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.

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