5.Assessment and Care Planning in Health and Social Care in the UK
(This is the fifth in a new series looking at different aspects of health and social care in the UK, which I originally wrote back in 2016. I hope you find it interesting!)
Care Planning Assessment Models and Tools
“The purpose of carrying out an assessment is usually to identify levels of need or risk or to form an understanding when making first contact with the service user” (Bolger and Walker, in Lishmann, p.176, 2014). Often when assessing the care and support needs of an individual, everyday activities are identified that will benefit their lives, but also put them at some level of risk. This requires a balanced decision to be made between the needs, freedom and dignity of the individual and their safety in the form of risk assessments. Care assessments should enable people to live fulfilled lives safely, rather than be a mechanism for restricting their reasonable freedoms. For statutory organisations, a key function of assessment is a gatekeeping one, ascertaining whether services should be provided and in what form. This can lead to tension between resources and individual need, leading to stress for care managers (Postle, 2002).
Coulshed and Orme describe “assessment as an ongoing process, which is participatory, seeks to understand the service user and his/her situation and sets a basis for planning how change or improvement can be achieved” (Lishmann, p.170).
The concept of needs is a complex one, and from the outset, the care practitioner may be required to distinguish between “needs” and “wants.” Maslow in his “Hierarchy of Needs” (1943) theorised that needs could be categorised into five levels from basic physiological needs, through to psychological fulfilment or self-actualisation. Some view this model as being too simplistic. Walzer, (1983) argues that “people don’t just have needs, they have ideas about needs” (in Stone, 1995, p.165). Food, for example, has a cultural as well as physical aspect to it, this may need to be considered when looking at dietary needs.
According to Bradshaw (1972), social needs can be defined in four different ways. Normative needs are defined by care professionals, felt needs are equated with “want”, expressed needs are in the form of a demand, and comparative needs, look at service provision in different geographical areas. There can be barriers to needs-led assessment, particularly when service users are unaware of services and practitioners being unable to define their needs, possibly due to mental or communication impairments or staff being inadequately trained.
The traditional care assessment approach was the deficit model, concentrating more on what a person cannot do (i.e. people’s deficits). This “negative” approach is used when assessing eligibility for certain disability benefits.
Smale et al. (1993) offer us three additional models — the Procedural, the Questioning and the Exchange — to guide us in carrying out assessments.
The Procedural model assumes a degree of professional expertise and autonomy on behalf of the assessor. Some would argue that by using pre-coded forms, checklists and eligibility criteria, this approach has a narrow scope and may be viewed as a box-ticking exercise, concerned more with evidence gathering for the care professionals rather than individual needs. Conversely, an experienced assessor may be able to concentrate on the minimum number of questions necessary to determine eligibility and contributes to the evidence base for social work practice.
The Questioning model of assessment assumes the assessor is “an expert in people” (p. 16). This model is a traditional approach of concentrating on the “dependency needs of the individual” (p.17). Such an approach can be restrictive and oppressive, with final decisions resting on the assessor. However, if the questions are open and probing, concentrating on individual needs, this can be avoided.
The Exchange model is more person-centred, assuming that service users are the experts on themselves, becoming empowered by the assessment process, and the assessor has expertise in problem solving and promoting independence. However, this approach can be very complex and time-consuming and not all service users may be able to articulate their concerns.
Evaluation of care planning policy
Prior to the NHS and Community Care Act 1990, assessment procedures were service-led, involving slotting people into a limited range of inflexible and traditional services, with limited attempts to respond to the individual needs of people requiring support. Wide-ranging community care reforms were signalled by the White Paper Caring for People (1989) which emphasised that the primary objective was to “make proper assessment of need and good case management the cornerstone of high quality care” (Department of Health, 1989, p.5).
Modernising Social Services (1998) changed how assessments are carried out in statutory agencies. Fair Access to Care Services (FACS) was introduced in 2003 and updated in 2010 in line with Putting People First. FACS is a national framework setting out the eligibility for receiving social care support from local authorities, ensuring consistency in how needs are assessed and setting out clear objectives which promote independence. The framework associates potential risks to independence through four eligibility bands, these being critical, substantial, moderate and low. There is a review process for those deemed ineligible for social care services. However, it could be argued that tightening of budgets and restrictive eligibility criteria can shift focus from assessment of need to rationing (Parry-Jones and Soulsby, 2001, pp.441–428).
Empowerment is a stated objective for many care organisations, but service users need to exercise their power (Milner and O’Brien, 1998, p.62). ). One danger in talking about service user involvement is that it is frequently taken to mean care professionals involving service users rather than service users involving themselves. Jack (1995) further argues that “professionals use their power to protect their own interests” (p.14). Thompson (1997) is more optimistic, stating that empowerment “involves seeking to maximise the power of clients and give them as much control as possible over their circumstances” (p.83).
The “Shaping Our Lives “project (1996) argued that service users should be able to participate in drawing up their own outcomes. However, some users have some difficulty with the idea of looking at services in terms of outcomes, especially where their previous experience of services have been poor or services did not meet their individual needs and users felt disempowered (Joseph Rowntree Foundation, 2003) .
