Introduction
The Single Assessment Process (SAP) is a framework for the interdisciplinary and interagency needs assessment of older people introduced in the National Service Framework for Older People (Standard 2 – Person-centred care)11. A key purpose of the SAP is to ensure that ‘older people’s needs are assessed and evaluated fully, with professionals sharing information appropriately and not repeating assessments already carried out by others’ (p 8)58. It is also stated that ‘the SAP should ensure that the scale and depth of assessment is kept in proportion to older people’s needs; agencies do not duplicate each other’s assessments; and professionals contribute to assessments in the most effective way’ (p 2)1.
Local implementation is based upon the geographical areas used for implementing the National Service Framework for Older People as a whole, and taken forward through the same local groupings, such as ‘Local Strategic Partnerships’.
Implementation commenced in April 2002 and progress has been monitored using a defined set of criteria59; by April 2004, all localities should have implemented the core aspects of SAP. Key professionals involved in implementation include social workers, nurses, therapists, general practitioners, geriatricians and old age physicians.
The SAP does not require the use of a single national assessment tool; rather it provides a ‘rigorous framework’ of key attributes, values, domains and stages of assessment59, intended to lead to ‘convergence’ of assessment methods and results over time. Local agencies are expected, however, to maintain a ‘Current Summary Record’ (CSR) as a shared source of key information about the older person. At a minimum, the summary must contain three sets of standardised information covering basic personal information, needs and health, plus a summary of the care plan. The SAP is set out in Annex 4.
The Centre for Policy on Ageing (CPA) was commissioned by the Department of Health to identify and make available learning and development materials on which practitioners can draw when implementing the SAP. The materials focus on practice and change with respect to joint working, assessment and the health/social care conditions of older people. The aim of this resource is to encourage the sharing of documents, strategies, protocols and, particularly, examples of good practice and successful solutions to help with the on-going process of implementing SAP. The resource is available online at: http://www.cpa.org.uk/sap/sap_home.html.
The Department of Health has commissioned the Personal Social Services Research Unit (PSSRU) at the University of Manchester to evaluate the development and impact of the SAP for older people in England (to be completed November 2006)60.
SAP Assessment Tools And Assessment Scales
Within SAP, an assessment scale is defined as ‘a means of identifying – and possibly gauging the extent of – a specific health or care condition, such as ability for personal care, mobility, tissue viability, depression and cognitive impairment. In the context of SAP, assessment scales may be used individually or collectively at all stages of assessment’61. For the purposes of SAP implementation, the DH provided guidance
on the selection and use of scales, introducing issues such as validity and reliability, and providing a list of ‘recommended’ scales relevant to SAP domains61.
Within SAP, an assessment tool is an instrument designed as a ‘package’ to cover all aspects of a particular type of assessment. Particular emphasis was placed on the development of tools for the overview assessment, for which a number of options were available to localities62. A first option was to adopt an ‘off-the-shelf’ tool that had been accredited by a DH Accreditation Panel. Six such tools were accredited63: CAT Electronic Version (developed by Cambridgeshire County Council), EASYcare v2004 (University of Sheffield), FACE for Older People v3 (FACE Recording and Management Systems), MDS Home Care v2.3 (University of Kent), NOAT (Northamptonshire County Council), and STEP (Royal College of General
Practitioners). A second option was for localities to develop their own assessment tool for local use. A third option was to adopt a ‘checklist’ approach whereby
‘professionals ensure that the domains of the SAP guidance are covered during an overview assessment’62.
The Aim Of The Research
The aim of this element of the study was to identify transferable key lessons from the Single Assessment Process for Older People by eliciting the views of key individuals who have played a role in SAP development and implementation.
Key Themes
The ‘framework’ approach
Most respondents viewed the SAP framework as attractive in principle. The framework’s characteristics of being highly prescribed and multi-dimensional are seen as having some direct, positive effects on inter-agency practice. It is regarded as a helpful structure to ‘really examine roles and responsibilities and identify where duplication is occurring’ (respondent 001). The concept of assessing against
particular domains has proved ‘useful picking up information that would otherwise have been lost’ (002).
