HHD/DGM (1991) 40

17 June 1991

Dear Sir/Madam

COMMUNITY CARE IN SCOTLAND

ASSESSMENT AND CARE MANAGEMENT

Summary

1.1 This circular contains guidance for local social work authorities and Health Boards on the assessment of the individual needs of adults for community care services. Arrangements for assessment need to be set within a system for care management and the circular also provides general guidance about care management.

1.2 Arrangements for addressing children’s care needs, including those of disabled children, are provided for in the general duties in section 12(1) of the Social Work (Scotland) Act 1968. The assessment of disabled children under section 13 of the Disabled Persons Act 1986 and the Education (Scotland) Act 1980 will need to relate to assessment arrangements for adults, in order to ensure a smooth transition for those requiring care both as children and as adults.

Background

1.3 New statutory requirements in relation to the assessment of individual needs for community care services are contained in section 55 of the National Health Service and Community Care Act 1990 which introduces a new section 12A into the Social Work (Scotland) Act 1968. The Secretary of State intends to implement section 55 by 1 April 1993. This circular is issued now to provide a framework of guidance within which all agencies can prepare fully in advance of new arrangements for assessment and care management coming into operation.

1.4 The Secretary of State does not intend to prescribe in detail how assessment and care management should be carried out. That can be achieved more effectively at local level and social work departments will have the lead role in setting up such arrangements which will involve other providers of care, especially Health Boards and housing authorities, and also voluntary and private organisations.

1.5 A practice guide on care management and assessment will be issued later this year. This is intended to assist local authorities, Health Boards and other agencies in establishing detailed arrangements for assessment and in developing effective methods of care management.

1.6 Assessment and care management take place in the wider context which will be descried in community care plans. In these plans local authorities and Health Boards, in consultation with local housing authorities, should determine their objectives and priorities within the resources available and should establish collaborative working arrangements which also include other housing agencies and voluntary and private organisations. Planning should be responsible to the findings of individual assessments which should inform future decisions about service provision. Local authorities are expected to include in their community care plans their proposals for assessment and care management. People engaged in assessment and care management should be fully appraised of the wider fieldwork.

1.7 Guidance on the role of housing in relation to community care is given in a joint circular (SWSG7/94, Env 27/1994, NHSMEL(1994)79).

2. Statutory Requirements

2.1 Section 12A of the Social Work (Scotland) Act 1968 will require local authorities to assess the need for community care services of any persons who appear to them to require such services and decide, in the light of the assessment, whether they should arrange any services and, if so, which services. Local authorities will be required to notify the Health Board or housing authority if it appears that there are services in either of these fields which the relevant agency may be able to provide.

2.2 Health Boards have a continuing responsibility to meet health care needs. They are required to co-operate with local authorities in the exercise of their respective functions which now extend, in the case of local authorities, to the assessment of need for, and provision of, community care services. Social work authorities will also be required by section 12A of the 1968 Act to consult a medical practitioner before deciding that a person’s needs call for the provision of nursing care.

2.3 There are particular requirements in section 12A of the 1968 Act in connection with the assessment of persons who are "disabled" within the definition in the Disabled Persons (Services, Consultation and Representation) Act 1986. These are dealt with in paragraph 10.

2.4 Section 12A of the 1968 Act enables local authorities to provide services without a prior assessment of needs if, in the opinion of the authority, services are required as a matter of urgency. When this happens an assessment should be carried out as soon as possible thereafter.

3. General Principles

3.1 Local arrangements for assessment and care management should:

- enable people to live as normal a life as possible in their own homes or in a homely environment in the local community;

- provide the right amount of care and support to help people achieve maximum possible independence and, by acquiring or requiring basic living skills, help them to achieve their full potential;

- give people a greater individual say in how they live their lives and the services they need to help them to do so;

- promote partnership between users, carers and service providers in all sectors;

- ensure that the resources available are used in the most effective way to meet individual care needs.

3.2 These principles are not new. They are widely held to underpin good social care practice. The Secretary of State would like to see them implemented more widely so that the best of current practice becomes the norm which service users can expect to encounter when their needs come to the attention of social and health care agencies.

