An evaluation of the use of self-assessment for the

Research

An evaluation of the use of self-assessment for the provision of community equipment and adaptations in English local authorities Sue Tucker, 1 Christian Brand, 2 Susan O’Shea, 3 Michele Abendstern,4 Paul Clarkson, 5 Jane Hughes,6 Jennifer Wenborn 7 and David Challis 8 Key words: Self-assessment, community equipment, older people.

1 Research

Fellow, Personal Social Services Research Unit, University of Manchester, Manchester. 2 Research Associate, Personal Social Services Research Unit, University of Manchester, Manchester. 3 PhD Researcher and Teaching Assistant, formerly at the Personal Social Services Research Unit, University of Manchester, Manchester. 4 Research Associate, Personal Social Services Research Unit, University of Manchester, Manchester. 5 Research Fellow, Personal Social Services Research Unit, University of Manchester, Manchester. 6 Lecturer, Personal Social Services Research Unit, University of Manchester, Manchester. 7 Clinical Research Fellow, Department of Mental Health Sciences, University College, London. 8 Professor of Community Care Research and Director of PSSRU, Personal Social Services Research Unit, University of Manchester, Manchester. Corresponding author: Sue Tucker, Research Fellow, Personal Social Services Research Unit, University of Manchester, Dover Street Building, Oxford Road, Manchester M13 9PL. Email: [email protected] Reference: Tucker S, Brand C, O’Shea S, Abendstern M, Clarkson P, Hughes J, Wenborn J, Challis D (2011) An evaluation of the use of self-assessment for the provision of community equipment and adaptations in English local authorities. British Journal of Occupational Therapy, 74(3), 119-128. DOI: 10.4276/030802211X12996065859201 © The College of Occupational Therapists Ltd. Submitted: 29 July 2010. Accepted: 14 February 2011.

Introduction: The Government plans to transform adult social care in England. Future services will place more emphasis on prevention and enablement, and promoting personalisation and choice. Self-assessment is one possible facilitator of this agenda. However, little is known about its utility in social care. This evaluation examined how eight local authorities employed self-assessment in the provision of community equipment and adaptations, and explored the implications for service delivery. Method: A multiple case study was employed, using a mixed methods approach. This drew on internal documents, management interviews, and service user and administrative records. Findings: Self-assessment was primarily used to facilitate service access. Although the authorities differed in the way in which they operationalised self-assessment, professional staff were almost always involved. The differences between people receiving self and traditional assessments were modest, but the people undertaking self-assessments in preventative services formed a particularly healthy subgroup. There was little consensus about the items suitable for provision through self-assessment. Conclusion: The concept of self-assessment was variously interpreted and not all its possible uses were explored. Nevertheless, the evaluation suggested that self-assessment can facilitate access to community equipment and adaptations and has the potential to extend the population traditionally served by social care services, thereby addressing the preventative agenda.

Introduction National policy has voiced high aspirations for the future of adult social care. The vision is of a more personalised approach to service provision, with service users given greater choice and control, a new emphasis on early intervention and prevention, and the delivery of services closer to home (Department of Health [DH] 2005, 2006a, Her Majesty’s Government 2007). The introduction of a new Common Assessment Framework, which challenges organisations to redesign local systems around people’s needs and, wherever possible, enable them to self-assess, is central to these ambitions (DH 2008). The pace at which this agenda can be delivered, however, is likely to depend, at least in part, on occupational therapists’ enthusiasm for such initiatives, for despite representing just 2% of the social care workforce, occupational therapy staff manage around 35% of all referrals to local authority social services departments (Department of Health and College of Occupational Therapists [DH and COT] 2008). Furthermore, although the expectation is that self-assessment will provide faster, easier access to services, freeing professional staff to work with complex cases (DH 2005, 2006a, 2006b, 2008), any change to service

