The ‘Single Assessment Process’

There are to be ‘agreed principles about best practice.’ This is to give ‘good assessment’ which is ‘matched to their individual circumstances.’ A systematic assessment approach is required with a renewed sensitivity to race and religion. Paragraph 2.32 on page 31 raises the issue that an older person may have non-immediate issues lurking in the background. The onus is placed on the primary care or social services staff to ensure such matters are explored. There can be no stepping over dead bodies on the way to investigate a murder.

It is to be noted that it is anticipated that in many cases an assessment even what is termed a ‘fuller assessment’ may be ‘carried out by one front-line professional’. Where other specialists are needed they can draw them in. Such an assessment by a single person being taken as a final assessment for an older person with complex needs would be unacceptable under the guidance. Further if there is a mere possibility of their needing to enter long-term care such an assessment is specifically not allowed under the guidance. However it is clear to the author that there is scope for abuse of the assessment process unless the practitioner insists upon the appropriate full multi-disciplinary assessment in that situation.

Full multi-disciplinary assessments are required for older people possibly in need of long-term care

Importantly although there is a sliding scale approach as to what an assessment might consist of and how many people might be involved in it paragraph 2.36 on page 33 notes ‘If admission to long-term care is a possibility full multi-disciplinary assessment should take place to identify opportunities for rehabilitation and to reduce inappropriate admissions. This will involve assessment by the most appropriate team such as the specialist stroke team old age multi-disciplinary team or the old age mental health team.’ Whatever the reason for it a full multi-disciplinary assessment is required in discharge situations or other situations where there is any even remote ‘possibility’ of admission to long-term care. Any individual written individual care plan must therefore reflect the work of the appropriate multi-disciplinary team. Any other form of assessment in those circumstances is not acceptable under Standard Two. Failure to effect it before discharge or entry into long-term care is unlawful and opens up the relevant authorities to challenge.

Paragraph 2.38 on page 34 notes that ‘Suitably trained registered nurses will be involved in any assessment process which has identified registered nursing needs including the decision on the appropriate setting for the delivery of that nursing care.’ Strictly this wording indicates that the registered nurse only gets involved once the assessment process ‘has identified registered nursing needs ’ past tense but the author would suggest that would not seem to make sense.  The effect of this in the author’s opinion that in the situation of a possible admission to long-term nursing care and any other assessment at any time where there is any question of free NHS nursing care being provided for example upon discharge from hospital or as a result of a reassessment in a residential home that assessment must include a registered nurse. This would appear to be logical given that free NHS nursing care is set in the context of it being provided by a registered nurse.

‘Process.’

It is important to note that the assessment process is just that a process. The same standards should apply at all times. Although discharge and other similar situations may merit the most thorough treatment there is no opt out in other circumstances although a lesser or more specific assessment may stand alone in some situations. To be in line with the single assessment process any assessment for any reason at any time must be in accordance with the newly enshrined principles. Otherwise how can it truly be part of the process? How can standards be improved? How can the assessment be ‘in the round?’ Rushed assessments by a single person of even apparently fairly healthy older people will rarely be acceptable at least once some sort of social or health need has been uncovered.

More detailed assessments ‘will consist of the exploration of a set of standardised domains of need... Further investigation of domains will need to be carried out by appropriately qualified professionals.... What is important in the fuller assessment [and logically the multi-disciplinary assessment] is that all the domains are considered and that no presumptions are made about whether exploration of a particular area is important.’ (Paragraph 2.33) The message is thus one of thoroughness.

Records of levels of help from carers health and social services and so forth should be kept up to date to ensure care needs are met as the older person proceeds through the care system.

Further ‘Carers should be identified and offered...the opportunity to be involved in the older person’s assessment.’ (paragraph 33 page 33.) This is very important. Carers have a say in all circumstances to be given a reasonable opportunity for input. ‘Carer’ is defined in the glossary on page 153 as ‘A person usually a friend or relative who provides care on a voluntary basis implicit in the relationships between family members.’ This deliberately excludes private nursing arrangements and care home owners and staff. Failure to take note of relevant point from ‘non-carers’ should not however be encouraged. The ‘opportunity’ must be realistic. Efforts to fit in with carers should be made. Failure to do so is a recipe for conflict and future challenge.

Carers should also be considered for the ‘carers assessment ‘in their own right.

. Under Paragraph 2.38 on page 34 determinations relating to free nursing care will be sent to the Primary Care Group/Trust manager responsible for implementation of that care. He is also the budget manager and is ‘responsible for agreement that the free nursing care budget will pay for the determined level of registered nursing care’. This is a suspiciously financially motivated comment. Does it mean that a person might be assessed as needing free NHS nursing care at a certain level but may not actually receive it for budgetary reasons? This might re-awaken in a new context all the kinds of debates local authorities had with the Courts in the ‘can’t pay wont pay cases’. Further does it really mean that whatever the budgetary situation the budget manager may veto or cut back such free nursing care as has been assessed? The author would suggest not. It appears that a proper interpretation of this paragraph is that the budget manager will be responsible to ‘do the deal’ with the service provider for the services required in accordance with the assessment. It is inconceivable that he should have any say in whether services will be provided and at what level. He will need to ensure NHS funds are available but he is not in charge of ‘rationing!’

Paragraph 2.39 on page 34 states ‘Consideration of what help to provide and how care should be managed follows assessment.’ This confirms the previously asserted principle of a ‘needs led’ care service. The single assessment process is not a system of needs assessment based upon what money is available. This is a comforting reiteration of the established position.

Paragraph 2.39 on page 34 also states that ‘the most vulnerable older people will often require fuller assessment and more intensive forms of care management. For this reason dedicated care managers should work with the most vulnerable older people over time.’ It adds ‘The care managers should be the most appropriate professional given the older person’s needs.’ This is all part of engendering a ‘process’ approach as older people move through the system. From the carer’s point of view a person who may be approached who is also responsible for their charge must be a positive.

Paragraph 2.40 on page 34 is very important. It states ‘Following assessment older people will receive an individual care plan that clearly describes the objectives and outcomes of providing help as well as the detail of that help... Care plans should be agreed with the older person who should hold their own copy of the care plan.’ This is a right to a written individual care plan. Presumably it also has to contain a right to see the written needs assessment as otherwise it will be difficult to see how the two elements link together. It also suggests it is to be ‘agreed’. That agreement will undoubtedly extend to carers as well as the patient. This is given that they are to be involved in the assessment process under the mandatory guidance and presumably its outcome as well.

If there is no agreement on the individual care plan then attempts should be made to reach a suitable agreement on an informal basis. If in hospital a person should not be discharged especially if the dispute concerns funding matters. Disputes in respect of eligibility for free continuing NHS health care may go to a continuing care review and thence to the Ombudsman. If the older person is living in the community or the matter does not affect funding then the social services and NHS complaints procedures might be more appropriate with the possibility of an application to the Ombudsman. Judicial review over a care plan is possible but is rather a last resort.

First assessment can never be the end of the matter in the single assessment process. Paragraph 2.44 on page 35 notes ‘There may...also need to be a common process to provide a proactive approach to inviting people for assessment.’ This is in the pipeline. The emphasis must be interpreted as meaning that there is a need for continued consideration of the needs of older people with a pro-active initial and continuing responsibility on the part of care services. This is to be welcomed as is much of the National Service Framework

David Coldrick is partner in charge of the Sheffield office of niche private client firm Wrigleys Solicitors: david.coldrick@wrigleys.co.uk