4. Care Management

4.1 Care management is a process of relating services to individual needs. It is founded on a needs-led approach to the provision of community care. It aims to respond appropriately to individual needs by enabling consideration of a range of options and by making effective use of available resources through concentrating on those people who have the greatest needs. Care management is generally considered to include the following tasks:

- identification of persons who appear to have community care needs;

- assessment of care needs for the individual;

- planning and arranging the delivery of care;

- monitoring and quality of care provided;

- review of individual care needs.

Assessment is therefore one key element of the wider process of care management.

4.2 Care management is a separate process from service provision and the two types of activity need to be distinguished. Care management involves carrying out the tasks listed in the previous paragraph. It can be seen as a system of brokerage for obtaining for individual clients the most suitable and cost-effective services from the statutory, voluntary and private sectors. Effective care management requires that the tasks outlined in paragraph 4.1 are carried out in ways that are determined by clients’ needs and not by the services which happen to be available. The evidence from care management projects indicates that this is accomplished best where budget management is devolved as far as possible to the point of decision making about the care to be provided.

4.3 Although the tasks of care management and service delivery are different it will be neither practicable nor appropriate for them to be carried out by different staff in all circumstances. There will be advantages to such an arrangement in complex cases and in these situations the appointment of a specific care manager is likely to be of value. Care

managers, where they are responsible for a devolved budget, can be seen as agents acting on behalf of purchasing bodies, ensuring that the most appropriate services are secured for the individual within available resources.

4.4 The skills required of care managers may be found in a number of professions and will vary according to the needs of service users and the model of care management that is adopted. Care managers need not be employed by a statutory authority. For instance staff in voluntary bodies may be well qualified for the role where service users have highly specialised needs. Where a care manager is not appointed service users and carers should be informed of the name of a nominated worker who will act as the primary point of contact in resolving any difficulties over service provision.

4.5 The development of care management will take place over a number of years and will be informed by the experimental projects which are now being established. The subject is explored thoroughly in the forthcoming practice guide which will help local agencies to consider how the core tasks of care management and service provision. The Secretary of State does not wish, at this stage, to issue further definitive guidance on the care management process as a whole. The remainder of this circular therefore concentrates on two of the particular core tasks of care management: assessing individual needs and deciding what care should be provided. These are the two tasks identified in section 12A of the Social Work (Scotland) Act 1968.

5. Key Features of an Assessment System (for individual needs for community care services)

5.1 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.

5.2 There should be an initial screening process to verify that the presenting problems lie in the field of community care and, if so, identify any basic needs and determine the appropriate form of response. Some people may need advice and assistance which requires no further assessment; others may require a limited or specialist assessment of specific needs; others may have urgent needs which require an immediate response. Procedures should be sufficiently comprehensive and flexible to cope with a wide variety of need presented in many different ways.

5.3 Assessment systems should ensure the participation of the individual and his or her carer. The wishes of both should be taken fully into account and, where they conflict, be considered separately. Individual choice should be based on adequate information about the different forms of care which may be available. It will often be appropriate for representatives to be invited by the user or carer to contribute to the assessment process on their behalf.

5.4 The assessment process should embrace physical, mental and social functioning. It should take into account the wishes of users and carers; their capacity for self-care; possibilities for arranging informal care; particular risk factors; abilities and life-style; and social support, health and accommodation needs.

5.5 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. Elaborate systems will not be helpful or appropriate for people with relatively straightforward needs. Procedures should be sufficiently comprehensive and flexible to cope with all the various kinds and levels of need which might be presented.

5.6 Assessment procedures should be readily accessible to all potential service users and their carers. Decisions about service provision must be non-discriminatory and should be seen to be so. People with communication difficulties whether due to sensory impairment, mental incapacity or other disabilities should be able to participate in the assessment process. Assessment should also be accessible to people from minority ethnic backgrounds.

5.7 The outcome of assessment should be a clear decision about what services are required to meet needs and by whom they could be provided. This should be recorded in a systematic way.

5.8 The assessment should conclude with an indication of how and when review will take place.

5.9 Users and carers should be informed of the conclusions of an assessment. The name of an individual to contact for any further discussion of the assessment should be given.

