CHAPTER THREE ASSESSMENT
- Describe the assessment process, comment on the merits of different assessment methods and variations between local authorities.
- Identify, across all local authorities, the number of people currently waiting for an assessment and the length of time they have been waiting and explore the underlying reasons for waiting lists for assessments.
- Highlight ways in which the assessment process could be improved.
The Assessment Process
3.1 The Guidance on Free Personal and Nursing Care 19 stipulates that access to FPC is determined by the Community Care assessment process as defined in detailed guidance on Assessment and Care Management and Single Shared Assessment. 20
3.2 Guidance on Community Care Management ( SWSG 11/91) sets out the key features of an assessment system for individual needs for community care services. It states:
- Assessment should be needs-led, not service-led. It should examine the needs of the individual for any form of care or support and not for particular services
- There should be an initial screening process to verify that the presenting problems lie in the field of community care
- Assessment systems should ensure the participation of the individual and his or her carer
- A flexible response system will be needed to ensure that the time and resources devoted to assessment are no more than is essential in each case
- The outcome of assessment should be a clear decision about what services are required to meet needs and by whom they could be provided, including by Direct Payment for self directed care. This should be recorded in a systematic way in a care plan.
Screening of referrals
3.3 Most referrals will be made to the local authority Social Work/ Services department, where either the duty manager or an appointed group will undertake a screening of referrals based on the information provided on the client and his/ her circumstance. This screening will determine how the referral should be responded to and in what timescale. The screening will be based on two key factors: risk to the client and complexity of the assessment.
3.4 The prioritisation given to referrals according to risk and other factors is determined by each local authority. Typically local authorities will have three or four levels of priority. For example:
- Urgent / Emergency - unacceptable and immediate risk of an unplanned admission to hospital or care home
- High Priority - serious risk in relation to daily living due to essential daily personal care and nutritional needs not being met; or where the client is in a hospital and cannot be discharged unless essential care services are put in place
- Medium Priority - moderate risk to daily living due to some personal care needs not being met
- Low Priority - where basic needs are being met and there is little or no risk that not intervening/ providing a service would lead to a reduction in quality of life.
3.5 Most local authorities place different targets on the response and completion times of assessments according to the level of priority. The case study councils show how target times for assessments vary across local authorities. (Table 3.1)
Table 3.1: Target Times for Assessments
Target Times for Assessments
Contact with the referral within 7 working days and completion of the assessment within 20 working days
Argyll and Bute
No specific target times for assessments; except hospital discharge - 20 working days
Dumfries and Galloway
Urgent cases allocated and undertaken within 24 hours
High priority - 10 working days
Medium priority - 20 working days
High priority - 24 hours
Medium priority - 20 working days
Low priority - 30 working days
Emergency cases - 24 hours
High priority - 2 - 5 working days
Medium priority - 5 - 33 working days
Low priority - 33 working days
Sources: Case study local authorities
3.6 Faster access to services is a key goal for local authorities and Joint Future Partnerships (the partnership of the local authority and NHS Board to deliver Community Care). Most partnerships have identified (as part of their Joint Performance Improvement Assessment Framework ( JPIAF)) specific Local Improvement Targets ( LIT) for improving response times for assessments. Since the targets and measurements vary across partnerships it is not possible to provide robust comparisons between local authorities.
3.7 Care assessments consist of three parts:
- Assessment of needs and circumstances
- Identification of needs which should be met by the local authority
- Financial assessment as appropriate to determine whether the 'client' would pay for non-personal services or, in the case of someone requiring a place in a care home, whether their level of income and savings are such that they would be liable to pay all or part of their own care home fees.
3.8 Local authorities should ensure that the people whose needs are being assessed play an active part in their assessment. Where the person is cared for, the carer's views should also be taken into account. The assessment should also consider the needs of the carer and, if requested, a carer's assessment should be carried out (see Chapter 4).
3.9 Community care assessments are delivered within the overall context of Single Shared Assessment ( SSA), which aims to ensure that the needs of individuals are identified as quickly and effectively as possible. SSA involves the sharing of information between agencies and applies to all levels and types of assessment. The Assessment Review Co-ordinating Group set up to support the development of SSA has prepared National Minimum Information Standards for Older People 21 that set out the practical requirements for information sharing at a local level to support the development of the cross agency approach to meeting service users' needs. A single agency assessment, as distinct from a SSA, may be undertaken when information is not required from other agencies.
3.10 Complex or comprehensive assessments will be led by a qualified social worker and are likely to require input from different agencies, such as the NHS and the Housing Department. They may also need the involvement of occupational therapists and specialists such as geriatricians.
