Feature

posted 21 Mar 2002 in Volume 7 Issue 3

Department of Health Guidance on the 'Single Assessment Process' (Guidance HSC 2002/001: LAC (2002)1)

Background.

The guidance on the single assessment process issued by the Department of Health HSC 2002/001: LAC 2002/001 is issued to Local Authorities under Section 7(1) of the Local Authority Social Services Act 1970. It is therefore, like the National Service Framework for Older People, mandatory. Local implementation of the single assessment process must comply with both the mandatory guidance in this guidance and also the National Service Framework for Older People.

At time of posting on the internet the crucial annexes to the guidance were subject to a serious a ‘printers’ error. They were the 'Consultation Draft.' The guidance was in force and consultation had closed. An e-mail to one of the single assessment process ‘inspectors’ (referred to in the guidance) appeared to result in a swift issue of a corrected version without any admission there had ever been a problem.... Is this what ‘interactive government interface’ means? Please take care if your copy was printed off soon after issue. The guidance web address is www.uk/scg/sap

Fundamentally the single assessment process is to avoid duplication of effort, waste of NHS resources and unnecessary inconvenience to the person being assessed. It is also to help supply information on the Registered Nursing Care Contribution if that is relevant to a specific case. The guidance does not recommend the use of a single assessment tool. The extensive search for one during consultation proved fruitless. The author imagines it was rather like physicist’s search for a ‘theory of everything’. Rather it 'provides a rigorous framework that will lead to convergence of assessment methods and results over time irrespective of the tools chosen for local use.' This convergence remains to be seen. The author's view is that the paperwork may look the same in different localities but local anomalies are inevitable especially as a diverse group of professionals in social work, nursing, therapy, general practice and geriatrics will be involved not to mention diverse user groups. The guidance notes that 'most assessment systems in current practice fall short of the requirements of the NSF for Older People and this guidance.' That is an indictment of the system advisers and clients laboured under for many years! Examples of assessment tools may be found on www.doh.gov.uk/scg/sap, click on tools and scales.

It appears to be the view of the Department that convergence should be complete by April 2005. However, this is not an excuse to delay as there are demands for a continuing review of progress. The 'guidance for local implementation' sub-section states twelve steps to implementation in outline. These steps range from 'Agree purpose and outcomes' to 'Agree shared values' to 'Agree stages of assessment and care management' to 'Agree joint working arrangements.' All very neat and tidy in theory. At least it gives the hard pressed health professionals a starting place and a systematic methodology with a clear goal. The author finds it particularly comforting that there is special emphasis on 'the older person's account of their needs and their views and wishes' which 'must be at the centre of all decisions that are made.' (Section VI on Page 4 of the guidance for local implementation sub-section) It is to be hoped that such expressions are not rendered meaningless by cash restraints.

Written enquiries about the guidance, apart from requests for copies can be made to 'Department of Health (SAP) Older Peoples Services CC3 Area 221 Wellington House 133-155 Waterloo Road London SE1 8UG

The single assessment process domains. (Annex F)

All the domains and sub-domains (or relevant issues) of the single assessment process must be covered in appropriate cases such as those involving older people who may need to enter long-term care. They can be further broken down locally but cannot be omitted.

The domains and sub-domains are as follows. Please note that the starred items are only applicable to comprehensive old age assessments:-

User's Perspective

Problems and issues in the user's own words

User's expectations, strengths, abilities and motivations

Personal fulfilment *

Spiritual fulfilment *

Clinical Background

History of medical problems and diagnoses

History of falls

Medication use and ability to self-medicate

Disease Prevention

History of blood pressure monitoring

Nutrition, diet and fluids

Vaccination history

Drinking and smoking history

Exercise pattern

History of cervical and breast screening

Personal Care and Physical Well-being

Personal hygiene, including washing, bathing, toileting and grooming

Dressing

Pain

Oral Health

Foot care

Tissue viability

Mobility

Continence and other aspects of elimination

Sleeping patterns

Eating and drinking*

Breathing difficulties*

Senses

Sight

Hearing

Communication

Mental Health

Cognition and dementia, including orientation and memory

Mental health, including depression, reactions to loss and emotional difficulties

Relationships

Social contacts, relationships and involvement in leisure, hobbies, work and learning

Carer support and strength of caring arrangements, including the carer’s perspective

Personal relationships*

Lifestyle choices*

Safety

Abuse and neglect

Other aspects of personal safety

Public safety

Immediate Environment and Resources

Care of the home and managing daily tasks such as food preparation, cleaning and shopping

