A Close and Practical Association with the Medical Profession: Scottish Medical Social Workers and Social Medicine, 1940–1975

This study is concerned with the development of the profession of almoner (renamed medical social worker in the 1960s) in Scotland in the period from the outbreak of the Second World War until the mid-1970s. In addition to primary and secondary documentary sources, it is based on extended interviews with practitioners of different generations, the collected personal records of individuals, and a witness seminar which involved medical social workers, members of parallel professions, and those who carried political responsibility for social work both at the Scottish Office and within the local authorities during the critical years.1 The story of the development of a small, well organized, purposeful, predominantly female, profession would be worth telling for its own sake, but there are wider implications. In the first place this is an example of a profession or, to be more specific, what we shall call an insecure profession, developing initially within one professional jurisdiction, the medical, and then switching to another, social work. As such, it offers an insight into the dynamics of professional politics. Secondly, there are social change issues and their impact on health services; all professions mirror the times in which they operate but the almoners’ experience was particularly interesting because they engaged with issues of poverty, poor housing, abortion, adoption, and domestic violence in a period when popular and professional attitudes were subject to challenge and change. Thirdly, the story carries implications for the NHS as a whole. Currently the social contexts of health and medicine are much debated and often outlined as if they rested on novel insights. In reality, there have always been individuals and organizations arguing passionately for the social dimension. By 1948 politicians and prominent physicians had identified the almoners as a way of advancing social medicine. Over the next twenty years the profession did much to justify such expectations. Almoners, or medical social workers, were never as numerous on the wards and surgeries of the NHS as they would have liked but they became a part of many medical teams and were involved in the “social” education of other health professionals, including doctors. In the late 1960s changes began which would take the profession out of the NHS and into the new social work departments of the local authorities. At the same time, the profession lost its separate identity and became part of the new generic social work profession. The developments, which in Scotland were completed with the reorganization of local government in 1975, represented, in the view of many practitioners, the moment when their profession lost its effectiveness. In discussing why this happened, it is possible to shed light on some of the difficulties of embedding social considerations in the practice of health care. The significance of this debate becomes clear when we note the striking parallel between what have recently been identified as key service weaknesses and what the almoners were trying to promote: an informed social input into clinical decisions on wards and in surgeries, and continuity of care linking primary and secondary, health and welfare, and state and voluntary services. Not for the first time, the intricacies of professional politics appear to have thwarted desirable ends. That the activities of almoners promised not only better but also more cost effective care only adds a degree of mystery.