3.11 In most areas, simple assessments, where the referral for assessment has suggested that the needs of the client could be met by the provision of a piece of equipment, aid or adaptation (e.g. stairlift) or provision of a simple package of care (e.g. housework or shopping service), will be carried out by non-social work qualified staff such as Social Work Assistants or Care Co-ordinators or, in some instances, community nurses or occupational therapists.
3.12 Local authorities use a range of different assessment tools for undertaking assessments. For example, three of the case study councils - Argyll and Bute, Dumfries and Galloway and Edinburgh - use CarenapE (Care Needs Assessment Package for Elderly) or a variation of CarenapE. West Dunbartonshire Council uses another generic assessment package - Carefirst. Stirling Council uses its own package, which has been developed jointly with Forth Valley NHS.
3.13 Assessments record all relevant information about the person whose needs are being assessed: their home circumstances; associated people (carers); and the person's needs. For example, a care assessment using CarenapE will include:
- details of the circumstances of the client leading to the referral for an assessment
- relevant background information
- contact details including next of kin and carer and whether anyone is empowered to act in the persons welfare or financial interests
- information about communication needs (e.g. language, hearing)
- a record of the person's views of their needs
- a record of the carers' views
- details of current care and supports (before assessment) provided by informal carers, statutory agencies, voluntary or private sector providers
- whether and what type of assistance may be required on a range of areas of daily living
- mobility (e.g. with walking or getting in and out of bed)
- self care and toileting
- mental health
- social behaviour/ community living
- initial risk assessment
- assessment summary based on the above
- the financial status of the person being assessed, and possibly a benefits check.
3.14 Assessments record the care needs of older people, including personal care. CarenapE lists nine possible forms of help that might be required by the person whose needs have been assessed:
- Social stimulation/ activity
- Physical assistance or doing tasks for the person
- Equipment and adaptations
- Specialist assessment
- Behaviour management
- Carer advice/ training.
Personal care services that are provided free under FPC could be provided under several of these headings including prompting (e.g. medication) and physical assistance or doing tasks for the person (e.g. bathing and washing).
3.15 The SSA is more efficient than the previous process of multiple assessments carried out by various agencies as it deals with all the care needs of individuals in one assessment. However, many of the frontline staff interviewed for the evaluation who undertake assessments expressed concern about the complexity of the process. A substantial amount of paperwork is involved in carrying out a full assessment and recording all the information as detailed above. Several staff from various council departments and the NHS may be required to have an input in the assessment. Much of the frustration with SSA in some areas is due to the delays in introducing eCare - electronic sharing of information within and across agencies. Without electronic recording of assessments and sharing of information, the process of completing assessments is still essentially a manual process.
3.16 The evaluation did not find any evidence to suggest that the assessment tool used to undertake assessments has any significant impact on whether / how FPC is provided. Nor is there any correlation between the time required to complete assessments and the type of assessment tools or assessment processes used by the local authority.
3.17 Many of the users and carers interviewed in the six case study areas could not recall their experience of the assessment. It must be borne in mind that assessments are mostly carried out when the elderly person is frail and during a period of great stress. However, from those interviewees, mainly carers, who could remember the assessment being carried out, we heard accounts of both good and bad experiences. There is no consistent evidence that any form of assessment tool or process provides a better assessment from the perspective of the service user and carer. The relationship between the professional carrying out the assessment and the person being assessed and their carer is a more important factor than the assessment tool used. Users and carers value information about how the assessment will be carried out and being kept informed of progress with their assessment. However, across Scotland there is no consistent picture of how users and carers are informed about the assessment process, what it entails and how long it should or might take.
3.18 Good experiences related by interviewees typically involve a sense that the social worker is committed to the case and is accessible and approachable and that the older person and/ or the carer feel that their views are taken into account. Poor experiences occur when people feel excluded from the process and feel that their views are not taken into account. The examples below, drawn from interviews with carers in Angus, illustrate that experiences of the assessment process can vary within the same local authority.
Mrs C (Angus) had been caring for her mother at home. When her mother's health deteriorated rapidly she had to go into respite care. Her Care Manager carried out an assessment to assess whether she should go into a care home. Mrs C found that the assessment process had been "excellent and both her own and her family's views were fully taken into account."
Mrs E (Angus) had moved her mother who had dementia to Angus from another area in order to live near her because of her deteriorating health. She feels her accounts of her mother's needs were consistently disbelieved and the assessment was made on the basis of very short visits and consequently without a proper understanding of her mother's needs.
