Feature

posted 29 Jul 2004 in Volume 9 Issue 5

Single assessment process
Passing the April milestone

LYNNE BRADEY, a solicitor at Wrigleys Solicitors, considers where the NHS should be now that the April 2004 milestone is long past. It will be for readers to decide how well the single assessment process for older people is working in practice.

The single assessment process (SAP) is an important part of health-service provision for older people. The aim of the SAP is to ensure that older people are assessed properly and by an appropriate person when potential health or care issues are identified, and that the assessment is set at the appropriate level. Agencies should work together locally to ensure that this happens, and that efforts are not duplicated.

We have now passed the April milestone. I intend to set out what should now be happening in the assessment of older people.

Timescales

The SAP guidance has been with us since 2002. The guidance was contained in HSC 2002/001 / LAC(2002)1. When the guidance was issued, a timetable was drawn up. There were dates in 2002 and 2003 for progress reviews to be carried out by local NHS bodies and submitted to the Department of Heath. These were designed to check how ready, or otherwise, local NHS bodies were for implementation. 1 April 2004 was another Milestone, the date by which the single assessment process was to be fully implemented. The final progress reviews were to be submitted to the Department of Health by 30 June 2004.

Effect of the SAP

The SAP guidance is mandatory for local authorities and ‘strongly persuasive’ for NHS bodies. Failure to follow it could be challenged in court.

Aims of the SAP

The SAP aims to ensure that the NHS and local authorities work together to use resources efficiently and minimise inconvenience to the person being assessed. It also tidies up proper discharge procedures. Put simply, the local NHS body should not assess Mrs Smith on Monday, only for the local authority to come along on Wednesday and do almost the same assessment. That wastes time and money and means twice as many people need to be going out assessing older people, even before we consider how inconvenient it is for Mrs Smith and her carer. A mild sense of déjà vu to say the least…

The individual being assessed should be central to the assessment and to any care plan. The service user must receive a copy of the needs assessment and most importantly of the written care plan arising from and justified by that. Information should be stored and shared by the agencies involved, again to avoid duplication. This is subject to consent.

What should be happening now?

The 12 steps identified in the guidance of 28 January 2002 should now have been followed by all local agencies such as Social Services, NHS Trusts etc. These are:

Agreeing within the agency what they want to achieve through implementation of the SAP. This should involve asking older people, carers, professionals and other people with an interest what they feel the good and bad points of the SAP to be;
Agreeing with other local agencies the shared values that everybody will have;
Agreeing the terminology that agencies in the same area will use when working with each other under the SAP;
Mapping the processes care users go through from access to delivery. This is designed to identify areas where work is duplicated, and areas one agency may be omitting altogether;
Estimating the types and numbers of older people needing assessment in the local area. This is to assist in planning;
Agreeing the stages of assessment and care management. The stages are to include publishing information about services, completing the four types of assessment (more about those later), evaluating assessment information, deciding what help should be offered, including decisions about eligibility, care planning, monitoring of how the plan is working and review of the care provided. The guidance says that a pro-active approach to finding people who need assessment is important for prevention of problems and promotion of better health, and that this is something that agencies may wish to consider. As David Coldrick points out in Protecting the Assets of Older People, it is unlikely that fiscally challenged agencies will be putting resources into something that is only optional;
Agreeing the link between medical diagnosis and assessment. The point here is that diagnosis relates only to the existence, treatment and prognosis of one health condition, and not the wider health and social needs of the patient. The guidance states that “the inter-related nature of specific health conditions (such as stroke or fractured neck or femur), with social, physical and mental-health needs makes separation in practice unhelpful”;
Agreeing the domains and sub-domains of assessment. The local agencies can chop and change and even add to the domains provided in the National Service Framework for Older People, but they may not leave any of these out of the assessment;
Agreeing assessment approaches, tools and scales. Agencies in an area should have a common approach to the collecting and evaluation of assessment information. There was no one assessment tool in existence in 2002 that covered all the required domains. Department of Health requirements are contained in Annex C of the January 2002 guidance;
Agreeing joint-working arrangements. Agencies should agree which professionals from which agency should co-ordinate assessment and care planning in specified circumstances. For example, where a person is living at home, agencies may agree that the local authority’s nominated professional should co-ordinate assessment in that case;
Agreeing a single-assessment summary. This is a critical step. Agencies need to agree the information they will collect. The Department of Health has issued guidance in Annex I of the guidance. I will discuss this in more detail later on;
Implementing a joint staff development strategy. This is to ensure that organisations and staff are able to deal with the SAP and will involve ongoing programmes of training in areas such as knowledge of old age and related health and social-care conditions, multi-disciplinary working and assessment skills and techniques.

