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The government is saying that its new procedure will cut down on the bureaucracy involved in assessing older people's needs. But, writes Mark Hunter, some agencies are worried the approach may lessen the involvement of social care.

Will social services suffer in new regime?

Announcing the launch of the government's guidance on the single assessment process for older people last week, health minister Jacqui Smith claimed the new procedure would prevent older people being passed "from pillar to post" as each agency involved in their care was required to collect ever more information.

In truth, the idea of health visitors, nurses, social workers and housing officers queuing up to perform identical interviews with frail older people rather overestimates the resources and personnel available to our health and social services. Nevertheless, there is no doubt the provision of health and social services to older people currently involves much duplication of effort and unnecessary paperwork.

The single assessment process, or SAP as it has become known, is designed to resolve all this. First mooted in July last year in the NHS Plan, and reinforced in the National Service Framework for Older People, SAP is designed to replace the current range of fragmented assessments carried out by different agencies with one seamless procedure.

If all goes to plan, health and social services will co-operate fully to produce a single, centrally held, electronic summary containing all the information needed to assess, and in turn provide for, an older person's health and social care needs. The end result will be a comprehensive "individual care plan" that will lay out their full needs and entitlements.

From the outset, however, serious questions have been raised over the practicalities of the SAP's undoubtedly laudable intentions. For instance, which agency will take responsibility for ensuring the assessment takes place at all? Can health and social services really co-operate to such a degree? Are social workers equipped to carry out assessments currently conducted by health care staff, and vice versa? Will personal social care assessments, with their less clear-cut endpoints, be usurped by clinical diagnoses? And, of course, who will pay?

Only last week, the annual report of the Social Services Inspectorate warned that acute staff recruitment and retention problems were jeopardising older people's assessments. In addition, "turbulent relations" with the NHS were impeding any improvement, chief inspector Denise Platt claimed.

It is to address such concerns that the government has introduced the latest guidance.

Presented as a consultation document - comments from interested parties are invited before 22 September and the final guidance will be published in October - the paper comprises a detailed account of what the SAP is expected to entail, a timetable for its implementation and separate advice for the different professionals expected to carry out the SAP procedures.

A set of "rigorous criteria" has been drawn up for NHS bodies and local authorities to meet by April next year. They will then be asked to take action to ensure their approaches comply with the guidance and are capable of producing standardised assessment information that can readily be shared between agencies. Authorities that fail to meet the criteria by April 2004 could be subject to "central intervention", the guidance warns.

As to what information the SAP should gather, the guidance lists nine different "domains" to be covered: user's perspective; clinical background; disease prevention; personal care and physical well-being; senses (vision, hearing); mental health; relationships; safety (including from abuse); and immediate environment and resources.

This list has already been criticised by user groups for concentrating too heavily on medical information at the expense of personal social care and users' own assessments of their needs. According to Age Concern, this medical dominance could end up "disempowering service users by downplaying social services and denying older people information about their statutory entitlements". A spokesperson for Age Concern expresses doubts as to whether SAP would, in practice, be genuinely holistic and "meet up to the rhetoric of being person-centred".

"We know that older people want health and social services to work together and in theory the SAP should help this happen," she says. "But we are concerned that older people who get services from both agencies will not know who is legally responsible and what they are entitled to.

"Although the focus is on assessment, we hope that there will be monitoring to check that older people actually receive the care that they are entitled to and that older people's experiences are included in monitoring, so the quality of services provided is kept under check."

Jonathan Ellis, a health policy officer at Help the Aged, points out that of the 34 sub-domains listed, only two relate to what older people actually want the outcome of their assessment to be.

"I suppose it is encouraging that the user perspective appears at the top of the list of domains," he says. "But the rest of the list does seem to be made up of a lot of clinical diagnoses which, of course, are often a lot easier to define than less specific social care needs."

Ellis stresses that the principle of single assessment is a welcome development in government thinking and will obviously be a good thing if it helps break down the barriers between health and social care services. "However, it is important that the process looks at the whole picture of older people's needs," he adds.

Ellis also points out that once an older person's needs have been identified, it is essential to have a system in place to ensure these needs are met. "An assessment procedure can only ever be as good as the services it leads to," he says.

No specific assessment tools are dictated in the guidance, which prefers to allow councils and health authorities to adapt existing measures to the new system or to develop new procedures to fit the requirements.

This is only sensible, says Ellis, given the steep learning curve facing local and health authorities in adapting to the new process.

How steep this learning curve turns out to be depends on the systems already in place - some authorities are already well down the road of joint working while others lag disappointingly behind.

"I think that some areas will find it very easy to get everything in place, but there are others where there is an awful lot still to be done," says Ellis. "It's important that those authorities are given the support they need because there are bound to be a lot of teething problems."

Where this extra support will come from is one area where the guidance appears somewhat vague. There is a passing reference to "taking account of resources" when determining priorities and setting eligibility criteria, but there is no commitment to providing any new funds for training or extra recruitment.

Indeed, as already pointed out by Denise Platt, a lack of suitably qualified personnel may be a major stumbling block to the SAP's success. Extra training is bound to be required and the guidance makes it clear that social workers should "be prepared to update their skills and knowledge so that they are able to work effectively with older people, other disciplines and the assessment procedures".

The guidance lists four levels of assessment, each of which may involve the input of social workers.

The basic level of assessment - the contact assessment - consists primarily of collecting personal information such as name, address, age, and so on. This can be carried out by an unqualified member of staff.