5.10 Information about the local authority’s complaints procedure should be provided so that users and carers know how complaints and representations about the assessment can be made.

6. Individual Care Plans and Decisions about Service Provision

6.1 The second care management task covered by the new statutory requirement is deciding what care should be provided. Once an individual’s needs have been assessed, the objectives of any intervention and the services to be provided or arranged to meet needs should be agreed by all the professionals involved in the form of a care plan. In drawing up the care plan the availability of resources and services for meeting needs will have to be taken into account. The care plan should describe in plain language the decisions reached about the individual’s agreed care needs, the desired outcome, what is going to be done, by whom and when, who is to be the responsible care manager and what are to be the arrangements for monitoring and review. This information should be conveyed to users, carers and all other agencies involved, taking account of the constraints of confidentiality. A written statement will normally be needed if a continuing service is to be provided. Written statements should always be supplied on request.

6.2 The objective of ensuring that care provision should as far as possible preserve or restore normal living implies an order of preference in the choice of services to be considered. The aim should be to provide support for the person in their own home, which might include periods of respite care, or the provision of equipment or physical adaptations. A move to more suitable accommodation, possibly in the form of supported accommodation or sheltered housing, together with social support, might be an alternative possibility. Admission to residential care, nursing home care and long-stay hospital care should only be considered where the person’s particular dependency needs require the kind of intensive care available in that type of setting.

6.3 In deciding which packages of care should be provided account should be taken of the preferences of users and carers and of the costs of service options and budgeting information. It was necessary to strike a balance between meeting the needs identified within available resources and meeting the care preferences of the individual.

6.4 Where an agency has agreed during the assessment process to provide a service it will be expected to deliver that service. There should be no commitment of any agency’s resources without the prior agreement of that agency.

6.5 Where it is not possible to meet all assessed needs for community care services, information about the nature and extent of the unmet needs should be fed into the authority’s community care planning process. Where it appears from individual assessments that there might be unmet need for the services of another agency, for example health or housing, that agency should be notified to enable it to make an assessment and take account of any shortfall in its own planning. Agencies will need to assess the effects of any shortfalls in relation to other priorities.

7. Published Information

In order to help users and carers to exercise real choice and to participate in the assessment of their care needs and in the making of arrangements for meeting these needs, local authorities should publish information about their care services and assessment procedures. This should be expressed in simple, plain language and should be readily understood. Information should be available in braille and languages other than English. The information should be compiled in consultation with Health Boards and housing authorities and other service providers. It should cover residential care homes, nursing homes and other community care facilities available in all sectors. The full range of information should include the authority’s criteria for determining when services should be provided; it should describe the assessment procedures, showing how and where to apply for an assessment; and it should give information about how to make representations and complaints.

8. Role of Users and Carers in Assessment

Most support for vulnerable people is provided by families, friends and neighbours. The overall provision of care should be a shared responsibility between informal carers and the statutory authorities. The relationship between them is one of mutual support. The assessment will need to take account of the support from informal carers that is available. The future availability of informal care and the preferences of carers should be taken into account. Both users and carers should therefore be consulted, separately if either of them wishes. The care plan should be the result of constructive dialogue between users, carers, social work staff and those of any other agency involved. Representatives or advocates may be included if that is the wish of a user or carer.

9. Carers’ Own Needs

The position of carers should be taken into account alongside the needs of the person who is the subject of the community care assessment. The level of support that could reasonably be expected from carers will vary and the social work department should take into account what support and assistance they require. Carers may sometimes have needs of their own for community care services. These may become apparent in the course of an assessment of another person with whom they are directly involved or they may come to attention separately. Any such needs should be the subject of a separate assessment. It should be made clear to carers that they can ask for such an assessment of their own needs.

10. Rights of Disabled People

In accordance with section 12A of the 1968 Act if the person being assessed is found in the course of his assessment to be disabled the local authority must so inform the person, advise them to their rights under the Disabled Persons (Services, Consultation and Representation) Act 1986 as it currently applies and, as required under section 4 of the Act, make a decision as to the need for any service identified in section 2(1) of the Chronically Sick and Disabled Persons Act 1970. If a need for a service defined in section 2(1) is established the authority is required in terms of that Act to make arrangements to meet it. Any assessment of a disabled person under section 12A of the 1968 Act will then extend automatically to the range of possible needs listed in the 1970 Act.

