news analysis of single assessment process for older people and London`s acute problems in social services

(It may be advisable to print this document as it is long).

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.

————————————————————————————————

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