Eleanor Roosevelt, 1958

'Where, after all, do universal human rights begin? In small places, close to home -- so close and so small that they cannot be seen on any map of the world. Yet they are the world of the individual person... Unless these rights have meaning there, they have little meaning anywhere. Without concerted citizen action to uphold them close to home, we shall look in vain for progress in the larger world.' Eleanor Roosevelt, 1958

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Monday, 11 February 2013

Medical and social work students' knowledge of the law

If you're involved in teaching medical or social work students I really recommend you get your hands on a paper called 'Exploring UK medical and social work students’ legal literacy: comparisons, contrasts and implications' by Michael Preston-Shoot and Judy McKimm, published in the journal Health and Social Care in the Community.  It tracks the legal knowledge and skills of medical and social work students during their studies, measuring their knowledge and confidence in those areas of law which impact upon their work.  It's a very interesting read.  A few findings stood out to me, which say a lot about the way law is taught to these students and how their perceptions of it change:

  • Both medical and social work students had positive perceptions of law. 
  • Medical students were anxious about 'litigation, defensive practice and the potential for tensions between professional values and the legal rules'; social work students were anxious about 'instructing lawyers, challenging decisions and practices in their own and other agencies, and using statutory authority when this ran counter to service users’ wishes.'  I wish there were a bit more qualitative detail about these sources of anxiety.  Both suggest a perceived potential conflict between professional values and the law - but what is the nature of this conflict?
  • They found that 'Medical students appeared to become more anxious and social work students less anxious as their studies progressed about keeping abreast of the legal rules.'  For both groups, the authors suggest that insufficient time was devoted to law learning.
  • By their final year, social work students were more likely to regard the law positively 'with respect to inequality, resolving welfare issues and protecting vulnerable people.', but were also less likely to be positive 'about legal rules as a vehicle for change and meeting people’s needs.'  Final year medical students were more positive about the law in some areas than first year student, but 'were less positive about the law’s support for professional values and meeting people’s needs'.  I'd love to know a bit more about what influenced these changing perceptions during their training.  Was it that the content of the law was a disappointment to them when they learned about it?  What were the attitudes of those teaching law and those they shadowed during their training towards the law?
  • The authors found that 'medical students were more positive about lawyers than social work students', suggesting that this might reflect 'power, prestige and standing among different professional groupings'.  I think I would like a bit more detail on why they drew this conclusion.  
  • One finding that I thought was especially fascinating was that social work students became more confident in their legal knowledge as their training progressed, whereas medical students became less confident.  The same pattern was replicated for their confidence in their legal skills.  This may not mean that social work students have better legal training; social work students might have misplaced confidence in their legal knowledge, and medical students might be more aware of the 'known unknowns'.  It would have been nice to have matched these self-reports with assessments of actual legal knowledge of both groups.
But for me, one of the most interesting findings in this research was contained within a table (Table 2), which reported students' confidence in their knowledge of various statutes or areas of law.  I've put some of the table in a chart which I've jiggled about a bit (see the original paper for N and Z-statistics); the vertical axis is the 'percentage of students who report no knowledge or a little knowledge':

The first thing that really stood out for me was that whilst the percentage of social work students reporting little to no knowledge of the Human Rights Act, Mental Health Act, Children Act, Framework for assessment for children in need and domestic violence law dropped massively by the second year, it didn't for the Mental Capacity Act 2005.  This is, to me, absolutely appalling, although I am not entirely surprised.  A friend who was studying social work showed me her course details - she was covering the law relating to child protection in great detail, meanwhile the Mental Capacity Act and the deprivation of liberty safeguards were stuffed into a single lecture.  No wonder we get cases like Neary and G v E!  I realise I am probably more interested in the Mental Capacity Act than most, but it strikes me that a large proportion of these social work students will go on to work with adults, and issues around mental capacity are going to come up for a large proportion of these. The Ministry of Justice estimate that:
'The Act’s definition of lacking capacity means that an estimated two million adults in England and Wales are unable on a daily basis to make decisions for themselves. This means in turn that three million paid social care and healthcare staff and three million people who care for people lacking capacity, typically family and friends, are required to make daily best interests decisions on their behalf. ' [88]
It strikes me that social work courses are in real danger of neglecting the needs of this population, and there can be absolutely no justification for this.  If children are worth teaching students about the Children Acts in so much detail, then social work students should be learning about the extremely complex legal issues which arise in adult care and protection.

The other thing I noticed is that by the final year of their training, the Mental Capacity Act appears to be the only area where medical students feel more confident about their legal knowledge than their counterparts in social work.  It is also the area of law that medical students feel most confident about.

