1. The SAP in Gloucestershire
2. IT and the NSF for Older People SAP : IT - Help or Hindrance?
3. SAP in the New Forest PCT

Introduction
For many, it may not feel like good news yet, but who can argue with the principles and objectives of the Single Assessment Process.

That’s if the “single” means a coherent, linked, time saving, and widely understood process, rather than the “single” meaning one assessment tool for all purposes, done by anybody and for any purpose.

There is no doubt that the engagement of geriatricians and generally of specialist elderly medicine departments in the implementation of the SAP has been patchy. This was clear from the DOH’s overview, based on reports from around the country in Autumn 2002 (available on www.doh.gov.uk/scg/sap/). Other points included difficulty in engaging general practitioners, frustrations with lack of progress in information technology, and the continuing ambiguity about how much freedom local health services have to develop tools of their own. All these issues are addressed in the articles below.

In many PCTs and boroughs, the SAP has become focused almost exclusively on the Overview Assessment., and in turn, the Overview Assessment has become focused almost exclusively on the use of a specific tool. Many people involved in this process have little theoretical understanding of the assessment technology, but on the positive side, there is plenty of evidence of a willingness to reduce repetitious assessments and improve communication.

Of course many geriatricians have been involved in forms of comprehensive geriatric assessments, tailored to particular tasks, such as assessment of acute inpatients. The SAP is an opportunity to review this work, and create more explicit links and more useful information for colleagues in community and primary care. Locally, our work has involved:

• Adapting the assessments to include domains specified in SAP guidance
  
• Identifying unnecessary differences in documentation (e.g. discharge summaries) between different, related parts of the local health service such as the elderly care units and the intermediate care teams.
  
• Revamping the appearance of these assessments so that they share some of the language of local overview assessment technology, thus making it easier for the important points in the comprehensive assessment to be understood by those working at a more generic level
  
• Clarify where an overview assessment simply doesn’t do the job and comprehensive old age assessment should be employed from the outset.

For example, we used an overview assessment (Easycare) in the day hospital to assess new referrals. This proved useful to focus people on the issues, but was always too superficial to clarify treatment or care plans. Thus selective use of some of the oft neglected domains has been retained whilst core medical issues are dealt with in a more comprehensive way.

Three different focuses
Ian Donald’s account of progress in Gloucestershire shows the importance of established successful inter-agency work. Bev Castleton describes the strategy and principles underlying IT developments both nationally and locally. In Gill Turner’s piece, it is clear that developing coherent local services is the best basis to move forward to useful single assessment processes. Likewise, the single point of access to non-acute but specialist services in the community seems a crucial step in service planning to really enable single assessment process to work for patients, rather than simply generating more paper.

A broader role for our specialty
These accounts show that the SAP can be a way of bringing much needed specialist knowledge and experience into a variety of community and intermediate care settings. After a decade or more of geriatric medicine increasingly becoming the backbone of acute medical services, to the detriment of its involvement in rehabilitation and less acute work, working collaboratively on the SAP is an opportunity to re-establish the broader role of the specialty.

Finbarr Martin

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Introducing the Single Assessment Process (SAP) across the Health Community in Gloucestershire - by Ian Donald

In approaching the SAP, Gloucestershire was able to build upon its history of good working relations between health and social services, and upon their “Joint Assessment of Care Needs” document which has been used to describe people’s needs as they consider long-term care or complex packages of care at home. Social Services wished to simplify their existing forms, the joint document was in need of review, and there was a desire to integrate the RNCC assessment into the process of assessment. Gloucestershire has sustained strong pockets of enthusiasm for the Over 75 Health Check, but with a diversity of approaches and an appreciation that the benefits could be broadened if clearer links were established between the Health Check and the provision of services. Within the hospital, there has long been an appreciation that improved quality of information, early in the admission, about the situation at home prior to the present crisis, could deliver better discharge processes – but no solution had been introduced.