11. Charges for Services

Separate guidance will be issued in due course on the powers and duties of local authorities to charge for social work services (including community care services). This will cover the statutory requirements in section 22 of the National Assistance Act 1948 for residential and, in due course, independent nursing home care, as well as the discretion afforded to authorities under section 87 of the 1968 Act for other social work services. The underlying principle will be that local authorities should institute arrangements for users of services of all types to pay what they can reasonably afford towards their costs. But the provision of services, whether or not the local authority is under a statutory duty to make provision, should not be related to the ability of the user or their families to meet the costs. The assessment of financial means should, therefore, follow the assessment of need and decisions about service provision.

12. Involvement of Other Agencies

12.1 The local authority’s legal responsibility will be to ensure that needs for community care services are assessed. However the aim of assessment should be to ensure that all the needs of an individual for care services are considered. Assessment may identify a wide variety of actual or potential needs such as for personal care, health care, meals, visits, counselling, help with domestic tasks, transport, financial affairs, accommodation, leisure pursuits, employment, education and assistance for carers. Assessment of these needs will require the involvement of other agencies, particularly local housing authorities and Health Boards. The health service contributions can be made by medical and nursing staff and from other professions such as occupational therapy, speech therapy and psychology.

12.2 The local authority has the lead responsibility for securing the involvement of other agencies in the assessment procedure in order to decide what should be done, by whom and when. Other agencies will have to make available the staff needed for assessment and will have to implement their own contribution to packages of care which they have agreed to deliver. All relevant agencies should be involved in he assessment and subsequent decision taking process before commitments are made. Section 12A of the 1968 Act requires the local authority to take action to ensure that any person’s need for health or housing services which may come to their attention in connection with an assessment for community care services is brought to the attention of the Health Board or housing authority as the case may be. When carrying out their own assessment the local authority is required to have regard to any information it may receive from the Health Board or housing authority in return.

12.3 Education services are also provided by the local authority which holds social work responsibilities. Social work departments should ensure that any apparent needs for education services which come to attention during a community care assessment are communicated to the education department.

12.4 When a service user has complex needs it may sometimes be necessary to call together the professional staff concerned for a case conference. The person whose needs are being considered and their carers should be invited to attend. It should often be possible to conduct consultations in writing or by telephone (with a written record) to avoid delay and limit the demands on scarce professional time.

12.5 It is essential for local authorities to establish clear links at local level with other agencies for the purposes of co-ordination of assessment arrangements generally and in order to enable decisions to be made expeditiously. Social work departments should recognise that the assessment process which they originate may be used by other agencies to assist them in fulfilling their statutory responsibilities. Assessment of individual needs for community care services can quite properly be combined with such assessments provided that the various stages of local authority assessments provided that the various stages of local authority assessments outlined in this circular (including the involvement of the service user and carer and sharing of the results of the assessment) are followed. The assessment of patients about to leave hospital is a specific issue and is covered further in paragraph 15 below.

12.6 Where a standing arrangement for inter-agency co-operation exists (eg a mental handicap or other inter-disciplinary team) it may not be necessary for the local authority with its community care responsibilities to institute new or separate arrangements for the handling of assessments on that account.

13. Assessment for Nursing Care Needs

13.1 Health Boards have a continuing responsibility to meet health care needs and can therefore continue to make contractual arrangements for nursing home placements. It is a specific requirement under section 12A of the 1968 Act that a medical practitioner should be consulted whenever the provision of nursing care is being considered. This will therefore include cases where admission to a nursing home is in question. Appropriate medical and nursing advice should always be sought in an assessment which is considering whether an individual’s needs call for residential or nursing home care.

13.2 For people who need nursing care, agreement will be needed between Health Boards and local authorities about the services which should be provided. Agreement will be necessary with medical and nursing staff on whether an individual’s needs for nursing care can be met through the provision of community nursing care, or require the purchase of a place in a nursing home, a residential home or admission to hospital.

