Every week a leading academic assesses the relevance of influential research. Here, Bob Hudson runs the rule over research concerning practitioners’ assessments of disabled adults in view of individualised budgets and direct payments
Title: Personalised Social Care for Adults with Disabilities: a problematic concept for front-line practice.
Authors: Michele Foster, Jennifer Harris, Karen Jackson, Hannah Morgan and Caroline Glendinning.
Institutions: The authors are based in several universities – Queensland Australia, Dundee, Lancaster and York. The work originated in the Social Policy Research Unit (SPRU) at the University of York and was funded by the Department of Health.
The advent of notions of choice and control for service users is gathering pace, most notably with direct payments and individual budgets.
This has huge implications for frontline practitioners who have traditionally undertaken initial assessments, yet there are still relatively few studies that examine how professional assessment is used during the micro-dynamics of the assessment process. Accordingly, this research seeks to better understand the conduct of assessments by frontline staff by looking at forms of professional interpretation and the influence of organisational and policy frameworks.
The work draws on an analysis of 28 semi-structured interviews with practitioners working with disabled adults in a social services department. Practitioners were asked about the assessment documents used, how they approached information gathering, and their experience of documenting assessment and care management. This work forms part of a broader research project undertaken at SPRU that examined the development and implementation of outcome-focused assessment with disabled adults of working age.
Variable dependence on key documentation: The key documents used by practitioners during assessment (the community care assessment and the care plan) were variably utilised. Some practitioners relied closely upon them to discuss assessment with users, whereas others reported a more conversational approach that was informed by the documentation’s key themes.
The selective and interpretative nature of assessment: Practitioners tended to focus on what they perceived to be the relevant issues for discussion during the assessment, and this was linked to their assumptions about the purposes of assessment based on the initial referral and their perceptions of the individual service user. It was unclear how far these priorities actually reflected those of the people being assessed.
The impact of organisational and policy constraints: Practitioners were expected to fulfil certain organisational expectations concerning documentation of assessment, and were only too well aware of the constraints upon their assessments of the broader resource and service environment. The investigation concluded that documented records may accordingly be less than systematic in recording data on all issues of significance to the service user, including some issues that may be crucial to the aspirations of service users but are not recognised as such by practitioners. For some practitioners the constraints and limitations created an incentive for “satisfactory” rather than “optimal” responses, such as focusing only on the services available rather than addressing the needs of service users. As the authors note, the efforts of practitioners must produce something useful or acceptable to the organisational and policy environment to ensure continued support and survival.
Some limitations of the study: The authors highlight some of the limitations of their study. There are limitations associated with “official” practitioner accounts of what they said they did as opposed to what they actually did as part of the assessment. Moreover, the data only reports practitioner accounts in relation to assessments actually carried out, and excludes the discretion exercised in screening out other requests for assessment – a crucial issue given the narrowing interpretation of the Fair Access to Care (FACS) criteria.
Finally, the work was undertaken before the recent emphasis on self-directed support (SDS) and the growing interest in self-assessment – important contextual changes that may have some potential to address the dilemmas identified in the findings.
LINKS & RESOURCES
The article on which this account is based can be found in Health & Social Care in the Community, 14, 2, 125-135, and forms part of a bigger report by the authors – Outcomes for Disabled Service Users. Details on accessing versions of all of these publications can be found at www.york.ac.uk/inst/spru/research/summs/outcdis.htm. Michael Lipsky’s Street-Level Bureaucracy: Dilemmas of the Individual in Public Services was published by Sage (1980). Other research referred to in this article is:
● Richards, S (2000), “Bridging the Divide: Elders and the Assessment Process,” British Journal of Social Work, 30, 37-49
● Tanner, D (2003), “Older People and Access to Care,” British Journal of Social Work, 33, 499-515
● Charles, N Manthorpe, J (2006), Understanding Social Care Assessments, Social Care Workforce Research Unit, King’s College London
● The In Control pilots evaluation report of self-directed support models
● The individual budget pilots website.
● CSCI has produced a paper on the implications of all of these programmes for social work practice.
● Diana Robbins has produced an overview of cash for care schemes for Scie.
● Finally, there is the Self-Directed Support Network
● Find out more about self-directed support
This study is not the first to identify the crucial role played by operational staff in determining resource allocation. The general idea that frontline staff can end up making (and not simply implementing) policy was popularised in the 1970s by Michael Lipsky in his superb theory of “street-level bureaucracy”. Power of this nature is of critical importance given that the assessment process shapes decisions about care and access to services, and several studies over the years have shown how frontline staff exercise discretion (see Richards, 2000 Tanner, 2003 Charles and Manthorpe, 2006).
The findings of this research help to put the issue of assessment at the forefront of new thinking about the role of service users in determining their support arrangements. The view of the researchers is that frontline practitioners will inevitably retain an element of power, regardless of efforts to tilt the balance of power towards service users.
The increasingly popular notion of self-directed support constitutes a fresh challenge to the established theory of professional power. Ideas about the individual’s capacity to formulate and act on self-determined plans are central to most theories of rights and have become an explicit goal of the disability movement. The role of the state in such circumstances is not to define what a person’s needs are or how they are to be met, but to negotiate with the individual what needs are legitimate claims against the state, and to support the person in meeting those needs. What implications does this have for frontline practice and for the conclusions of the research?
Advocacy: The authors note that the greater use of direct payments and individual budgets could transform the role of care managers, with a much greater emphasis on brokerage and advocacy activities, and less scope for professional discretion at the point of assessment. The SDS model is based on a self-assessment of need rather than a professionally led assessment.
Self-assessment: There was strong support for exploring the scope for self-assessment after the consultation on the Independence, Wellbeing and Choice social care green paper. In the subsequent white paper, Our Health, Our Care, Our Say, the Department of Health committed to introduce a new common assessment framework which would include enabling people to self-assess where possible. Eleven pilots have now also been launched to explore self-assessment for people with long-term needs. Most of the individual budget pilot sites have developed self-assessment questionnaires, and service users are completing the forms with help from their care manager, support worker, family or friends, though some sites still regard self-assessment as too risky, especially for older people.
The social work role: The process of self-directed support requires a calculation of how much money it is reasonable to spend on an individual with certain kinds of need. This notion of reasonableness is important because this is the link between self-determination and rationing a process that is fair and transparent to the user but also affordable for funders. The process is widely known as the resource allocation system (RAS), several versions of which are in use and which can all be accessed on the In Control website. Of critical importance here is determination of eligibility for service – application of the FACS criteria – which will presumably remain as a professional decision. The question then will be the extent to which the variability and discretion identified by the research in the case of assessment of need is replicated in the case of assessment for eligibility.
Equity between user groups: The authors record a perception among some of the practitioners they interviewed that older people displayed less interest in assessment documentation than younger adults, and warn of the implications for equity if service users are unable to easily engage with a more user-driven approach. There will remain an important role to be played in an SDS model in responding to the low expectations held by some groups of users, and supporting them in feeling more confident about making choices. This may well be an important task for social workers to undertake, but not necessarily as local authority employees as at present.
Overall this study adds to our understanding of the ways in which frontline practitioners engage in the everyday practice of assessment, and exposes the problems they face in reconciling the needs of service users with organisational constraints and resource limitations. The study was undertaken before the advent of SDS, and it remains unclear how far the SDS model will affect professional roles and behaviour.
the social work role
equity between user groups