No off-the-shelf tool
The SAP has been the catalyst to bringing these ingredients into a new integrated assessment system. We have not chosen an off-the-shelf tool, but have developed the components we require. Within the hospital, we have made use of our universal nurse assessment tool, the Gloucester Patient Profile (see Age & Ageing 1999 Suppl 2), which has an embedded Barthel score, to define triggers for the Overview Assessment tool. In the hospital setting, the Overview captures the person’s home setting and their abilities prior to the current crisis. This provides a baseline to inform therapists in deciding about rehabilitation potential. When rehabilitation within hospital is complete, the Overview is updated, ready for transfer to the community or to the Intermediate care services.

Within the community, we have developed an 8-question screening questionnaire which can be used to trigger an Overview Assessment, both in the context of ‘opportunistic screening’ where a nurse is seeing someone, perhaps for an injection, and also within systematic case-finding of vulnerable older people. The screener can be used as a postal questionnaire, and to indicate if disability has changed.

Overview Assessment
The Overview Assessment itself amounts to a 16-sided booklet, including a 4-paged clinical section, and is frequently updated in the light of experience. It has been accepted as the principal assessment tool across the Health Community. One early success was the agreement and incorporation of the screening tools for dementia (6-CIT) and depression (GDS-4). It will reside in people’s homes, in a folder alongside nurse assessments, information leaflets from hospital etc. A short supplement has been produced to cover specific areas relevant to admission into long-term care, including the RNCC assessment. It will help ensure that multidisciplinary assessment has been thorough before admission.

Going Electronic
Finally, we hope to launch the Overview Assessment in electronic format, on a platform accessible to the 3 existing Intranets in Social Services, Primary Care Trusts, and the Hospital Trusts. No-one will be surprised to learn that IT connectivity appears more challenging than “connectivity” between staff caring for older people!

Ian Donald

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Information technology and the NSF for Older People Single Assessment Process : IT - Help or Hindrance?
- by Beverley Castleton

The Development of an Integrated Care Record Services (ICRS) is moving apace as a part of the National Programme for Information Technology. This requires a phased introduction. It is not planned for the full implementation of the shared record services to be in place until 2008.

The National Health Services Information Authority (NHSIA) has appointed a group to address the further development and implementation of the information strategies of the various National Service Frameworks and how they link to the ICRS.

This NHSIA Information Strategy Group has 6 Clinical Coordinators (one for each of the NSF published thus far). I was seconded in August 2002 to be the Clinical Coordinator for the Older People’s NSF. I also have a link into the Department of Health Information Strategy for Older People Advisory Group and the Implementation Team, and I am the Chairman of the External Reference Group of Clinicians that advises on the Datasets developments.

There is a need to ensure that Information Policy and Strategy links with health changes, and the close working of the clinicians with those developing the technical side of the IT programme, is most encouraging.

In developing the strategies for the NSFs there are national issues, which need to be addressed within the NHSIA, and there are more local actions, which require major process change.

Information flows require the relevant technology support and nowhere, in the NSF for Older People, is this more important than in the development of the Single Assessment Process (SAP). However, waiting for the full ICRS programme is not an option. Getting the care pathways worked out; process mapping the work flows; agreeing common language; adopting agreed information sharing protocols; and working on the cultural differences, are pieces of work that need to be done if we are to get the SAP underway by April 2004.

To support this development of the SAP, the NHSIA Datasets Group has been working intensively on the data format for the Personal Information, Contact Assessment and the Summary Assessment. There is already draft guidance available on the content of these forms on the DOH SAP website. Although these datasets have to be piloted and refined, and finally signed off by the Information Standards Board, major changes to the data definitions are not contemplated.