Delays in Assessments
Waiting for Assessments
3.19 There are no comprehensive statistics showing the number of older people waiting for a community care assessment and the length of time they have been waiting. The "Patients Ready for Discharge" quarterly census provides information on the number of people awaiting a community care assessment in hospital; but fails to record the number of people waiting for assessments who are living at home or in care homes. The information submitted by Joint Future Partnerships as part of their Joint Performance Information and Assessment Framework ( JPIAF) provides information on the number of assessments carried out and waiting times from first contact to first service delivery, but not waiting times for the assessment itself or the number of people waiting for assessments to be completed.
3.20 The problems associated with trying to provide robust and accurate figures for the number of people waiting for assessments, and the length of time they have been waiting, are evidenced by attempts by the Scottish Executive and Scottish Parliament Health Committee to obtain accurate information from local authorities.
3.21 Table A6.1 (Appendix 6) provides the results of a snapshot survey carried out by the Scottish Executive in February 2006 and a Freedom of Information (FoI) question issued to all local authorities by the Scottish Parliament Health Committee in April 2006.
3.22 The Scottish Executive's snapshot survey found that 21 local authorities reported that that had people waiting for assessment. A total of just over 3,600 people were waiting at home for an assessment, just under 60 people were waiting in care homes and 321 people were waiting in hospital. The Scottish Parliament Health Committee's FOI request showed that the median wait for a community care assessment ranged from 0 days to as much as 63.5 days.
3.23 Despite being the best evidence available at that time on the extent of older people's waiting for community care assessments, the information shown in Table A6.1 should be treated with considerable caution.
3.24 A number of definitional issues must be agreed with local authorities before accurate information on waiting times for assessment can be systematically collected and analysed. Local authorities currently take different approaches to defining whether or not people are waiting for an assessment.
3.25 Neither the Scottish Executive survey nor the Scottish Parliament FOI request collected comparable data on waiting lists as there was no consensus as to when waiting for an assessment begins or ends. For example, when responding to the Scottish Executive survey some local authorities deemed referrals that had been screened and allocated to an assessor as having started as the client was no longer waiting for the assessment. Other local authorities defined people as waiting for assessment where the assessment process had started but had not been completed.
3.26 Most of the local authorities that answered the Scottish Parliament Health Committee's FOI request on the 'median wait for a community care assessment' reported on the median time taken from referral to first service start (as reported in their JPIAF 6 return) rather than specifically the median time taken to undertake the assessment.
Data recording and reporting issues
3.27 Many local authorities do not have information systems in place to enable them to report accurately on the number of people waiting for assessment and the average length of wait. For example, nine local authorities did not provide the information requested by the Scottish Parliament Health Committee's FOI request on the 'median wait for a community care assessment' stating they do not hold the information. Local authorities that have not yet implemented or are not fully operating electronic data recording and sharing systems (e-care) and still rely on paper based systems are not readily able to generate and analyse information on people waiting for care assessments.
3.28 Whilst it may not currently be possible to definitively answer the question 'how many people aged 65 or over are waiting for an assessment of care needs to be completed and how long are people having to wait?' it is clear that a significant proportion of Scotland's local authorities do have older people waiting for assessments to be undertaken or completed. Twenty one local authorities reported to the Scottish Executive in February 2006 that they have 'people waiting at home for an assessment' and 15 local authorities reported to the evaluation's local authority survey that they operate a waiting list for assessments, i.e. have a backlog of uncompleted assessments. Other local authorities may have people on a 'pending list' of cases but do not describe this as a waiting list.
Reasons for delays
3.29 The local authority survey and case studies explored the underlying reasons for delays in undertaking or completing assessments. Seventeen local authorities (those that operate waiting lists or have reported people waiting for assessments) reported that they have people waiting because there are insufficient staff to meet demand for assessments. Reasons given for the lack of staffing capacity to undertake assessments included vacancies and recruitment problems; staff absence; growth in the elderly population; and increased referrals for community care assessments.
3.30 Amongst the case study councils, both City of Edinburgh and Stirling Councils reported that vacancy levels and high levels of sick leave amongst care management/ social worker posts, combined with the growth in demand for assessments partly due to the growth in demand for FPC, have at various times led to a backlog of community care assessments waiting to be completed.
3.31 The problems relating to recruitment of social work staff have been well documented and were one of the issues addressed by the 21 st Century Social Work Review. 22 However, whilst vacancies and staff shortages amongst qualified social work staff are undoubtedly a factor that contributes to delays in undertaking assessments there is no direct correlation between vacancy levels amongst social work staff in local authorities and backlogs of assessments waiting to be completed. Several local authorities that reported people waiting for assessments have relatively low social work vacancy levels and some local authorities with relatively high social work vacancies have not reported delays in undertaking assessments. Other factors such as the configuration, efficiency and effectiveness of the social work service and how assessments are monitored and managed are also factors that contribute to backlogs of assessments waiting to be completed.
