The assessment gap

Paul Clarkson is research fellow at the Personal Social
Services Research Unit (PSSRU), University of Manchester. Since
joining PSSRU in 1998, he has worked on an assessment and
performance measurement programme of research. He was previously a
hospital social worker and a researcher in mental health
settings.

David Challis is professor of community care research
and director of the PSSRU. He has been responsible for a series of
demonstration studies of intensive care management for older people
in the UK. He is currently engaged in work on care management,
assessment and performance measurement.

Assessing older people’s circumstances and needs will always
necessitate a comprehensive and structured approach – one that
considers health, housing, social and medical care needs and wider
environmental factors.

Rationalising the process so that professionals and older people
alike are clear about what information is collected and who is
doing what is therefore a logical and necessary step. The idea of a
single assessment for older people has been broadly welcomed and
was formally introduced this April. Yet there have been widespread
difficulties with meeting this deadline for implementation. So what
is the problem?

Several sticking points have been identified by those involved in
the SAP implementation. These include problems with professional
boundaries, resources, inappropriate structures and day-to-day
practicalities. In fact these difficulties – particularly around
professional boundaries – were one of the driving factors behind
the introduction of the SAP in the first place.

The framework and guidelines set by the SAP have great value. They
should result in the disparate approaches to assessment being
pulled together and centred on the needs of older people rather
than on those of professionals. Most practitioners would agree that
these are laudable aims. Yet the process of implementing the SAP
has – to date – been far from smooth.

One difficulty is the uncertainty that surrounds the idea of
assessment itself. Different professional groups have different
perceptions as to the purpose and content of their assessments.
Professionals have tended to defend their own territory and have
considered the way in which they conduct their own particular
assessments as more crucial to older people’s care than rival
approaches. In some cases, attempts to break through these barriers
have been seen as a threat to professional identity. Also
practitioners may attempt to ensure that assessments include all
areas of need by overemphasising the importance of their own
approach at the expense of others.

Another area of difficulty lies in the minutiae of practice – what
assessment tools and documents to use, how to reconcile different
information technology systems and what resources are needed to
support joint working. These lead to the heart of the problem: the
stumbling block to implementation seems to be organisational,
rather than personnel issues.

If the SAP is to be effective, an organisational structure is
needed to bring together the elements. This is about more than
shared buildings and technologies. Giving professionals experience
of joint working and evaluating their contributions are far more
important first steps. Fundamentally, the issue of a lead person to
co-ordinate the assessment – and how this links with existing
processes – is crucial.

We have recently completed a study of 256 older people on the value
of integrating the specialist assessments of secondary health care
clinicians with those of care managers.¹ Research
evidence suggests that including a clinician’s perspective in the
assessment process is valuable. Yet specialist health care
clinicians, such as old age psychiatrists and geriatricians, have
traditionally worked separately from care managers and were not
formally involved in the community care reforms. Particularly for
older people with complex needs which may necessitate entry to a
care home, these clinicians view their assessments as identifying
remediable illness and planning treatment which can delay or avoid
admission. Collaboration between such clinicians and those
responsible for placement decisions has been left to local
arrangements.

By contrast, in Australia, a nationally planned process for
approving placements in care homes has been implemented in which
multidisciplinary “aged care assessment teams” consider the
appropriateness of potential admissions. The result has been a
reduction in the number of people entering care homes.

In our study, assessments by specialist clinicians were reported to
care managers, through the research team, who acted as a
go-between. This resulted in a “pooling” of information concerning
the care of very vulnerable older people.

Rigorous research evaluation of this process showed that older
people benefited. Their ability to perform daily living activities
improved and professional recognition of significant problems such
as cognitive impairment and dementia also improved. The approach
resulted in less contact with nursing homes and was no more costly
to health or social services.

These findings contain important messages for the implementation of
the SAP. First, particularly for the comprehensive type assessment,
it is important that the professionals responsible for placements
for people with multiple needs have ready access to appropriate
medical personnel. Our study showed that care managers valued the
information received from clinicians and that – perhaps
unsurprisingly – it helped them in planning appropriate care for
older people.

Second, the potential benefits of such collaboration cannot be
realised without first establishing arrangements to make it
possible. The failure to specify an overarching structure across
health and social care such as care management may cause
difficulties. This is a road we have been down before: when the
care programme approach for adult mental health was instigated in
1990, the ensuing debates among professionals in health and social
care mirrored almost exactly those now being voiced. Moves towards
integrating the roles of professionals such as social workers and
community psychiatric nurses, through the key-worker system were
consistently hindered by the lack of joint structures and training.
And there was little guidance on how to avoid the inevitable
communication difficulties between professional groups from across
the health and social care divide.

The result was that professionals retreated into their own
assessment documents. The key-worker role led to much frustration
as professionals argued over the limits of their involvement with
users and over the way their responsibilities under the CPA linked
with – or duplicated – other processes such as care management.
Some recent work suggests that these disputes almost certainly
resulted in poorer care for the user.²

These lessons from past developments and new evidence offer a way
forward in overcoming the difficulties with SAP implementation.
Joint structures, providing incentives for effective collaboration
and the evidence base for assessment and existing good practice,
need to be drawn on to help integrate the assessment process.

– PSSRU is investigating the implementation and impact of the
SAP in England. For more details of this research please contact
the authors.

Abstract

The single assessment process is intended to overcome the
difficulties with assessments of older people, avoid duplication
and promote an effective response to needs. This article examines
the relevance of recent research for the debates leading up to the
deadline for full implementation in April this year. Integrating
assessment practices between health and social care will require
more than the breaking down of professional barriers. Joint
structures, providing incentives for collaboration, are just as
important.

References 

¹ D Challis, P Clarkson, J
Williamson, Hughes, D Venables, A Burns, and A Weinberg, The value
of specialist clinical assessment of older people prior to entry to
care homes, Age and Ageing, 33, 25-34, 2004 

² C Miller, M Freeman and N
Ross, Interprofessional Practice in Health and Social Care:
Challenging the Shared Learning Agenda, Arnold,
2001

Further information  

1 K Stewart, D Challis, I Carpenter, and E Dickinson, Assessment
approaches for older people receiving social care: content and
coverage. International Journal of Geriatric Psychiatry,
14, 147-156, 1999 

2 Department of Health, Guidance on the Single Assessment
Process for Older People. HSC 2002/001: LAC (2002) 1. www.dh.gov.uk/PublicationsAndStatistics/fs/en 

3 Centre for Policy on Ageing, Single Assessment Process for
Older People. Professional Learning and Development Materials
– training, protocols and practice. www.cpa.org.uk/sap/sap_home.html

Contact   

Paul Clarkson can be contacted on Paul.C.Clarkson@man.ac.uk
or 0161 275 5674.