Transitional Options for IT support for the SAP are being piloted using web browser technology. This should achieve connectivity between the GP systems, Community systems, Acute units, Mental Health Services, Social Services, and District and Borough Councils.
In my local area we are embarking on one of the Framework for Multi-agency Environment (FAME) projects funded by the Office of the Deputy Prime Minister, promoting the independence of vulnerable older people. This project will be scoping the processes necessary to get the SAP underway, and the IT support to improve the information flow.

The implementation of the SAP is a huge undertaking requiring resources, skills and a degree of joint working. This will require major cultural changes to take place. The sharing and timely flow of information is crucial to the process. The Education and Training programme that underpins the implementation of SAP will be massive. The ICRS development will be a catalyst for change, should improve processes and thus release time for the joint training that is needed and time to cascade knowledge effectively. IT is a help not a hindrance, a friend not a foe!

Beverley Castleton

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Single Assessment Process in the New Forest PCT
- by Gill Turner

Firstly, it is important to say, we have not implemented the Single Assessment Process in the New Forest yet. However, we have every expectation that we will have most of the systems and processes in place for April 2004.

Background
As always, it is probably worth describing our local service in terms of its strengths and constraints. This may put into context the decisions we have subsequently made.
The positive features about the New Forest PCT are that we had already made a strategic decision to move to a locality team model of service. This means that (eventually!) there will be ‘patch based’ teams of rehabilitation therapists, geriatricians, social services care managers, CPN’s and community nurses working with specific communities of patients and relating to specific general practices. Many of the discussions arising out of our locality team implementation have been entirely relevant to the implementation of the SAP.
Secondly, although for convenience, all the geriatricians working in the New Forest are employed by, and also work in, the acute trust, there has never been anything other than full participation by those in the community based services (whoever ran them - community trust or PCT).

Thirdly, we had been considering for some time, the need for a ‘screening and prevention’ strategy. The Single Assessment process was seen by the geriatricians as a route to achieving this and was eagerly seized on.

On the other hand, the local constraints are that the New Forest PCT is seriously broke! Implementing the SAP means employing a whole new project management team and investing in a costly IT solution. This does not mean that we don’t want, one day, to consider and invest in a tool, but we are keen to sort out the processes first. In addition PCT patients are admitted into 3 local acute Trusts and we are right on the edge of the Strategic Health Authority (SHA) area, so we weren’t sure that the guidance we received from them would be relevant to all our providers.

Finally, the New Forest PCT was in the unfortunate situation of not just having no community based information system, but inheriting an extremely poor system which is currently being decommissioned, and which has no relevance for the Single Assessment process.

What we’ve agreed so far
So what is to be done?

Firstly, one of our senior OT’s has volunteered to lead this process and to be a project manager, which she does for 10 hours a week (as well as being a team leader). She set up a clinicians and practitioners’ group which is examining and developing the processes. This group also led the pilot locally, of one of the national tools which I will describe later. There is also an SAP steering group which is a sub group of the Older Person’s strategy group of the PCT. This steering group is chaired by a geriatrician.

Step by step to an SAP
Between the two groups, we’ve decided to make the Overview Assessment our main goal initially, and we are working to merge this with the initial multidisciplinary assessment currently used by our community rehabilitation teams. We are examining the assessments used by all future members of the locality teams to consider areas of overlap before developing them into one single overview assessment, which will be used by whichever agency is approached first, or has the first referral. Obviously when the locality teams are formed and there is a single point of access for older people, this will be easier, but until then we are looking for convergence so that similar responses and actions will be taken after a similar positive pointer in the Overview Assessment. In other words the expectation is that if urinary incontinence, for example, is revealed in the Overview Assessment done by a social worker, the same action will be taken as it would be if the same symptom was revealed by a physiotherapist.

For most of the rest of this article I will use the word locality teams on the understanding that until they are formally in place, this is shorthand for any professional using the standardised Overview Assessment, who will become a member of the locality teams when they are formed.