In addition to this, older people’s needs are to be assessed according to the January 2002 guidance. Individuals are to be at the heart of assessment and care planning. The four types of assessment are to be used as a framework. The four types of assessment are under Annex E and will be dealt with below.

The assessment domains and sub-domains of Annex F of the guidance are to be covered when an overview of combined assessments is undertaken. Again, I will discuss that below.

Arrangements for care co-ordination are to be agreed under Annex H

Professionals are to have received adequate and appropriate training to enable them to undertake assessments in care planning under Annex J.

The localities’ approaches to the SAP are to be disseminated locally and to be published in Better Care, Higher Standards charters.

Annex E – stages of assessment

The stages of assessment for the SAP are:

Publishing information about services;
Case finding (optional);
Completing assessment – the four types;
Evaluating assessment information;
Deciding on what help should be offered, including eligibility decisions;
Care planning leading to service delivery;
Monitoring review.

When publishing information about services, the agencies involved should use information based on the ‘Key Implications for Older People’ section of the guidance. They reiterate the need for the older person to be at the centre of the assessment, and that the scale and depth of the assessment should be kept in proportion to the person’s needs. Older people are the most important people in the assessment process. There are requirements about courtesy and non-discrimination on account of age, sex, race, lifestyle, and other equivalent factors such as disability.

The four types of assessment

The Department of Health advises that the assessment systems in each area are based on the following four types of assessment.

1. Contact assessment

This includes the collection of basic personal information. This type of assessment takes place “where significant needs are first described or suspected”. Therefore, not every appointment with, for example, a GP would come under the category of a contact assessment. Annex I basic information should be collected. It may be that this could be done at the annual over-75 assessment to save time later. At a contact assessment, professionals should establish what the needs of the older person are. They need to address:

The nature of the need;
The significance of the need for the older person;
The length of time the need has been experienced;
Potential solutions identified by the older person;
Other needs experienced by the older person;
Recent events or changes relevant to the problem;
Perceptions of family members and carers.

The person undertaking the contact assessment (there need only be one person) does not need to be professionally qualified, but should be trained. They should ask simple questions.

Overview assessment

This should be done by a professional who should focus on undertaking an all-round assessment. The overview assessment should encompass all or some of the domains of the SAP, such as personal care and physical wellbeing, senses and mental health. The overview assessment may be the first assessment if, during a consultation, it becomes clear that this would be appropriate. Alternatively, a contact assessment or specialist assessment of a specific problem may already have taken place on another date. Professionals should use their judgement to decide whether to explore all of the domains or just some of them in the overview assessment. It is very important, however, that if there is a strong likelihood that the person may need intensive support or prolonged support, which is defined as a year or longer, which may include admission to a care home or a substantial package of care at home, all of the domains and many of the sub-domains should be explored. Specialist assessment should be carried out in a number of domains. This would, therefore, be a comprehensive assessment.

Department of Health guidance states that if a professional is in doubt, they should include all of the domains. Many treatable health conditions in older people are not diagnosed correctly or even detected at all according to research undertaken as part of the National Service Framework for Older People.

Professionals are encouraged to discuss the need for an assessment with the older person and explain the potential benefits to them. The Department of Health appears to recognise that not everybody will be keen to be assessed.

The Department of Health guidance states that overview assessments do not have to be undertaken by qualified professionals, although the person assessing should have received training. The Department of Health states: “It is both possible and practical for all of the overview assessment to be completed by a single professional from either the NHS or social services.”

Specialist assessments

These assessments may flow from a contact or overview assessment. Specialist assessments deal with “the presence, extent, cause and likely development of the health condition or problem or social-care need”. These assessments should also establish links to other related problems and needs.

Specialist assessments should be undertaken and interpreted by the “most appropriate qualified professional”. In some cases, it will be obvious who should be assessing and local agencies should not make blanket decisions that would apply to every case. Each case needs to be looked at on its own merit. In particular, the Department of Health notes that therapists should not be overlooked as they can deal with many different areas and provide useful input.