3.32 Lack of funding to provide services after assessments have been completed was not reported as the reason for delays in assessments being carried out. Indeed, several local authorities (including City of Edinburgh, Argyll and Bute and West Dunbartonshire) reported that they will backdate payment of FPC/ FNC to self funders in care homes if their assessment is delayed, contrary to the Guidance on Free Personal and Nursing Care which states that "payments will commence once the nursing and/ or personal nursing care is being provided. It does not start before and will not be backdated, e.g. to the date of referral or assessment." 23 For example, City of Edinburgh Council backdates payments to four weeks after receipt of the referral, that being the target date for the completion of non urgent referrals. In Argyll and Bute FPC/ FNC is paid within three months of admission to the home. West Dunbartonshire backdates FPC/ FNC payments either to first point of contact, date of assessment or four weeks after the date of admission.
Managing delays or waiting lists
3.33 The legal position on waiting lists for community care assessments and service provision was set out in a judgement made by Lord Hardie in December 2000. 24 This can be summarised in the following terms: the resources available to a local authority are irrelevant in coming to a judgement about an individual's needs, but are relevant in coming to a decision about how to meet these needs. It is not an option to do nothing if resources for providing the optimum care are not available. The local authority should put interim care arrangements in place wherever possible and actively manage cases so that optimum long term care can be provided at the earliest opportunity.
3.34 Local authorities that reported to the evaluation that they operate waiting lists or have backlogs of assessments waiting to be completed reported various methods through which they attempt to manage the problem:
- Screening and prioritising referrals according to risk
- Reviewing and monitoring waiting lists
- Tackling staffing capacity problems.
Screening and prioritising referrals according to risk
3.35 Screening and prioritising of referrals is a key aspect of managing waiting lists for assessments. As shown above (paragraph 3.4), referrals are prioritised according to risk or other factors. Emergency cases (e.g. someone whose unpaid carer can no longer provide care because of an illness and who is therefore at risk of having to be admitted to a hospital) will be dealt with as a matter of urgency, whilst assessments for people who may only require non-personal care such as a shopping or housework service would be given lower priority. Some local authorities (e.g. Stirling) reported that since they prioritise assessments according to needs and risk criteria, people in care homes waiting for assessments relating to requests for FPC/ FNC are allocated a low priority for assessment since they are considered not to be at risk.
3.36 Some local authorities prioritise assessments for older people who have been referred whilst in hospital in order to try to avoid delayed discharge. Many local authorities (usually through the Joint Future Partnership) have created specialist hospital based multi-disciplinary teams to assist in reducing delayed discharge by fast tracking assessments and delivery of care to older people being discharged from hospital. (see paragraph 7.35)
Reviewing and monitoring waiting lists
3.37 In order to actively manage waiting lists, local authorities need to have a process in place for recording and monitoring their waiting lists. Four case study councils reported various measures to record and monitor waiting lists for assessments.
3.38 Argyll and Bute Council monitors cases awaiting assessment via four area based multi-agency Local Resource Review Groups that meet weekly to consider and prioritise referrals. Information from the local resource groups is collated centrally. In Dumfries and Galloway Council a monthly monitoring report indicates the number of unallocated cases which have been prioritised according to presenting needs. Stirling Council records all referrals on an electronic information system. Cases that are pending for allocation or review are managed daily and prioritised by relevant managers. City of Edinburgh Council moved from a paper based recording system to a new electronic database in 2006. Following the reorganisation of Practice Teams (April 2006), a suite of Key Performance Indicators has been developed and senior managers and the Performance Management Group routinely receive and monitor this information.
Tackling staffing capacity problems
3.39 Local authorities that claimed that staff vacancies and absences were the main reason for delays in assessments being carried out reported adopting various measures to try to tackle capacity problems including:
- Reviewing services and restructuring social work practice teams (e.g. Aberdeen City Council has re-designed services to employ extra staff as Community Care Co-ordinators whose principal role is to assess, arrange and review home based services, including personal care)
- Proactive staff recruitment and retention initiatives such as high profile recruitment adverts, offering recruitment incentives and supporting national schemes to increase graduate recruitment
- Developing self-assessment where appropriate (e.g. for carers and people requiring equipment and adaptations) as a means of reducing demands on staff undertaking assessments.