If in doubt, file it!
As part of this work, the clinicians and practitioners group decided to pilot one of the National Tools on a small scale, using patients referred to our local rapid response team. We were keen to consider patient held records as part of the pilot and thus emphasised that patients being referred to other specialists should take the Overview Assessment with them for reference. Sadly our enthusiasm is not matched locally by the orthopaedic surgeons, who simply filed the assessment, dutifully brought to the clinic by a patient, since they had no idea what it was all about!!

Other feedback from the local practitioners was that the tool was not as rich in content as they would want an assessment to be, but that nonetheless it was quite cumbersome.

In summary, we have not yet therefore sorted out our local cut on the Overview Assessment but we know what we want.

Getting the GPs on board
The second issue we needed to grapple with was how we got the GP’s on board. We knew that realistically, GP’s were unlikely to do Overview Assessments and have therefore made the policy decision that all the Overview Assessments will be done by a member or potential member of the locality team. Thus, a GP or practice nurse who is concerned about an older person who appears to have more problems than the initial contact assessment has revealed, or who has one of the locally determined ‘trigger’ problems, can simply refer to the locality team for the overview assessment and onward referral. Plainly this begs the question of what happens to a patient who is referred by their GP to a hospital specialist for one problem, but who also has other issues which should have triggered an Overview Assessment. If the specialist is a geriatrician, the Overview Assessment will be done by us (possibly meaning a change in practice by us - the implications of which I am not sure we have taken on board). However, of course if the specialist is a urologist, for example, we have to think of other solutions. We are considering the implications of empowering the outpatient nurses to do Overview Assessments, or at least to refer people to the locality teams so as to reduce the number of people who fall through the cracks.

Specialist and summary assessments
We have no rules about the specialist assessment locally. However, we will be asking that a plain English, single paragraph summary of any specialist assessment and plan is produced, and this will also be available on the website together with the associated overview assessment. We have not yet made much progress in the implementation of this plan. Eventually when we have the appropriate resources to implement a mega IT solution, the summary assessment (as directed by the DoH) will be the one published on the website – at the moment we don’t have the capacity to do this.

Inpatients
Finally, there is the question of inpatients. Plainly there is a need for a two way process here. The nurses on the wards looking after older people who are already known to the locality teams need access to information we have already gathered, but also we need to access information which they and other health care professionals have gathered as part of their in patient assessment.
For sharing information ‘inwards’, we are looking at using the PCT website to post the overview assessment (with appropriate confidentiality protection of course) so that it can be accessed by any care professional, but not updated – that will have to be done by the locality team base. We have not yet worked out how information from assessments done in hospital will be moved outwards to be shared with the locality teams. However, since one of the service strategies of the locality teams is to operate an inreach service (for home visits, etc.) this may not be such a problem.

What is untenable for inpatient teams is that they have to use a different assessment tool for each PCT’s patients – however that remains a risk since even if we do adopt our host SHA decision (which is not yet made), we abut three SHA’s. (Sometimes one wishes for a little more guidance from on high!). However, we believe this vindicates our decision not to go with a specific off the shelf ‘tool’, but instead, to go with an intuitive assessment.

Still to be done
Anyone reading this could be forgiven for wondering if we’re seriously deluding ourselves about setting this up by next April. However, we still feel optimistic since we have spent the majority of our time working out how all the processes and different types of assessments will fit together. I believe that this is the most important bit to get right, and I am also sure that geriatricians need to be in there helping to sort it out. Certainly as a geriatrician, my motivation for this process is about ensuring people don’t slip through the net, rather than getting bits of paper nicely aligned. We have full sign-up by a lot of coal face staff, and we know that there are complicated older patients whom the GP’s and practice nurses don’t really know what to do with - the SAP provides a simple process to solve this. There are also real anxieties about the amount of unmet need we will uncover, but as we all know,
today’s unmet need in the community is tomorrow’s emergency admission, so it seems pointless not to at least try to tackle it.

Perhaps we’ll be able to update you in a year.

Gill Turner

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