New assessment approach for older people faces uncertainty

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?