3.40 City of Edinburgh Council has taken action on all three of these areas. In 2006 it re-organised its adult services practice teams responsible for care management and created a new contact centre - Social Care Direct - as the first stop for people wanting adult care services. It has undertaken recruitment drives to increase the number of qualified social workers and has also made use of agency staff. It is exploring the greater use of self assessment for carers and people requiring equipment and adaptations. The Council claims that these measures are beginning to reduce the numbers of people waiting for assessments and bring down the time taken for assessments to be completed.
Improving the Assessment Process
3.41 There is no separate assessment process for FPC. As highlighted above (section 3.1), access to FPC is determined by the Community Care Assessment process. The assessment process has been developed to meet the needs of all community care clients, not just elderly people who may require personal care services at home or a care home placement resulting in a FPC/ FNC payment.
3.42 The SSA is the key means of reducing complexity and delay at the point of assessment, and in accessing services thereafter. In setting out minimum information standards for SSA for older people the National Minimum Information Standards for Older People states: "Service users will benefit through the delivery of better integrated, better informed services that meet their individual and changing needs." 25
3.43 Therefore the way in which SSA is operated by local authorities and their Joint Future partners is the key determinant of the speed and effectiveness with which older people's personal care needs will be assessed. Improving the assessment process for FPC is linked to improving community care assessments through the full and effective implementation of SSA, including implementation and effective use of electronic information sharing systems.
3.44 However, without accurate and verifiable data across all areas it is not possible to assess exactly how factors such as the relationship between the local authority and its NHS partner, the pace at which electronic SSA/ e-care is being implemented, and which assessment tool is used for SSAs impact on the effectiveness and speed with which community care assessments are carried out.
3.45 As highlighted above (paragraph 3.6), local authorities and their Joint Future Partnerships are using Local Improvement Targets within the JPIAF as a means of driving improvements in response times and increasing the speed and effectiveness of the assessment process.
3.46 As well as working to implement SSA effectively, local authorities that claim staff shortages are the underlying cause of delays in assessments need to continue to take appropriate action to tackle this problem. This should extend beyond staff recruitment and retention initiatives, to looking at re-designing and re-structuring services in order to increase the capacity to undertake assessments.
Summary and Recommendations
The Assessment Process
3.47 All local authorities screen referrals to prioritise assessments and ascribe target times to their completion according to factors such as risk and need. Target times for completion of assessments vary considerably across Scotland. (3.3 - 3.6)
3.48 Local authorities use a range of different assessment tools to undertake SSAs but there is no evidence to suggest that the assessment tool being used has any impact on whether/ how FPC is provided. (3.7 - 3.16)
3.49 Users and carers reported that their relationship with the professional carrying out the assessment is a more important factor in determining their satisfaction with the assessment process than the assessment tool that is used. (3.17 - 3.18)
Delays in Assessments
3.50 Although Joint Future partnerships do provide information on waiting times from first contact to first service delivery, these statistics do not provide a breakdown of the number of people who are waiting for FPC. A number of definitional and data collection issues need to be resolved before a robust measure can be provided of the number of elderly people waiting for assessments (that may result in FPC) to begin or be completed, or of the time taken to complete them. (3.19 - 3.28)
3.51 Around half of Scotland's local authorities reported operating waiting lists for assessments to be completed, mainly due to a lack of staff to meet the demand for assessments. No local authority reported that assessments are being delayed because of funding pressures on their budget for providing FPC. (3.29 - 3.31)
3.52 Some local authorities backdate the payment of FPC/ FNC to self funders in care homes if their assessment is delayed beyond their target time for completing assessments, contrary to the guidance on FPNC that states that FPC/ FNC payments should not be backdated. (3.32)
3.53 Local authorities use a number of approaches to reduce the number of people waiting for assessments and to manage waiting lists, including: screening and prioritising referrals, reviewing and monitoring waiting lists, taking a proactive approach to staff recruitment and retention, reviewing services and restructuring social work teams. (3.33 - 3.40)
Improving the Assessment Process
3.54 The assessment process works well for most people in most areas. However there are legitimate concerns about the delays in completing assessments in some areas. Full implementation of Single Shared Assessment ( SSA), the principal means by which assessments for people who might receive FPC is undertaken, should improve the speed and effectiveness with which assessments are carried out. (3.41 - 3.46)
R3.1 Local authorities and their Joint Future partners should address concerns in some areas about delays in completing assessments by developing challenging Local Improvement Targets ( LITs) for assessments and ensuring that they have the organisational capacity to meet the demand for community care assessments and their LITs.
R3.2 Local authorities and their Joint Future partners should provide clear and easily understood information about the assessment process, including target times for completion of the assessment to clients, carers and relatives.