The heyday of
HIV social work was in the 1990s, Pearmain explains, where the combination of
an assertive and very distinct client group, gay men with HIV, and workers who
themselves were often people personally affected by the virus resulted in the
development of a social care service offering high levels of commitment and
care to individuals, ongoing case management, and a holistic approach to what
people with HIV needed, other than health care, in order to lead what he calls
the most “dignified, bearable and rewarding” life they could.
Since then,
despite the AIDS Support Grant rising each year under New Labour, HIV
specialist social work services run by local authorities have tended to shrink,
be absorbed into generic social care, or disappear altogether, with local
authorities funding voluntary agencies to do the social work.
Despite this, when in 2008 NAT conducted a review of the AIDS Support Grant (ASG),3 they concluded that the need for social care for people with HIV was greater than ever, and that the grant should continue to be ring-fenced. It praised the
open-access nature of HIV social care and praised the innovative partnerships
formed between statutory and voluntary agencies in some areas. But it also
found that half of all local authorities conducted no needs assessments to
decide how to allocate the grant and that there was no reporting of, or
accountability for, how it actually had been spent.
Although tales of the ASG being entirely diverted into general social work, or even into council car parks, were fewer than in the early days of the grant, many local
authorities had either subsumed HIV social care into the generic service or had
used the money to support voluntary agencies without ensuring that they
provided services with the professionalism, rigour and fairness that they
should.
Following the NAT review, Pearmain undertook an in-depth review of HIV social care provision in 16 local authorities in England, writing his own report, the findings of
which were also presented to the last BHIVA (British HIV Association)
Conference in April.4,5 He chose only those ones where some form of HIV specialist social care survived, and warns that the situation may be even bleaker in other parts of England.
The statutory service, he found, had dwindled to a core of around 86 HIV specialist social workers in England. However, these 86 workers are supporting around 3000 people with HIV and - if you include those in recent and imminent need, help up to 9000 people. Most HIV social workers have an ‘open’ caseload of around 30, including between five and ten ‘active’ cases at any one time, and around 70 more who have recently had or will soon need support.
Few people outside the profession really understand what social workers do. We are trained to find whatever tiny bit of room for improvement we can find in the client's circumstances and then help them achieve that if we can. Andrew Pearmain, consultant social worker
Despite the
original intention of the AIDS Support Grant, which was to standardise state
social care for people with HIV, Pearmain found that services and structures
varied hugely across the country. In some areas, such as his own Essex and Brighton, HIV specialist social work teams are
maintained. He’s particularly impressed by Brighton,
which offers, he says, a “professional, dedicated and consistent service, but
quite hard-nosed because they’ve heard all the sob stories”.
In other
areas, however, there is no provision, or it’s all done by generic social care teams,
HIV voluntary agencies or in part by generic voluntary agencies like the
Citizens Advice Bureau. This is the case in the inner London authorities, says Pearmain, which “got
out of local authority HIV social work before anywhere else”.
Provision by generic
and voluntary agencies does not necessarily imply poor service. Well-funded and
professional voluntary organisations can provide valuable coverage, especially
if they have good contacts with statutory services. The worst examples of
provision Pearmain saw were in areas which continued to operate local authority
HIV social care but where it was done poorly. He especially criticises the
situation illustrated in one council, where “they give a grudging amount of
money to one voluntary agency but the HIV social workers are stuck up in an
office [in a local hospital]”. Now this hospital has a well-respected HIV
clinic, but in this situation hospital social workers can become very limited
and demoralised in the work they do, he says, because they are constantly
subject to the demands of medical staff, who mainly see social workers as
arrangers of ‘beds and benefits’ for inpatients who need to be moved on to free
up space.
On the other
hand, he lavishes his highest praise for one local authority where the HIV
social worker was based at the local HIV clinic but was funded and managed by
the local authority team, and had an explicit remit to care-plan for the
non-medical support needs of all eligible clinic patients.
Faced with the
demise of the AIDS Support Grant, Pearmain says, HIV specialist social care is
likely to be squeezed out of the system even more, and voluntary agencies will
face loss of funding in the areas where the AIDS Support Grant was largely
spent on them, though it’s more a question of the political will of the local
authority to maintain HIV social services than of any inevitable decline. Essex got a ‘Letter of Indication’ from the Department of
Health pointing out that £350,000 of the council’s block grant was still
allocated for HIV services “and our accountants said ‘That’s fine, that’s all
we need to continue to support the present service.’”
One promising
development in this gloomy picture is ‘direct payments’. The New Labour government
expanded a scheme where people with disability and social care needs could be
given budgets to employ their own support workers. Although, as yet, it is not
known whether the coalition government will take its axe to this scheme, it is
thought likely to survive in at least a slimmed-down form. Direct payments
allow people with conditions such as HIV to select services and carers appropriate
to their needs rather than have to accept whatever the local authority
allocates to them.