There are a nervous few weeks ahead for the local implementation teams currently setting up the single assessment process for older people. Their interim progress reports were due to be submitted to the strategic health authorities at the end of June, and many will be hoping for a little latitude regarding their progress towards the final April 2004 deadline, writes Mark Hunter.

Cash starved and stifled by the bureaucracy that accompanies much of the government’s implementation guidance, many localities appear to be struggling to keep up with the timetable. The implications for local control of single assessment are serious. Areas that cannot meet the government’s criteria by April next year will be forced to adopt a system chosen for them by the department of health.

Meanwhile, the older people for whom the single assessment process was intended to deliver timely, efficient and unduplicated health and social care assessments, are still waiting for the first sign of these benefits.

“It’s not a question of getting a single assessment, more a question of whether people can get assessment at all within a reasonable timescale,” says a spokesperson for Age Concern England.

“People who are not at immediate risk often find they have to wait weeks for an assessment or even an indication of when to expect one.”

It is now over two years since the single assessment process (SAP) was first announced as part of the national service framework for older people. Local implementation action plans have been up and running since April 2002.

Detailed guidance on its implementation, issued by the doh, outlines how local councils and health authorities should work together to ensure assessment of older people is “kept in proportion to their needs”. The new system should mean an end to the bad old days where an older person could face a sequence of assessments by social workers, nurses, health visitors and housing officials with the inevitable disparities in information held by each different agency. 

The guidance stresses that single assessment requires a cultural change in which staff from different agencies learn to communicate effectively with one another. Yet according to Kathryn Willmington, Help the Aged’s policy officer in community health and social care, most areas still have a long way to go to reach this ideal. Many are still bogged down in the early stages of building information systems and preparing staff from the two sectors to meet the challenge of single assessment, she says.

“I think quite a lot of areas are still very much at the beginning of the process. Most of the discussion seems to be about IT systems and protocols, putting teams into place, management structures – all very practical things. But there’s a real concern that people are skipping the thing that really matters – getting people from health and social services talking the same language.

“There’s no point in putting the process in place if we haven’t addressed the whole ethos of what single assessment means. The idea of assessment means different things to different people. They need to be sitting down in the same room, sharing ideas.”

Willmington is also concerned that while health and social services are dominating the single assessment agenda, other services such as housing and transport are being neglected. Yet these services can be vital to an older person’s well being, she stresses.

There are, of course, some obvious exceptions to the SAP’s stuttering start. In Cambridgeshire, for instance, the local implementation team has successfully piloted a paper-based single assessment format used by health, social care and housing staff, and then adapted it into the computerised Cambridge assessment tool. In London, the London Older People’s Programme has piloted joint initiatives between health and social services in a variety of settings including hospitals, the community and intermediate care.

Elsewhere, however, the lack of ring-fenced funding to finance the implementation programme has left SAP teams waiting on scraps from the budgets of their local councils and health authorities.   

“It’s a bit of a postcode lottery at the moment,” says Willmington. “In some areas they have been very creative in finding the funds and running pilots and so on. But others seem to be much further behind.”

One such area is Worcestershire, where SAP programme manager Jonathan Monks openly admits single assessment will not be ready for full implementation by the April 2004 deadline.

“We’ll be in a position for partial implementation,” he says “But the whole structure won’t be in place. And without that we don’t believe single assessment will work.”

The two major reasons for the slow progress are lack of funds and the difficulty in using off-the-peg assessment tools, says Monks. “The problem is we are doing everything on a shoestring. There are nowhere near enough resources to cover all the training and IT costs. We’re told to find funding from existing resources but we then end up bidding against other services.

“We’ve been told there may be ring-fenced monies coming from the strategic health authorities but we’ve no idea how much, or when we’ll get it. We are in the lap of the Gods really.”

Shortage of funds is also preventing the Worcestershire team from using commercially available assessment systems such as the Easy-Care assessment instrument produced by the University of Sheffield. Although these computerised systems can be introduced quickly and adapted to local needs, they require the payment of copyright fees and specialised computer software.

“They are just far too expensive for us,” says Monks.

Nor have the tools supplied within the government’s implementation guidance proved any more practical.

“That’s not working at all,” says Monks “It’s very prescriptive, it’s all paper-based and it’s far too complicated for people to use. So one of the things we have been trying to do is to simplify the whole process and produce tools that people can actually use.”

This approach does appear to be bearing fruit and, despite his frustration at the slow progress, Monks does believe that the team is moving in the right direction.

In fact, contrary to the reservations expressed by Willmington, Monks claims it is the cultural change involved in single assessment that is beginning to have the biggest effect and is already offering real benefits to older people.

“Single assessment is a large cultural change for the organisations involved but we’ve made a lot of progress. We’ve been looking at ways of introducing person-centred assessment programmes, we are ensuring that referrals are being made to the right people at the right time and that kind of thinking is bound to have an effect on day-to-day practice. I strongly believe that these changes are benefiting people right now.”

Monks believes that the SAP will eventually produce the kind of one-stop assessment shop that was originally envisaged in the NSF for Older People. However, it will take time and, more importantly, a significantly greater investment.

It will be interesting to see what happens when the progress reports from local implementation teams finally arrive at the doh. If, as seems likely, the interim audit shows that SAP is falling behind schedule, will the government simply let the deadline slip? Or will it stand by the principles outlined in the NSF for older people and finally put its money where its mouth is?