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The Single Assessment Process (SAP) was formally introduced in England from April 2004, although separate but similar processes apply elsewhere in the United Kingdom.

It was intended to improve the assessment process for older people by reducing duplication and ensuring that each professional contributes to the care a person receives in the most effective way. The policy has generated widespread debate including: concerns about the speed of local implementation; the nature of the guidance from central government; the readiness of information technology to support assessments and information sharing; and the perennial issue of lack of funding to promote additional training and shared processes among staff.

A national survey
At the Personal Social Services Research Unit (PSSRU) at the University of Manchester, we have recently completed a national survey describing the involvement of geriatricians in the SAP.

A questionnaire was sent to all consultants specialising in geriatric medicine in England, identified from a database drawn from the membership list of the British Geriatrics Society. We would like to thank both Peter Crome and Ian Philp for their advice and assistance. The questionnaires were sent to respondents in October 2005, over 18 months after formal implementation of the SAP. Three hundred and eighty two geriatricians (49%) returned completed questionnaires which were designed to elicit their views on the SAP in five areas of information, reflecting processes likely to be important in judging the impact of the policy.

Assessment: its content and process
The SAP is expected to change the way assessments are conducted across health and social care. Assessments by multiple professionals are intended to be brought together, often by the use of electronic information, and it is anticipated that that this will involve closer multidisciplinary working and information sharing. However, only 36% of geriatricians informed us that the introduction of the SAP had altered their assessment practice to an appreciable degree, with most citing changes in the types of paperwork required as the major impact. Some respondents suggested that the SAP was still in a pilot phase although better co-ordination across health and social care did exist. Delays in implementation were often attributed to difficulties associated with the introduction of an electronic patient record. There was a general concern that a concentration on changes to paperwork had led to a lack of attention being given to other implementation and information sharing mechanisms.

Standardised assessment tools
The Department of Health guidance identifies the use of standardised assessment tools, to support professional judgement, as a key component in agreeing a common approach to assessment. Specialist clinicians in particular are signalled as playing a crucial role in selecting assessment tools for use in ‘specialist’ or ‘comprehensive’ assessments. The overwhelming majority of geriatricians reported using standardised measures as part of the assessment process with almost a quarter using at least one of the formally accredited SAP tools – Easycare being the one most frequently used.

Service integration
An integrated approach to the assessment of older people is one of the core aims of the SAP. It is expected that if services are delivered in a ‘joined-up’ and integrated fashion then this will improve patient care and result in more appropriate and timely interventions. There was felt to be a varied impact of the SAP in this area. The existence of a single care plan, containing details of all staff/agencies’ inputs into an older person’s care, was reported by 62% of geriatricians. Over half of geriatricians worked with social workers as core members of the multidisciplinary team and also reported the use of multidisciplinary single case files for in-patients, although these were less commonly used for community patients. However, only just over a quarter of those surveyed reported using the same structured assessment documentation across their team and only a minority were aware of a shared record system operating with social services.

Patient involvement
Involving older people in the assessment process is one aim of the SAP, noted in the National Service Framework for Older People. Placing the older person at the heart of assessment is expected to give them a voice with which to exert greater influence over the care they receive. We found that geriatricians were less involved in this aspect of the SAP. Around a quarter of geriatricians reported that patients routinely received copies of their care plans and/or clinical letters and only about a fifth reported that their patients received a copy of their SAP documentation with a summary of needs identified and agreed actions. Almost half of the geriatricians surveyed did not know whether or not this was the case in their locality.

Training and involvement
Involving clinicians in supporting implementation of the SAP, including training on assessment, were key objectives voiced in the guidance. In this area, we found that just over a quarter of geriatricians were members of a Local Implementation Team for the National Service Framework prior to the SAP. Only 20% of geriatricians had been actively involved in the development of the SAP whereas 40% reported that training on assessment had been provided. Of these, however, only 22% of consultants had taken part. The largest professional group seen as taking part in training were nurses followed by occupational therapists. Just over a quarter of geriatricians used information from assessments for the purposes of their Clinical Governance arrangements.

Where do we go from here?
It is tempting to think of national policy guidance as ephemeral to the detail of clinical practice, but there were significant problems with assessment for older people before the SAP came into being. The policy was intended to address these, although there are obviously concerns about its implementation locally. The issue for geriatricians is how they can contribute to and shape this process in the best way possible. In particular, more integrated practices between health and social services, a particular concern of the SAP, will continue to be important. Geriatricians are key players in such initiatives and they can make an impact both through their specialist knowledge, and through assisting with training and development.

Our survey showed that geriatricians’ involvement in the SAP was variable with active involvement in some activities, such as the use of standardised tools, and less involvement in others, such as patient involvement and integrated processes for information sharing with social services. The actual implementation of the policy with its new systems for information collection, joint working and its resource implications, were viewed as controversial by a significant minority of those surveyed. As yet, we do not have the data available from another survey looking at local implementation of the SAP, but the views of some geriatricians here indicated that the policy may have been viewed as primarily a social services responsibility and that some clinicians may not have had the opportunity to be involved. However, the SAP, with its expectations of closer professional working and shared recording procedures, may depend for its effectiveness on these local factors.

Whilst a full evaluation of the SAP from the perspective of all participants is not yet possible, geriatricians can satisfy themselves that the policy is guided by one of the fundamental principles of geriatric medicine, that of effective specialist and multidisciplinary assessment. However, it is the realisation of this on the ground that is crucial and issues of local implementation are therefore of enduring importance in this respect.

Paul Clarkson, Michele Abendstern, Jane Hughes, Caroline Sutcliffe and David Challis
Personal Social Services Research Unit
University of Manchester

BGS Newsletter, October 2007
Issue 13 ISSN 1748-6343 13