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An evaluation of the use of self-assessment for the provision of community equipment and adaptations in English local authorities

delivery models should be evidence based (Bannigan et al 2008), and knowledge about virtually every aspect of selfassessment – its very definition, application, scope and effectiveness – is undeveloped. Against this background, in August 2006 the Government in England announced details of 13 local authority projects that would pilot the development of self-assessment in social care (DH 2006b). The intention was to determine if selfassessment was feasible in this sector and, to this end, a multisite evaluation was commissioned. This aimed to: 1. Classify and describe the different approaches taken to self-assessment 2. Gauge service users’ experience of self-assessment 3. Evaluate the cost-effectiveness of self-assessment 4. Appraise the implementation and sustainability of new assessment practices (Challis et al 2008). The work described in this paper formed part of this evaluation and draws on a subset of the data collected in eight projects concerned with the provision of community equipment and adaptations. It addresses the following key questions: ■ How has self-assessment been used? ■ Who undertakes self-assessment? ■ What services do people receive following self-assessment? ■ Is self-assessment associated with more timely service delivery?

Literature review A critical appraisal of the relevant literature relating to the use of self-assessment in social care was undertaken, drawing on a wide range of sources including government and professional bodies’ policies and statements, academic journal articles and reports. In comparison with the situation in health care, where self-completed screening questionnaires have long been used to identify individuals requiring further professional assessment or advice (for example, Tulloch and Moore 1979, Bowns et al 1991), the use of self-assessment in social care is a relatively new phenomenon. The emerging literature, which contains a disparate mix of descriptive and evaluative reports, is still, therefore, quite limited, while the self-assessment tools themselves range from the locally developed to the rigorously tested. Indeed, the concept of selfassessment in social care has not yet been clearly defined and, as Griffiths et al (2005) have noted, at its broadest this term has been used to refer to any situation in which professionals take account of service users’ views of their needs or respond to evaluative questions about their health. In contrast, the definition of self-assessment offered by Qureshi (2006) stresses the potential for individuals themselves to use information about their goals, circumstances and environment as a basis for decision making. However, this does not necessarily preclude the participation of professionals or professionally employed lay people altogether. While self-assessment can serve as a substitute for professional assessment, therefore, it may also be undertaken in preparation

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for, as part of or in addition to a professional assessment (Griffiths et al 2005, Qureshi 2006). Although the use of self-assessment in social care has attracted the attention of practitioners and researchers in the United Kingdom, this appears to have been directed at particular client groups. Carers form one focus of interest, and at least one authority has used self-assessment to determine carers’ needs (Arksey et al 2000), whilst other carer initiatives have sought to identify carers requiring a professional assessment (Nolan and Philp 1999) and to assist carers to prepare for a professional assessment (Nicholas 2003). There has also been considerable enthusiasm for the use of self-assessment within the (usually) professionally led overview assessment schedules developed for older people as part of the Single Assessment Process (for example, Philp 2000, FACE Recording and Measurement Systems 2005, Griffiths et al 2005) and as an element of the In Control programme of self-directed support for people with learning difficulties (Duffy 2004, 2005). However, many further examples of the use of self-assessment in social care are found in occupational therapy services. Indeed, the prospect of providing minor pieces of equipment and adaptations through self-assessment has attracted much attention, and some local authorities already offer a restricted range of services on this basis (College of Occupational Therapists and Housing Corporation 2006). There are, furthermore, at least two commercial web-based self-assessment systems that enable individuals to assess their need for (and access information on) simple pieces of community equipment, initiating, completing and acting upon the assessment themselves (Disabled Living Foundation 2007, ADL Smartcare 2007). In view of the early stage of its development, little has been reported about the characteristics of service users undertaking self-assessments in social care or the extent to which they differ from people receiving traditional – usually face-to-face, professionally led – assessments. Still less is known about the effect of self-assessment on the timeliness, nature and extent of service receipt, whilst the ability of self-assessment accurately to determine people’s needs in social care settings does not appear to have been evaluated. However, health research that has explored the difference between people’s responses in self-completed surveys and face-to-face interviews suggests that, whilst agreement about factual information, such as sociodemographic characteristics and service receipt, is good, people paint a less positive picture of their symptoms and abilities in selfassessments (Lyons et al 1999, Smeeth et al 2001, Griffiths et al 2005). This would seem to counter concerns that people who self-assess, particularly older people, may under-report their needs because they do not want to appear demanding, or have low expectations or communication problems (Bauld et al 2000, Walters et al 2001, Hancock et al 2003). That said, many studies suggest that individuals report fewer (or different) needs from staff or carers who know them, and this work has been used to


