Social Workers and National Health Care: Are There Lessons from Great Britain?

Although the 1994 effort to obtain universal health care in the United States failed, American social workers continue to revisit, sharpen, and rearticulate their policy position in the context of a more conservative and constantly shifting political environment. British social workers have had nearly 50 years of experience with various phases of a government-operated national health care system and can offer guidance to American social workers. Many similarities exist between British and American social work. The professions in both countries share a long history of medical social work, a contentious struggle over generalist versus specialist practice, concern about the emphasis on social work versus social services, a diminished social action role, and the presence of a case management model. In both countries there has been public criticism of social work professionalism, which has partly contributed to the reduced reliance on professional expertise. To some extent in both countries, the public has blamed social workers for the ills of the welfare state. Historically, public provision of social and health care services has dominated British social work. American social work does not share the strong commitment to social care (supportive services that promote, maintain, and enhance the social and physical well-being of people) or the government base; instead, it has been influenced by psychotherapy and a substantial private practice sector. In both countries the role of government has been reduced in relation to nongovernmental organizations, especially for-profit entities in the United States. Today in Great Britain there is a small but slowly increasing number of social workers in private practice and consulting. The professional associations in both countries have paralleled one another in their focus on training and standards and have shown a maturing of their political sophistication and activity in responding to changes. This article reviews the experience of British social workers with the National Health Service (NHS). Of particular interest to American social workers are the British view of health care as a social service, the close relationship between the NHS and local social services, the relationship between social workers and physicians, and the impact of care management (a form of case management) on social work. Implications for revising and rearticulating the national health care policy position of American social workers are offered. The conclusions reached in this article are based on a synthesis of information provided by key informants, official government and professional association documents, and other historical works. Because of the overlap between the health and social care systems, it was necessary to examine them together. There is a reasonable degree of consensus on the issues discussed; however, other perspectives not reflected here include those of frontline social workers and clients. AMERICAN SOCIAL WORK AND NATIONAL HEALTH CARE By the early part of the 20th century, social workers were organized as a profession with one of its emphases on health. In 1918 the American Association of Hospital Social Workers (later the American Association of Medical Social Workers), the first specialty group in the profession, was formed, and in 1926 the American Association of Psychiatric Social Workers was founded (Barker, 1995). In 1935 Congress passed the Social Security Act, in which national health insurance was originally considered but was not included in the final draft. The end of World War II brought military and veterans health care and the slow growth of nonprofit and commercial health care plans (Williams & Torrens, 1988). NASW first articulated its principles and official policy statement in favor of universal health care in 1979 (NASW, 1997). The statement acknowledges as part of a comprehensive health policy the desirability of developing companion national social and economic policies to meet the essential needs of all people. …