Comprehensive assessment

The comprehensive assessment may be the first assessment that takes place or may be prompted by other assessments. It may be that the professional seeing the older person for the first time feels that it is best to conduct a comprehensive assessment on the spot as one will obviously be needed. The professionals should use their judgement.

If the care offered to the older person is even just possibly going to be admission to a care home, intermediate care services or substantial care at home, a comprehensive assessment must be carried out. Decisions about where a person should be placed should not be made until a comprehensive assessment has been carried out and evaluated. It is important to explore rehabilitation potential before making these decisions.

A comprehensive assessment, will involve a number of different professionals or professional specialist teams. The Department of Health anticipates that geriatricians and old-age psychiatrists should usually lead a comprehensive assessment.

In all assessments, the older person should be encouraged to participate and give their views. They should be encouraged to give biographical information about themselves including any past needs and their feelings on relationships, motivations and beliefs.

Important decisions on assessment, eligibility and service provision should be in writing and a copy should be given to the older person. This is something we need to insist on for our clients.

Agencies should bear in mind their housing duties under 47(3)(b) of the NHS and Community Care Act 1990. If it becomes clear that the older person has a housing need, the agency should invite the housing authority to assist in the assessment. This could be particularly important if the older person has to move to different accommodation more suitably adapted for their needs.

Care plans should be reviewed every year at least. The guidance states that if a major event occurs, unscheduled reviews of the care plan will be necessary.

The domains

The domains to be covered are:

User’s perspective

a. Needs and issues in the user’s own words;

b. User’s expectations, strengths, abilities and motivation.

Clinical background

a. History of medical conditions and diagnoses;

b. History of falls;

c. Medication use and ability to self medicate.

Disease prevention

a. History of blood-pressure monitoring;

b. Nutrition, diet and fluids;

c. Vaccination history;

d. Drinking and smoking history;

e. Exercise pattern;

f. History of cervical and breast screening.

Personal care and physical well-being

a. Dressing;

b. Pain;

c. Oral health;

d. Foot-care;

e. Tissue viability;

f. Mobility;

g. Continence and other aspects of elimination;

h. Sleeping patterns.

Senses

a. Sight;

b. Hearing;

c. Communication.

Mental health

a. Cognition and dementia, including orientation and memory;

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

Relationships

a. Social contacts, relationships and involvement in leisure, hobbies, work and learning;

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

Safety

a. Abuse and neglect;

b. Other aspects of personal safety;

c. Public safety.

Immediate environment and resources

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

b. Housing – location, access, amenities and heating;

c. Level and management of finances;

d. Access to local facilities/services.

Single-assessment summary

The information to be included in the single-assessment summary consists of basic personal information, needs and health information and a summary of the care plan. The care plan should also address who will fund the care, that is, the NHS or local authority or otherwise. It is a holistic approach with a ‘needs led’ emphasis.

Basic personal information includes name, address, telephone number, type and tenure of accommodation, NHS number, date of birth, gender, ethnicity and religion, preferred first language, household details, employment details, contact details for carers and closest relative or friend, and GP and dentist details.

Needs and health information consists of all of the domains and sub domains of the SAP (see above).

The summary of the care plan should cover all care received, whether from family carers, professional carers, meals on wheels, transport, hospital attendances or stays in care homes.

Further NHS-related developments

Progress reports should have been delivered to the Department of Health by all agencies by the end of June. Outstanding matters should have been dealt with by April 2005. Watch this space.

The relevant guidance and annexes etc. can be found on the Department of Health website. As the web addresses have a habit of changing, it is best to go to the homepage, www.dh.gov.uk/Home/fs/en, and search using the alphabetical site index.

As a further note to my last article about choice of accommodation and top-up payments, thank you to the reader who pointed out that the Department of Health website had rearranged itself after I had finished the article, which meant that the references given no longer take the reader to the correct page. As the website will probably rearrange itself again between today and the day you need to look up a reference, it is best to use the alphabetical site index on the homepage (see above). In addition, I should have made it clear that the guidance I was referring to on choice of accommodation was in draft form and is being updated, although it should be followed in the meantime.

I hope this article assists readers through the quagmire of the SAP. There was certainly enough guidance about it to paper at least one of my office walls.

If you have any comments, further information or other feedback, I would be very grateful.

Lynne Bradey is a solicitor at Wrigleys. She can be contacted by e-mail at lynne.bradey@wrigleys.co.uk