Accommodation including location, access, amenities and heating

Level and management of finances

Access to local facilities and services

Notes:
If investigation of a domain is triggered all relevant factors in the sub-domains within it must be investigated to avoid mis/wrong diagnosis. (See Annex E)       Assessment tools and scales should be used in investigating the domains. These are recommended in WWW.doh.gov.uk/scg/sap/toolsandscales

The stages of the single assessment process (Annex E)

Assessment is expressly about collation of information and making sense of that information to facilitate support or treatment. The stages of assessment are:

1.    Publishing of information about services by the local authority/NHS

2.    Case finding. (Most cases rather present themselves. Pro-active case finding is 'optional')

3.    Completion of relevant assessment. (Four types - see below)

4.    Evaluation of assessment information.

5.    Decision on what help to offer

6.    Care Planning leading to service delivery.

7.    Monitoring and review. (The 'process' never ends.)

By way of comment: It is regrettable that 'local terminology' may be used in respect of these stages. The author submits this is a recipe for confusion. Whilst pro-active case finding is optional the guidance points out that it 'can make an important contribution to preventative strategies and health promotion.' It suggests postal questionnaires might be used. This is sensible but in the author's experience anything 'optional' will not be taken up. It will not be a priority in a cash-strapped service.

Types of needs assessment (Annex E)

It is important to note that the assessment is to identify 'actual or potential needs' with an emphasis upon 'their impact on independence, daily functioning and quality of life'. The user and their views are always paramount. This also extends to carers. Annex E notes that older people should be encouraged to contribute fully to their assessment.

Further Annex E notes that 'Agencies should consider at the earliest opportunity whether older people might need or benefit, from the assistance of advocates, interpreters and translators, and specific communication equipment, during the assessment process.' Further, Where such a need exists, councils should either arrange for this support or facilitate access to it.’ (Page 15)

Also support from carers should be consulted and there may need to be a separate 'carer's assessment.' This should be to help both the older person and the carer.

Benefits advice and finances will also need to be considered and the local authority/NHS is expected to have appropriate links with relevant agencies.

There are three basic types of single assessment:-

Contact Assessment. This is the first contact between an older person and health and social services ‘where significant needs are first described or suspected.’. Basic information is taken and explored. If immediate matters are not clear cut or other potential problems are identified or requests for more intensive support or treatment are made then a higher level of assessment may be required. The basic personal information may be effected by trained non-professional staff but a single professional is required to explore the problems/issues raised. The original consultation guidance suggested that non-professional staff might be used 'where this is agreed and appropriate'. Presumably 'agreed' meant with the 'contact'/their carers. Now it simply says that ‘Basic personal information may be collected or verified by trained, but not professionally qualified, staff. This is a departure from the consultation draft and is, in the view of the author, regrettable. If an older person appears to have complex and multiple needs then this will trigger a comprehensive old age assessment. That will miss out the other two possible forms of assessment as unnecessary and to avoid time consuming delays. Councils are advised to remember their duties to their older citizen’s housing needs and community care services. Confidentiality applies.

Overview Assessment. All or most of the domains in the single assessment process are explored to ensure a 'more rounded' assessment. It may be that a contact assessment rolls into this type of assessment automatically without a pause after the preliminary stage. The guidance suggests it is best to 'err on the side of caution' in deciding whether or not to effect investigation into domains. A properly trained single professional from the NHS or social services is required to effect an overview assessment. Councils are advised to remember their duties to their older citizen’s housing needs and community care services. Confidentiality applies.

In depth or ‘Specialist’ Assessment. This is a further exploration of specific domains indicated by a less stringent assessment. The aim is to confirm the presence, extent, cause and likely development of a health condition or problem and establish links to other conditions and problems. An appropriately qualified and experienced ‘best suited’ professional is required. This may be a registered nurse, qualified social worker, geriatrician, old age psychiatrist or otherwise. Their 'professional judgement' is emphasised in the guidance. Councils are advised to remember their duties to their older citizen’s housing needs and community care services. Confidentiality applies.

Comprehensive old age assessment. This involves the in-depth assessment of all or most of the domains of the single assessment process. It arises in cases where an older person has complex or multiple needs. It should also be effected if the level of support is to be intensive and complex, including permanent admission to a care home, intermediate care services, or a substantial package of care at home. It will also involve investigation of the additional, age related, sub-domains included in Annex H. The reason for the additional sub-domains is broadly to help the professionals involved be aware of what is important to the particular older person. Annex H makes the important point that ‘Final decisions on where people should receive support should not be made until the comprehensive assessment is complete, and all information, including rehabilitation potential has been evaluated.’ Annex H suggests that in cases where a person is likely to enter a care home the full range of professionals will be involved including relevant specialist teams. It is certainly not for a single professional person to make such an assessment. The guidance also states that 'It is vital for managers of care homes to be fully involved in the admission of older people to their homes, and to play an important part in care planning, monitoring and review.' This is rather a new departure. If nursing home care, as opposed to residential home care, is ultimately decided upon a registered nurse will be involved in the determination of the registered nursing care contribution and thus the extent of free nursing care. This aspect is dealt with separately in HSC 2001/17: LAC(2001)26.

