ic ti m s
ra th er
th an
ad d re ss in g d efi ci en ci es
in sy st em
; la ck
o f tr u st ; an d se rv ic es
o ff er in g co n fl ic ti n g ad v ic e (B o o th
an d B o o th , 1 9 9 9 ; W ar d an d T ar le to n ,
2 0 0 7 ).
R ec o m m en d a ti o n s: P la n n in g , d es ig n
an d m an ag em
en t o f E C H , sh o u ld
p ri o ri ti se
so ci al w el l- b ei n g o f re si -
d en ts (E v an s an d V al le ll y, 2 0 0 7 ). S ta ff
tr ai n in g /r em
u n er at io n is k ey
to d ev el o p in g in te g ra te d , re sp o n si v e
se rv ic es , es p ec ia ll y w h er e n ee d s ar e
d iv er se
(A ll ar d ic e, 2 0 0 5 ).
Social Work Education 603
T a b le
6 B e A cc o u n ta b le fo r th e Q u al it y o f T h ei r W o rk
an d T ak e R es p o n si b il it y fo r M ai n ta in in g an d Im
p ro v in g T h ei r K n o w le d g e an d S k il ls
E ar ly ye ar s
K in sh ip
ca re
P ar en ts w it h le ar n in g d is ab il it ie s
O ld er
ad u lt s
F in d in gs : T o re d u ce
in eq u al it y o f
ac ce ss , m o re
sh o u ld
b e d o n e to
ad d re ss b ar ri er s to
ac ce ss in g se rv ic es .
V ar ia ti o n in
se rv ic e u se
b y d if fe re n t
m in o ri ty
g ro u p s, g en d er s, d is ab il it ie s
an d re g io n al v ar ia ti o n s n ee d fu rt h er
ex p lo ra ti o n . S o ci al w o rk er s m ay
p la y
a ro le in
im p ro v in g ac ce ss to
se rv ic es
b y d is ad v an ta g ed
fa m il ie s.
F in d in gs : R es ea rc h su g g es ts so ci al
w o rk er s co u ld
re d u ce
in eq u al it y b y
ad v o ca ti n g fo r eq u al it y o f su p p o rt
b et w ee n k in
an d n o n -k in
fo st er
ca re rs . L it er at u re
o n k in sh ip
ca re
fo cu se s o n b eh av io u r an d p la ce m en t
st ab il it y ra th er
th an
h ea lt h an d w el l-
b ei n g . E v al u at io n s n ee d ed
o f
h ea lt h /w el l- b ei n g o u tc o m es
fo r
yo u n g p eo p le an d k in sh ip
ca re rs
co m p ar ed
to st an d ar d fo st er
ca re .
F in d in gs : E v id en ce
sh o w s th at
in te r-
v en ti o n s fo r p ar en ts w it h L D
m ay
im p ro ve
p ar en ti n g sk il ls an d p ro -
m o te
p ar en ti n g b y p ar en ts . B u t,
in te rv en ti o n s ca n n o t ad d re ss
st ru c-
tu ra l is su es : p o v er ty , so ci al is o la ti o n
an d p o o r se rv ic e p ro v is io n th at
m ay
p re v en t p ar en ts w it h L D
ac h ie v in g
eq u al ca re . R es ea rc h as se ss ed
d o es
n o t ad d re ss
re g io n al v ar ia ti o n . P ra c-
ti ti o n er s m an ag e d u al ro le s: su p -
p o rt in g p ar en ts an d m o n it o ri n g
p ar en ti n g ca p ac it y. R es ea rc h n ee d ed
to ad d re ss
in cl u si o n in
d if fe re n t
re g io n s o r am
o n g g ro u p s th at m ay
b e
fu rt h er
m ar g in al is ed
d u e to , e. g .
et h n ic it y, re li g io n , p h y si ca l o r se n -
so ry
d is ab il it y.