13.3 Health Boards have been involved in the financing of nursing home placements in the past. It will be important for local authorities to be clear about the Health Board’s criteria for funding placements in nursing homes so that questions relating to funding responsibilities in individual cases can be resolved independently of the process of community care assessments.

14. Urgent Admissions to Residential or Nursing Home Care or to Hostels

Under the Act, services may be provided without assessment in cases where they re required urgently. Urgent admissions to nursing homes do not require consultation with a medical practitioner. Authorities will need to negotiate arrangements for emergency care. Voluntary and private agencies providing such services on behalf of statutory authorities should be informed what resources they can commit and for how long without reference to the authority. Assessment must be carried out as soon as possible afterwards.

15. Hospital Admissions and Discharges

15.1 Decisions about admissions to an discharges from hospital require the closest liaison between all the agencies providing services to a particular patient. It is clearly undesirable that anyone should be admitted to hospital or remain there when they can be cared for more appropriately in a different setting. Before a patient is admitted to hospital all the agencies involved in providing care for the patient should consider collectively whether appropriate community-based facilities could be provided within the timescale which meets the needs of the patient.

15.2 Similarly, in the case of patients in hospital, all the agencies involved with a particular individual need to consider from an early data the services that he or she will require at the point when they can be discharged back into the community and what the likely date is of their discharge. The aim should be to ensure that patients do not leave hospital until at least the essential community-based services that they will need on discharge have been agreed with them, their carers and all the agencies concerned and can be provided at the point when the clinical judgement is that the patient is ready to be discharged from hospital. In order to achieve this aim, all those involved in the care of a patient once discharged to the community will need to know as well in advance as possible what services they are expected to provide to that patient and from when. Local assessment arrangements will therefore have to be devised by local authorities, in co-operation with other agencies, to enable this to happen. Under the new arrangements the responsibility for assessing and meeting needs for community social services rests with the social work department. This will include persons seeking nursing home care other than those receiving continuing care from the NHS under arrangements made by Health Boards with the nursing home and for which the Health Board takes financial responsibility. In practice, decisions about what care an individual needs following discharge from hospital should be taken in the context of a full assessment of that person’s care needs, involving case collaboration between local authorities and Health Boards.

15.3 Specific guidance on hospital admissions and discharges for people with a mental illness will be given in a circular to be issued in 1991 about the care programme approach for such people. This circular will also cover other people seen by the specialist psychiatric services who require structured arrangements for health and social care.

16. General Medical Practitioners

16.1 Local authorities will need to agree with Health Boards how to promote the important contribution of general medical practitioners to the assessment of need. They should together ensure that general practitioners are given sufficient information on assessment procedures to enable them to be involved effectively in this process and to advise patients. Health Boards should consult local representative committees of general practitioners as necessary.

16.2 It is expected that, as a matter of good practice, general practitioners will wish to make a full contribution to determination of their patients’ needs. It is part of GPs’ terms of service to give advice to enable patients to avail themselves of services provided by the local authority. Where advice is needed by the local authority in the course of assessment, this should normally be possible to obtain without the need for a meeting. A record should be kept of the advice given. In addition to the information that only the patient’s own GP can provide, local authorities may, on occasion, also require a clinical examination or an interpretation of the medical report provided by the GP. Local authorities should, therefore, be aware that GPs have a personal duty to and a relationship with their patients and may not be best placed to act in addition as an assessor on the authority’s behalf. In such circumstances local authorities may wish other practitioners, including hospital-based consultants, to act in this capacity.

17. Role for Independent Agencies in Assessment

Voluntary organisations may be involved in the assessment process either by undertaking assessments in specialised fields on behalf of local authorities or through individual professional workers who have a particular contribution to make because they have specialist knowledge or have an existing or prospective involvement in the provision of care. Where the provision of a community care service is undertaken by a voluntary body on behalf of the local authority it must be clearly established whether their role extends into the field of assessment and if so what discretion they are entitled to use in reaching decisions to provide services to individual people on the local authority’s behalf. It should be clear however in all such arrangements that the ultimate responsibility for reaching decisions on service provision has to remain with the local authority.