Advocacy and other support.

Where a person might benefit from an advocate then councils should either arrange or facilitate this. The guidance notes that ‘The role of an advocate is a specialism in its own right, and should ideally be provided by professionals who are independent of both statutory agencies and the older person.’ This is a rather mysterious sentence. Does it imply that a family solicitor is not a suitably ‘independent’ person as he or she is paid by the older person? Such an assertion would be to subvert the role of legal adviser. It would, it is submitted, probably be illegal under the Human Rights Act if nothing else. In practice who else might fulfil the role is a well kept secret. It implies a freestanding agency, free of charge so as to be truly ‘independent’, with a full range of legal and technical skills. Most unlikely.

Evaluation of the assessment.

The assessment tools are used in conjunction with protocols to help the professionals make sense of the details and to help guide them to the appropriate service response. The evaluation process emphasises individual independence and the threats to it. If rehabilitation is possible then that will be the priority. Rehabilitation however must not be allowed to be an excuse for cost savings. Annex E re-iterates the existing law that decisions are to be taken upon the basis of clinical need whilst NHS and local authority resources may be taken into account in the provision of services. The extent of how far resources can legally be taken into account is a quite separate complex matter. Councils should make eligibility decisions with reference to ‘Fair Access to Care Services’. It helps set ‘eligibility criteria’ so a person may be defined as within or without the ‘eligible need’ criteria

Care plans: Nature and contents

Under Annex E, following the National Service Framework for Older People, the care plan arising from a comprehensive old age assessment is to be in writing. This must be given to the assessed person. The detail of the care plan is to 'be in proportion to the assessed needs and service provision.' (Page 18) For older people who might need to enter care the author would expect it to be thorough and detailed following investigation of all the domains under the comprehensive old age assessment. It is clear from the guidance that 'bitty' care plans cobbled together by different parties to the assessment process are not acceptable. It should be an understandable and consistent whole. This is particularly clear as the part of the process which would perhaps most natural, be separate, being the nursing plan, is specifically required to be 'integrated.' It is likely to be the social services hospitals attachment or rather the 'care plan co-ordinator' who will have the task of drawing up the care plan as required. It will be an art rather than a science. As it is key to the avoidance of disputes it is to be hoped its drafting will be taken very seriously and will objectively be needs driven rather than costs driven.

Care planning should lead to a single written care plan which should, according to the guidance, include:-

Summary of assessed needs indicating the intensity, instability, predictability and complexity of problems, the associated risks to independence and the potential for rehabilitation.

Notes on whether or not the service user has agreed the care plan, and a reason where not possible.

The objectives of giving help and anticipated outcome for the service user.

Summary of how services will impact upon the assessed needs and risks.

The part the user will play in addressing needs, including their strengths and abilities.

Details on managing risk. Note of any risk accepted by the user.

Details of what carers are willing to do and related needs and support.

Description of the level and frequency of the help to be given stating which agency will supply what.

Nursing plan (integrated and not attached) if any is required.

Level of registered nurse care contribution for nursing home admissions.

Name and contact number of care plan co-ordinator.

Emergency/alternative contact number and a contingency plan if matters go wrong.

Monitoring arrangements and a review date.

Note: A care plan must not be confused with a ‘single assessment summary’ which is the local agency’s collected and stored information made available to relevant professionals which should be kept up to date. Certain standardised information is required to be stored. Basic personal information, needs an health details, needs eligible and not eligible, a summary care plan and anything else of note/importance.

Complaints.

Older people or their carers should be informed in writing of comment and complaints procedures.

Monitoring and Reviews.

Clearly the service provider, usually the care home, will be best placed to monitor the resident's situation in general. Reviews by the local authority are to take place 3 months after the placement in care. Then they should be at least annually. Re-assessments must follow the single assessment process procedure.

Summary.

As with the National Service Framework for Older People there is much to be welcomed. Particularly, and at long last, the requirement for a clear and detailed needs assessment and written care plan in the form of something approximating to a national standard. Watch this space....

David Coldrick is partner in charge of the Sheffield office of niche private client firm Wrigleys Solicitors: david.coldrick@wrigleys 0114 2675588. Queries welcome.