However, almost all respondents considered the SAP as unworkable in practice in its entirety. This criticism has two separate elements: the size and complexity of the framework itself and the scale and complexity of intra- and inter-agency
implementation. A key point was that the complexities of the implementation process themselves distract from its purpose and ethos:
‘The structure chosen is trying to do absolutely everything and this will lead to overkill for individuals and for staff. It is a very cumbersome structure in practice and can easily take over as the focus (i.e. the process and
paperwork) rather than a person centred approach.’ (010)
Almost all respondents reported that the ‘contact’ and ‘overview’ assessments were now beginning to work well, typically after substantial teething problems. However, the implementation of ‘specialist’ or ‘comprehensive’ assessments appeared not to have progressed to any great extent. Apart from the fact that implementation of ‘contact’ and ‘overview’ have taken priority, the key reason for hesitation is a distinct lack of clarity about the purpose of the ‘specialist’ and ‘comprehensive’ assessments, about how they ‘fit’ with the domains and other assessments, about who should be doing them and when, and how this information might be shared. In short,
respondents indicated that implementation of ‘contact’ and ‘overview’ assessments in itself was such a mammoth task, and a task still far from completion, that in many localities there was little prospect of the other assessment types coming on-stream in the foreseeable future.
The diversity of tools
The issue of assessment tools was massive for respondents in the implementation group, and one of some complexity. Of the 14 respondents in that group, eight stated that their locality was using a DH accredited tool (FACE or EASYcare), five were using home-grown tools, and one was using a multiplicity of approaches.
First, the majority of responses suggested that a ‘national tool’ would have been preferable to the model of ‘local solutions’ adopted for SAP, as the process of arriving at a local solution consumed an enormous amount of time and energy. This was regardless of which solution was eventually selected – an off-the-shelf accredited tool, a locally-developed tool, or a local checklist. The reason the process was so laborious is that it consisted of a number of separate processes – selection of a ‘local solution’ option, identification of tools, agreement/selection of a tool, or development of a tool – each of which required significant discussion and negotiation, as well as the eventual reaching of consensus between a large number of stakeholders. In some cases, a consensus was simply not reached, and a solution had to be imposed, as this example illustrates:
‘Initially, this led to a lot of debate and discussion on the local tool to be used, and led to people concentrating on the tool more than the more person-
centred objectives of SAP. It was only when the Strategic Health Authority decided on the tool for the region that we made progress, as we could concentrate on implementing this and not arguing on a tool. Although this initially lead to resentment, people accepted the health authority’s decision and are now using the chosen tool. Feedback so far has been positive.’ (009). A second key issue is the timing of the implementation, particularly with regard to the lack of IT solutions to ‘join up’ different local systems, as SAP implementation in most localities preceded roll-out of NPfIT. The joining-up of local systems ‘after the event’ is now causing a fresh set of difficulties:
‘The idea of everyone producing their own local solution has caused enormous problems for everyone, especially as we now have to deal with issues coming from NPfIT relating to interfacing NHS and local authority systems. A national model which we all could have commented upon – and then worked together in order to implement – would have made much more sense, as developing the tools has taken such a long time and implementation, given the
complexities of local authorities and PCTs/acute trusts, has been fraught with problems.’ (002)
Third, a caveat must be noted. The processes of arriving at a local solution, although demanding, did have positive aspects in that it required localities to take ownership of their solution and required inter-agency negotiation at an early stage. This is
illustrated in the quote below. This quote also illustrates a fourth point: that ‘local solutions’ in fact form part of a bigger, more complex picture, and that the pace of development of local solutions needs to be cognisant of the development of other local, regional and national elements:
‘In the initial stages, we felt that the framework approach was frustrating and we would have preferred to have been told exactly what was required and performance managed on this. It was a question of doing something and then saying, “Is this what you meant?” By working together as a regional group, we became more empowered and started to develop a regional approach. But it was too late for any major standardisation and different SAP partnerships had gone down very different routes. Consequently, we have 14 approaches in [the region] – all different to varying degrees – all 14 areas using home-grown tools. Would have preferred standard tool from the outset.’ (016)
The responses of the ‘development’ informants suggest that a single national tool was the preferred option for many parties, and that at some point a high-level decision was made that this option would not be pursued. Two of the three respondents in this group strongly voiced the opinion that this decision was a mistake. The third informant, a DH officer, indicated that the justifications for this decision were (a) that a number of existing local systems had been identified which were considered effective and (b) that it was considered simply impossible to design a single solution to cater for the hugely diverse range of local needs.