18. Sharing Health and Social Work Information

Effective assessment and care management will be promoted if agencies can exchange and share information about community care needs at both individual and service-wide levels. The development of such arrangements must be governed by the detailed guidance which currently exists to ensure the confidentiality of such information. This is contained in Circulars SWSG1/89 and NHS 1990(GEN)22. Account must also be taken of guidance on the disclosure of personal information under the Data Protection Act 1984 in Circulars SWSG8/87 and SHHD/DGM(1987)49 and under the Access to Personal Files Act in Circular SWSG2/89.

19. Review of Individual Care Needs

19.1 Individual care needs, for which services are being provided, should be reviewed at regular intervals. In order to preserve the needs-led approach it would be preferable for this review to be undertaken by someone who is not involved in direct service provision (such as a care manager). This is particularly advisable where the review relates to complex needs. The projected timing of the first review should be stated in the original care plan. However, reviews should take place earlier if it is clear that community care needs have changed. It may be necessary also to review services already being provided before introducing new arrangements.

19.2 The purpose of review is to establish whether the objectives in the original care plan have been met and to adjust services accordingly. Reviews should take account of any changes in needs or service delivery policies. They should also monitor the quality of services provided and, in particular, note the views of service users and carers and any changes in their wishes or preferences. These views should be fed back into service planning, together with any identified shortfalls in provision.

19.3 The type of review will vary according to need but all those involved in the original care planning should be consulted. Large-scale review meetings should rarely be necessary. All relevant agencies, service users and carers should be notified of the results of the review, subject to the same constraints of confidentiality as the care plan.

20. Suggestions and Complaints

Decisions on service provision should be reached in discussion with users and carers and every effort should be made to ensure that the result is acceptable to them. A formal judicial appeal procedure would be foreign to such arrangements and it would not be appropriate to introduce one. The local authority’s published information about the assessment process should indicate how to make representations or complaints about a service or refusal of a service or any aspect of the assessment system. Separate guidance on the complaints procedure which the Act requires local authorities to establish is contained in SWSG Circular SWSG5/91 issued on 20 February 1991.

21. Staff Training

Staff involved in assessment and care management should be properly prepared for these tasks and many will require particular help to adjust to the needs-led approach. Multi-disciplinary training and training with staff from other authorities will help to build mutual confidence and encourage working together. In-service training will be needed to consolidate and develop the skills of existing staff at both vocational and professional levels. Future basic, qualifying and post-qualifying training arrangements should reflect the need for skills in assessment and care management, particularly in developing imaginative care packages and involving users and carers.

22. Action

22.1 When the community care arrangements are fully implemented local authorities will need to have in place:

- arrangements for assessing all individual community care needs including arrangements with other agencies for determination of how these needs should be met;

- arrangements for communicating the outcome of assessments and decisions on service provision to applicants and carers and other participating in the assessment process;

- arrangements for regular review of individual care needs and any necessary revision of services provision;

- an information system to support the assessment process and feed back information on individual community care needs into the planning system;

- published information accessible to potential service users and carers on assessment procedures, types of community care services available, and criteria for provision of services.

22.2 Local authorities should progressively refine their arrangements for assessment of need in accordance with the principles in the White Paper "Caring for People" and in this guidance. They should also progressively introduce arrangements for carrying out the tasks involved in care management with supporting budgetary frameworks, and include their proposals in their published plans.

22.3 Health Boards will need to secure arrangements for:

- staff to be made available to contribute to local authority co-ordinated assessment of individual care needs;

- information on individual care needs to feed back into the NHS planning system;

- care managers to be appointed (where appropriate) from health care staff;

- the provision of the appropriate health care and the communication of decisions to the Social Work Department and to care managers;

- review of individual health care needs and revision of service provision.

23. Enquiries about the terms of this circular should be addressed to Mr N Rennick, Social Work Services Group, Room 52, James Craig Walk, Edinburgh EH1 3BA

(telephone 0131 244 5389).

Yours faithfully

N G CAMPBELL G SCAIFE

Under Secretary Chief Executive

Social Work Services Group NHS in Scotland