I wonder why this has happened - how it is that medical schools seem to have taken ownership of the Mental Capacity Act in a way that social work courses have not?  I would like to see more research on the reasons for this, but even more than that, I'd like to see no medical or social work students graduating feeling that they have no or little knowledge of laws which are fundamental to ensuring they do not breach the rights of patients and service users.


  1. Both fascinating and utterly depressing as far as MCA understanding goes but it doesn't surprise me. Having been a practice educator for students coming through, knowledge of MCA has been appalling - mind, it's not better among many practitioners. I don't understand why when there's so much more emphasis on MHA but MCA is much more relevant to so much more of the social work role (across all areas) and certainly much more that a newly qualified practitioner needs to know.

    I suspect it isn't as interesting to academics so doesn't get taught as well. Oh how depressing. How utterly utterly depressing.

    1. As an outsider, I am genuinely puzzled. MCA will be relevant to needs assessment, support planning, adult safeguarding - it's even relevant to working with parents with mental disabilities! It's totally perplexing to me that it's not emphasised more, especially when there's just so much scope to get it wrong. As you say, it's especially odd that MHA is taught in more detail when that will apply to relatively few people.

  2. When I spoke to a mental health lawyer a few years back, at a time I was looking to challenge the local authority, he stated I had as much knowledge of the MCA as him- I had managed to get a good grasp by reading it and cases. This was all the more telling as I had documentation which highlighted that no one in adult services in the local authority, especially the social workers, had any grasp at all. The younger clinicians in the NHS did however I noted.

    I realise from your depressing article Lucy, and it confirms my views about most social work practitioners, that medical students have a clear concept of the requirement for legal consent for interventions. I have noted social workers largely do not, seeming to believe they have a right to advocate without consent to do so- hence many make a mess of care assessments as a result as clients wishes / needs are overridden by the social workers ideas.

    The MCA is not a good legislation or particularly empowering one and adult social services has not the 'status' of children's services / child protection. This act reflects the position in British society of the most vulnerable people and is a complete disgrace to humanity.

  3. I have made a formal complaint about the care my mother received who was imprisoned in a care home against her wishes. I was banned by the care home manager from visiting. It was social workers who coordinated and instructed the various agencies and my complaint was about them. In order to substantiate my complaint I had to look at the law regarding incapacity. Social workers justified their actions by informing me that they followed the request of the power of attorney, a relative. My argument was that they never obtained the views of my mother, made no attempt to help her make her own decision and neither did the power of attorney who never visited my mother. There was no attempt to intervene with the least restrictive action, and it was not in my mother`s best interest to be deprived of her one and only visitor.

    It was obvious to me that social workers did not understand the law, but even when I pointed it out to them my complaint was not upheld. What I feel is that there is no point in having a law that is so little understood and ignored.

    The Ombudsman did not uphold my complaint either which makes me very suspicious. It seems there is a system in place that allows the elderly and vulnerable to be shipped off into care homes and the law is merely there to pretend there are safeguards. If social workers are not taught about this law in any thorough way, that does not surprise me. Those in power know what they are doing. After all they have a problem with a growing elderly population and what to do with them.

    1. Dear Alice

      Your experience mirrors mine- except that thanks to the medics having properly undertaken the relevant capacity assessments making social workers looked bad by the turn of events- a result of my empowering the person I care for to know what options were possible.

      I of course became the subject to a long 'witch hunt' and coercive behaviours by social services for daring to complain and challenge when their staff were made to look fools. If you refuse to talk to them they will behave very badly indeed.

      But social services / workers are frequently vindictive - that has been noted by one of their directors- and I remain with the knowledge the will do what they can to make my life difficult- as Mark Neary has found.

      I look forward to the day that more of the public start to condemn social services and social work staff and relegate them to obscurity in favour of a truly empowering and caring system with well educated and knowledgeable professionals. Like the NHS they too need a root and branch review as failing in care and compassion.

      The Ombudsman is a complete joke and was severely panned last year by a cross party government committee scrutinising its operations. Mostly employs and is managed by local authority wallahas of same calibre as those complained about so unlikely to challenge real injustices or harm to complainants and their loved ones. It chooses easy cases it likes, those more popular and gainful of public sympathy, to investigate. It will never challenge a local authority officers word or decision.

  4. Maybe biased due to working in the mental health field but i see an appalling lack of knowledge of the MCA in medics, that i don't see in social workers but most of us are also AMHPs and BIAs. I think the reality is that the majority of social work students do end up in children and family sector and the content of the course reflects this with them only gaining knowledge of the other areas post qualifying

  5. It is certainly highly important to help healthcare social workers be more knowledgeable about the law. And that I can agree of. Reading articles about it has helped me too. http://www.elearners.com/online-education-resources/careers/healthcare-social-worker-career/