Many care practitioners take it into account that their practice is already person-centred. However, terminology and jargon can often present even the most well-meaning of care package as business-like and clinical. In the assessment process, the person’s whole situation must be considered. This can include their health, housing, income, education, training and employment; their family situation, whether there are children or young people, or other family members with care and support needs; and risks to their social inclusion and participation. Subject to everyone’s agreement, whole family assessment can enable individuals, carers and others in their family network to reach good conclusions about care and support. The views of family and significant others are crucial if a person lacks capacity to make their own decisions.
Monitoring and reviewing care plans
Monitoring is one of the most important aspects of care plans in order to comply with Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and Outcome 16: Assessing and Monitoring the Quality of Service Provision of the CQC Guidance about Compliance: Essential Standards of Quality and Safety. Regulation 16 requires care providers to have systems for regularly assessing and monitoring the quality of the services and of risks to the safety of the people who use the service. In carrying out these activities, providers must take into account service users’ views and act accordingly.
However, monitoring should be conducted in a way that minimises disruption and distress to the users’ daily pattern of living (Department of Health, 1991, p.78). Monitoring becomes easier the clearer and more specific the care outcomes are. From the very outset, any targets and objectives should be set on the basis that they are “SMART”, meaning specific, measurable, achievable, realistic and time-limited.
For many agencies, the accent of care planning is putting the plan together, with care workers implementing the care plan. The period between implementation and review tends to be a reactive rather than proactive one. How care plans are monitored and reviewed may be dependent on the model of care planning used at the assessment. For example, Essential Lifestyle Planning (ELP) focuses on a person’s life now and how that can be improved, whereas Planning Alternative Tomorrows and Hopes (PATH) focuses more on a desirable future or dream and what is required to move closer to that (BILD, 2007). Monitoring is not a sole responsibility of one individual, but may be undertaken by a care manager or a key worker. For truly person-centred care, service users should be encouraged to monitor their own care plan. External monitoring is the responsibility of the Care Quality Commission, or other accredited agencies.
Reviewing completes the assessment and care planning cycle. One of the purposes of a review is to “reassess current needs” (Practitioner’s Guide, 1991, p.84). “Policy states that the review process should look at whether services need to be increased revised or withdrawn” (Mandlestam, 1998, p.172). Reviews, like assessments should be needs-based and the scope and frequency of the review will depend upon the complexity of the need, resources invested and how much the needs are subject to change. Person-centred reviews should be “user-led and supported by the social care professional (SCIE, 2005).”
References
Bradshaw, J.R. (1972) “The taxonomy of social need”, in McLachlan, G. (ed), Problems and Progress in Medical Care, Oxford, Oxford University Press
Department of Health (1989): Caring for People: Community Care in the Next Decade and Beyond, London, HMSO
Department of Health (1991): Care Management and Assessment: Practitioner’s Guide, London, HMSO
Department of Health (1998): Modernising Social Services, London, HMSO
Department of Health (2001): Fair Access to Care Services, London, HMSO
Department of Health (2001): Putting People First: a shared vision and commitment to the transformation of adult social care, London, HMSO
Jack, R. (ed.) (1995): Empowerment in Community Care, London, Chapman & Hall
Lishmann, J. et al (eds) (2014): Social Work: An Introduction , London, Sage
Mandlestam, M. 1998: A-Z of Community Care Law, London, JKP
Maslow, A. (1954): Motivation and Personality, New York, Harper & Brothers
Middleton, L. (1997): The Art of Assessment, Birmingham, Venture Press
Milner, J. and O’Byrne, P. (1998): Assessment in Social Work, Basingstoke, MacMillan
Parker, J. and Bradley, G. (2010) Social Work Practice: Assessment, Planning, Intervention and Review (Transforming Social Work Practice), 3rd edn. Exeter: Learning Matters.
Parry-Jones, B and Soulsby, J. ( 2001): “Needs-led assessment: the challenges and the reality” in Health and Social Care in the Community, November, Volume 9, Issue 6 pp.441–428), Oxford, Wiley and Sons
Postle, K. (2002): “Between the idea and the reality: ambiguities and tensions in care managers” in British Journal of Social Work, 32 (3), Oxford, Oxford University Press
Smale, G. and Tucson, G. (1993): Empowerment, Assessment, Care Management and the Skilled Worker, London, HMSO
Walzer, M. (1983) in Stone, D. (ed.)(1997): The Art of Political Decision Making, London, Norton
Thompson, N. (1997) in Davies, M. (ed.) (2000): Blackwell Encyclopaedia of Social Work, Oxford, Blackwell
Wakefield, (2003): Shaping Our Lives — From outset to outcome: What people think of the social care services they use, York, Joseph Rowntree Foundation/York Publishing
Walker, S. and Beckett, C. (2010) Social Work Assessment and Intervention. Lyme Regis: Russell House Publications.
Worth, A. (2002) : “Health and social care assessment in action” in Bytheway, B, (eds.) Understanding Care, Welfare and Community, London, Routledge
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