Electronic solutions
The strong and consistent message from respondents (and the literature) is that the aims of SAP – to ensure that ‘the scale and depth of assessment is kept in proportion to older people’s needs; agencies do not duplicate each other’s assessments; and professionals contribute to assessments in the most effective way’ – will only be achieved when electronic systems are in place that will enable information to be shared between different agencies and locations. As one respondent indicated ‘The whole concept is not workable without enormous difficulty without joined up electronic solutions’ (006).
The picture at present is one of disorder. Most areas are using paper-based systems. Although some efforts are being made to introduce client-held records to enable information sharing between agencies, on the whole there remains a good deal of duplication of assessment, with copying of paper assessments to other agencies. In
one locality, four key teams – district nursing, intermediate care, mental health for older people, and social services – were all using the same FACE assessment tool independently: therefore an older person quite feasibly might have exactly the same assessment four times.
Electronic solutions are appearing piecemeal. Some localities have developed their own IT solutions and others are NPfIT pilot sites. Respondents typically considered these solutions to have advanced SAP implementation significantly:
‘We are part of the NPfIT rollout. We went live in March. The system is being well used, and certainly IT became an enabler and a catalyst for getting things moving. People were very negative without IT, regarding the amount of
paperwork.’ (009)
The importance of electronic solutions has recently been acknowledged within the Department of Health; this is in a consultation document issued by the Care Record Development Board SAP Action Team and based upon a national SAP stakeholder workshop:
‘Present approaches are perceived to be fragmented and failing both the users of services, the staff who seek to support them and organisations that strive to be more efficient … The gains to be made in delivering an electronic based SAP approach are now seen to be far greater than originally considered in delivering a paper based approach which is now seen as having significant limitations. There is now a great desire across agencies to use the National Programme for Information Technology (NPfIT) to drive the implementation of SAP to a further higher level. Information will be captured and shared
electronically within and across agencies.’ (p 5)64
Inter-agency working
A final theme was inter-agency working, specifically variation in the commitment to – or priority of – SAP between different sectors and agencies within localities.
Respondents reported the perception that, broadly speaking, social care agencies were driving SAP implementation and that health care agencies were engaged to a lesser degree. General Practitioners were one group repeatedly identified as being slow to engage:
‘SAP is only progressing due to the determined perseverance of the [social services directorate]. Some PCTs are finally showing some interest but this is very sporadic. The role of SHAs seems critical and in areas where they are not as proactive or inclusive there has been much less progress. In general health agencies have not seen it as an important agenda and the lack of progress with NPfIT has not helped this.’ (004)
Some Recommendations
The informants were asked to identify factors that would have improved the SAP implementation process. The strongest emergent recommendations were:
• The process should be a robust, nationally-managed, ‘project’, with realistic timescales, clear targets and appropriate systems and support;
• The DH should give ‘clear and unequivocal’ direction to all stakeholder
organisations on the level of priority to be accorded to the work; this should be supported by clear lines of accountability and a clear performance framework; e.g. SAP should be in GP contracts and a key deliverable for acute trusts; • An electronic, integrated, trans-agency information management solution
should be built in from the start;
• There should be provision of a single, national assessment tool, at least for ‘core’ assessments;