Sue Tucker, Christian Brand, Susan O’Shea, Michele Abendstern, Paul Clarkson, Jane Hughes, Jennifer Wenborn and David Challis

support the case for a professional assessment that probes beneath the presenting problem, particularly where people have cognitive impairment and /or lack of insight (Ellis 1993, Hancock et al 2003, Carter 2003).

information was subsequently summarised in a 24 -cell matrix according to its cost and function. Unit costs (four bandings based on a categorisation used by Care Services Efficiency Delivery Workstream 2007) were estimated from a range of equipment brochures, websites and local sources and, where applicable, included installation costs calculated from information provided by Curtis and Netten (2006). In addition, the primary function of each piece of equipment was coded according to guidance developed by the occupational therapist within the research team (Challis et al 2008). Eight categories were described: meal preparation; mobility; bed and chair (including positioning, transfers and manual handling); dressing; bathing and showering (including washing and personal care/grooming); eating and drinking; toileting; and sensory (including seeing, hearing and communicating). If an item could be categorised into more than one function, it was placed in the category that reflected the higher level of dependency. For example, a non-slip mat was categorised as eating and drinking rather than meal preparation.

Method The evaluation took the form of a multiple case study, in which each pilot project was viewed as an instance of the phenomenon under study (that is, self-assessment). An extensive data collection was undertaken in 2006-2007 using a mixed methods approach, so as to produce a rich, multidimensional understanding of each case (Burke Johnston et al 2007). Four strands of this are relevant to this paper. ■

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In the first element of the data collection, the members of the research team examined internal documentation and interviewed key staff in each local authority to ascertain their concept of self-assessment and its place within the care process. In combination with the findings from a selective literature review (Challis et al 2007), this information was used to develop a taxonomy of self-assessment in social care, identifying both its location (within occupational therapy, assessment and care management or preventative services) and function (screening to identify individuals who require further professional assessment, contributing to a wider professionally led assessment, contributing to care planning or providing direct access to services). Secondly, local authorities collected a range of information about the sociodemographic characteristics, health and functioning of service users who completed a self or traditional assessment. The data collection items were drawn from the Easycare assessment tool (Philp 2000) and information about user dependency was summed to identify the number of daily activities people needed assistance with (Katz et al 1963). As the extent and method of the data collection varied between sites (with some authorities integrating this into their usual assessment process and others undertaking a separate data collection) and the samples were not random, a number of key variables (including age, gender, ethnicity and dependency) were compared with data from a large national survey (NHS Information Centre for Health and Social Care 2008) to check that the studied groups were broadly typical of the expected service user group. The statistical significance of any differences between groups was assessed by the use of confidence intervals and chi-square tests – as well as, where applicable, t-tests and non-parametric Mann-Whitney tests – all at 95% confidence levels (using Stata 10). Thirdly, local authorities compiled information on the services provided to service users receiving self and traditional assessments. In the majority of projects this information was available by individual service user, but in some only aggregated data were available. This

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Fourthly, local authorities provided information on the number of days elapsing between three key elements of the assessment process as experienced by people receiving self and traditional assessments: the time between first contact (referral) and assessment; the time between assessment and first service receipt; and an aggregated indicator of the time between referral and first service receipt.