F in d in gs : E x is ti n g ev id en ce
o n h o u s-
in g n ee d s o f o ld er
p eo p le fr o m
et h n ic
m in o ri ti es
re la te s m ai n ly to
sh el te re d
ac co m m o d at io n (J o n es , 2 0 0 6 ), w it h
li tt le p ro v is io n fo r et h n ic -s p ec ifi c
E C H . C o n si d er at io n sh o u ld
b e g iv en
to m ix ed
en v ir o n m en ts an d to
b al an ci n g in te g ra ti o n w it h re li g io u s
g ro u p s’ d es ir e fo r se p ar at e p ro v is io n
(A ll ar d ic e, 2 0 0 5 ; Jo n es , 2 0 0 8 ).
K n o w le d g e o f h o w to
m ee t n ee d s o f
o ld er
p eo p le fr o m
m in o ri ty
g ro u p s
re m ai n s li m it ed , an d is a g ap
in U K
ev id en ce
b as e (C
ro u ch er
et a l. , 2 0 0 6 ).
S o m e su g g es t th at
th e ev id en ce
b as e
fo r E C H
d o es
n o t su p p o rt th e cl ai m
th at
it p ro v id es
a fu ll y su p p o rt iv e
en v ir o n m en t, an d ar g u e fo r fu rt h er
re se ar ch
(C an tl ey
an d C o o k , 2 0 0 6 ).
604 E. Coren et al.
related to the social determinants of health. These examples reinforce the general
assertions of the Marmot Review (Marmot, 2010) that social care services contribute
to healthier outcomes for disadvantaged people.
Thirdly, the reviews highlight the potential damage which may arise when social
work or social care interventions do not adequately address the health dimensions of
people’s lives, including social determinants of health, such as housing, income and
life skills. Failure to reach potential beneficiaries of services (fathers, or minority ethnic
parents, for example), or to provide parallel support to kinship and non-kinship
carers, exacerbates the unfair distribution of health and other life chances. The limited
evidence which could be found which evaluated social care interventions aimed
directly at service users’ health is another marker of a lack of attention being paid to
this in current practice and research.
Fourthly, to alter this requires greater focus in social work and social care education
on the centrality of social aspects of physical and mental health in service users’ lives.
Three models for integrating teaching on health inequalities in social work education
have been outlined in a recent digest of the Social Work and Social Policy Subject
Centre of the Higher Education Academy (SWAP) in England (Bywaters et al., 2009):
. Permeation: spreading learning about health inequalities throughout the curriculum in college and practice settings;
. Focused health modules: teaching about health in a discrete module or modules, taking a health inequalities perspective; and
. Interprofessional modules: teaching about health inequalities as a core element in interprofessional modules.
Such a shift in research, practice and education requires a policy context which current
trends in England make less likely. The social care sector is not resourced to address the
core social determinants of health and well-being; in particular, incomes, housing, and
aspects of access to opportunities. For example, programmes aimed at supporting
parents cannot compensate for low incomes and environmental deficiencies.
Unsupported kinship carers, often elderly and on low incomes, do not have the
same level of material support as their paid counterparts, and the continuity, stability
and attachment they can offer may therefore be compromised. Reduced budgets and
increased caseloads within professional social work have discouraged involvement in
debt counselling, community engagement and other social determinants of healthy
living. Moreover, the current UK coalition government’s economic policies herald
substantial cuts in local authority finances and health care funding, as well as
approaches to social policy which emphasise greater targeting [for example, in
Children’s Centres (HM Treasury, 2010)]. These policies are unlikely to support social
workers to consider the structural risk factors in service users’ lives, or to encourage
population based interventions, despite evidence of potential cost savings in the longer
term (Aked et al., 2009). However, social work education and practice should continue
to use its unique perspective to highlight the failures of policy which sustain
inequalities in health outcomes, with particular effect within marginalised groups.
Social Work Education 605
The sector should promote service delivery approaches that reduce inequalities and
advocate for individuals and populations caught in lifelong cycles of disadvantage.
Recognising health as a central dimension in service users’ lives and health disadvantage
as a universal focus for social work intervention is the key starting point.
Acknowledgements
This paper is based on work funded and commissioned by the Social Care Institute for
Excellence (Coren et al., 2010). The views expressed in this paper reflect the individual
views of the authors rather than those of the SCIE. The work also received institutional
support from Canterbury Christ Church University. The authors gratefully
acknowledge assistance from Manuela Thomae of Canterbury Christ Church
University at the final draft stage.
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