Next comes the overview assessment. This will cover all the aforementioned "domains", although it will not require any specific health examinations. This stage will be completed by a single professional from either the NHS or social services, and one of its key objectives will be to determine which profession would provide the most appropriate personnel to carry out the next stage - the in-depth assessment.

This third stage will involve the relevant tests and associated scales being applied by the appropriate professional. It is vital therefore that social workers have ready access to the appropriate medical personnel and vice versa.

The final stage is termed the comprehensive old age assessment and involves bringing together all the information gathered during the previous stages. It is at this stage that the individual care plan is produced.

Quite how this four-stage cascading approach can truly be considered a "single" assessment is not clear. Nevertheless, if the SAP puts older people's entire needs at the centre of the assessment process, who are we to argue with the semantics?

Single Assessment Process from www.doh.gov.uk/scg/sap/index.htm

Timetable:

- By April 2002: all local and health authorities should have reviewed how their assessment systems compare with government criteria. Action plans should be in place to address the most serious difficulties.

- By end June 2002: results of reviews and action plans must reach the Department of Health.

- April 2003: further review to address remaining difficulties. Revised action plan prepared if necessary.

- April 2004: any local or health authority that has not fully met the criteria will have to implement action agreed with the Department of Health to ensure compliance by April 2005.

- April 2005: all health and local authorities should have met the criteria.

- After April 2005: the operation of the SAP should be regularly reviewed to ensure the interests of all stakeholders continue to be addressed, and the system is delivering a person-centred and standardised approach.

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For the first time, the chief inspector of social services has picked out a single geographical area for special attention. Sarah Wellard looks at London's problems and the road ahead.

Capital gains needed

London has always known of the problems with its social services, but last week those problems became official when the chief inspector of social services, Denise Platt, dedicated a whole chapter of her annual report¹ to the capital's social care issues.

"As a whole, London councils are not performing consistently or coherently in delivering social care to an acceptable standard," Platt concludes. "Many councils still do not provide adequate and safe services within a clear performance management and accountability framework."

London's difficulties are similar to those elsewhere in the country, but on a bigger and more intense scale. Many parts of the capital are characterised by high levels of deprivation, social exclusion and homelessness. Even rich boroughs have pockets of extreme poverty.

Forty-five per cent of Britain's black and ethnic minority population lives in the capital. People from many ethnic minorities are at above-average risk of unemployment and live in poor and overcrowded housing, and many have correspondingly high health and social care needs.

And, despite the controversial dispersal programme, most refugees and asylum-seekers arriving in the country are still drawn to London. In the past two years alone, more than 4,700 unaccompanied refugee children have arrived in the city, adding to the pressure on children's placements.

Major health issues for Londoners are mental illness and drug and alcohol abuse, often linked with unemployment and violent crime, and all combining to create a complex profile of social and health needs.

On the other side of the equation, a buoyant labour market and the highest house prices in the country make recruiting and retaining staff a problem at all levels and across all boroughs.

London authorities dominate the Department of Health's list of failing social services departments. At the last count, five out of 12 departments on special measures are London boroughs.

In short, London needs to turn things around. Platt points to initiatives such as the London Association of Directors of Social Services' agreement to fund and develop pan-London child protection procedures for all 33 councils. In addition, a London children's services forum - for the exchange of information and good practice - has been set up by the government office for London, London social services inspectorate and the London NHS regional office.

But despite the common pressures and moves towards regional working, each council has its own individual problems.

Julia Ross, director of social services at Barking and Dagenham, which came off special measures in March this year, says that shifting the department's culture was the key to turning around performance.

"The department was too inward-looking and isolated," she says. "What's made a real difference is working together with all local partners and really engaging with users and carers."

Graham Betts, director of social services in Hillingdon - also taken off special measures this year - says political interference by elected members was at the root of inadequate performance.

He explains: "There were lots of changes in senior management. What tipped Hillingdon over the edge was an influx of unaccompanied asylum-seekers, which put pressure on children and families provision. The whole department lost focus and began to spiral downwards."

Betts held seminars to educate members about the role of social services and took a grip on the department's shambolic finances. Recruitment and retention are now much improved. As well as working closely with frontline staff to build morale, Betts has invested in "grow your own" approaches to bring in trainees.

Betts believes there is scope for greater co-operation across London to ease some of the shared pressures. He wants departments to work faster towards developing unified child protection procedures to operate across London.

The Association of London Government (ALG), which represents all London boroughs, is supporting departments in addressing the issues identified in the chief inspector's report. Mark Brangwyn, ALG head of health and social care, explains: "We're working with boroughs and elected members to improve services. For example we're looking at protocols for exchange of information between departments and across authority boundaries."

This is important given London's mobile population. The ALG is also examining how boroughs can build their management capacity.

Social services are covered by the ALG's taskforce on staff recruitment and retention, which also covers teaching and the police. Brangwyn says: "We're looking particularly at relationships with agency staff and developing schemes for subsidised housing for key workers." The strategy will also look at fostering and adoption to achieve greater consistency in remuneration between boroughs.

Surprisingly, in the light of Platt's report, some of the best services in the country are also to be found in London. Kensington and Chelsea and Kingston-upon-Thames are both highlighted as councils that serve local residents and users well. Westminster has won Beacon status for its leaving care services, as has Bexley for its fostering services. But whether these pockets of good practice can be developed London-wide remains to be seen.

¹ Social Services Inspectorate, Modern Social Services: A Commitment to Deliver: The 10th Annual Report of the Chief Inspector of Social Services 2000/2001, Department of Health 2001