The bulk of the analysis was thus descriptive in nature, mapping the realities of self-assessment in practice and, wherever possible, comparing these with traditional assessment procedures. Appropriate ethical approval for the work was received from three sources in early 2007: the Association of Directors of Adult Social Services (ADASS) Research Group; the Committee on the Ethics of Research on Human Beings at the University of Manchester; and research governance departments in each pilot site. No ethical concerns were identified.

Findings Context As noted above, eight of the 13 pilot projects focused on the provision of community equipment and adaptations and all of these targeted some combination of older and /or disabled adults. Five projects were located in occupational therapy services (which have traditionally focused on the delivery of equipment, housing adaptation services and assistive technology for disabled people; Mountain 2000, Riley 2007) and three in preventative services (which typically provide low level support to people with modest needs with a view to promoting their independence and wellbeing and preventing or delaying their need for more intensive services; Personal Social Services Research Unit 2010) (Table 1). These


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An evaluation of the use of self-assessment for the provision of community equipment and adaptations in English local authorities

Table 1. The self-assessment pilot projects* No. Setting Aim (as described by the authority) 1 Occupational To improve access to equipment, the customer experience therapy and cost efficiencies by piloting the use of an electronic tool

Primary assessment format Electronic

Staff involvement in assessment Local authority staff oversaw all

4

Occupational therapy

To expand existing opportunities to self-assess for minor adaptations and equipment by a ‘fast track’ client-led self-assessment system

Telephone or paper plus telephone

Local authority staff participated in all

5


To promote direct access to occupational therapy services and access to equipment to reduce waiting list times

Electronic


7


To evaluate the introduction of self-assessment for simple pieces of equipment and moderate levels of home care

Paper

Local authority staff participated in some

8

Prevention

To develop an online self-assessment tool for community equipment, based on a national tool customised for local use

Electronic

Voluntary sector staff oversaw all

9


To develop different methods of assessment for (in particular) shower/bath adaptations – direct access, the use of trusted assessors and assessments by occupational therapists

Telephone or face to face

Various levels of participation by local authority and other statutory agency staff

10

Prevention

To introduce self-assessment for simple items of community equipment

Telephone


11

Prevention

To introduce an electronic self-assessment tool for assistive Electronic Voluntary sector staff participated equipment in some *Please note that the project numbers are those used in the original evaluation and have been used here in order to maintain consistency of reporting across publications.

represented a number of different types of local authority (units of local government responsible for the provision of adult social care services), although there were more urban than rural settings: four sites were London boroughs, two were shire unitary authorities, one was a metropolitan city and one a metropolitan district. In each case, the primary function of the assessment was deemed to be the provision of direct access to services /equipment, whilst in Projects 1, 9 and 10 the self-assessment process also served to identify people requiring a professional assessment. Self-assessments were variously available on paper, by telephone and on a computer. In the vast majority of cases, local authority (often occupational therapy) or voluntary sector staff played some part in their completion, ranging from talking the service user through the entire assessment on the telephone to the provision of ad hoc support with the completion of an assessment online as needed, although in some authorities (for example, Projects 7 and 11) service users could also complete assessments without professional help. In all except one project (Project 11), local authority staff played some role in determining the response to the assessment, that is, deciding what equipment or adaptations should be provided.

Service users Data were collected about the sociodemographic characteristics, health and functioning of approximately 1,200 people who completed self-assessments for community equipment and adaptations and nearly 450 people who

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had traditional assessments (Table 2). Although information about self-assessment users was provided by all eight projects, information about individuals who received a traditional assessment was available from just four (Projects 4, 5, 7 and 11). The number of projects that provided information about each element of the data set also varied substantially. As seen in Table 2, the average service user undertaking a self-assessment for community equipment or adaptations was likely to be in their early 70s, female, white and in poor or fair health, although still relatively independent in undertaking activities of daily living. Differences between people undertaking self-assessments and people receiving traditional assessments were mostly modest, although the former group were significantly less likely to live with others ( χ2 14.57, p