Adult Social Care Glossary, v 0.6

“where it appears to a local authority that an adult may have needs for care and support, the authority must assess (a) whether the adult does have needs for care and support, and (b) if the adult does, what those needs are.”
Care Act 2014 [1]

The Care Act guidance describes the assessment ‘process’ as “one of the most important elements of the care and support system”, and claims that the assessment “is one of the key interactions between a local authority and an individual, whether an adult needing care or a carer”. [2]

So if it’s such a fundamental part of our social care world, why does the term ‘assessment’ make me go hmmm?

Assessment: the gateway to care and support

The Care Act statutory guidance is clear that the assessment “should not just be seen as a gateway to care and support”. Language matters – and the ‘just’ in that sentence is key, because ultimately its presence confirms that the assessment is a gateway – the gateway – to care and support. And therein lies the first problem. However much the statutory guidance describes the assessment as an appropriate, proportionate, person-centred experience, it also states that “the outcome of the assessment is to provide a full picture of the individual’s needs so that a local authority can provide an appropriate response at the right time to meet the level of the person’s needs”.

As ‘assessors’ we identify, and provide, the ‘appropriate response’. We decide the ‘right time’. We fix the ‘level’. We determine the ‘needs’. And as such we hold the keys to the social care door. The power is well and truly in our hands.

The assessor and the assessed: the dynamics of the power imbalance

“Many people are put off by the idea of an assessment, but it’s not something you should worry about. A social care assessment is not a test you can pass or fail.” Money Advice Service [3]

If only that was true.

Any kind of an assessment is a test, and tests are generally nerve-wracking experiences, particularly when we know the outcome will have a significant impact on our lives. Tests have right and wrong answers. You can pass or fail. Our social care assessment is a test, and the result either opens or closes the door to support. And as such, the power imbalance between the assessor and the assessed is stark. In the world of social care, we call the shots and we control people’s futures. Sounds scary doesn’t it? And it is.

“Steven has been very anxious and destructive all week. It might be the stopping of the medication. It might be anxiety about the house move. It might be that he knows that assessments can turn his life upside down. It was probably all three. I find the pre assessment anxiety unbearable.” Mark Neary [4]

To assess is to judge

The dictionary definition of assessment is “a consideration of someone or something and a judgment about them”.[5] To assess is to judge. As assessors we judge needs, risks, eligibility, capacity, best interests and finances, and the people we assess await our verdict as passive recipients. And regardless of our Care Act duties, we’re quick to walk away if we judge that people’s needs aren’t ‘eligible’, or if their eligible needs are met by family or friends, or if they can fund their own support.

Our decisions are influenced by thresholds and checklists and calculators – not by our principles or our values or our hearts. And as such we’ve detached ourselves sufficiently to think that we have the right to assess and judge people against pre-determined criteria and rules, while we get on with pursuing our own ambitions, building (and breaking) our own relationships, taking our own risks, making our own unwise decisions, living our own lives.

The assessment form: set questions and tick-boxes

“I am struck by the fact that there is no discussion, no talk of what could be changed. There is just the recording of facts, the processing of problems. It’s a tetchy interview, not a conversation”. Hilary Cottam [6]

When our assessment is based on set questions from a generic form, we’re setting the agenda for, and limiting the scope of, our conversations. If we ask questions about personal care needs (managing and maintaining nutrition, personal hygiene, toilet needs etc), we get answers about personal care needs.

Despite the Care Act guidance suggesting that the assessment should be a “critical intervention in its own right”, in reality our assessments are often rushed and usually take place in response to a crisis. As a result, the assessor gleans a ‘snap-shot’ of the person’s life when they’re at their most vulnerable, and all too readily reaches for the standard suite of service solutions to fix the problems they’ve defined. By limiting the scope of conversations and fitting people into the corresponding boxes, we remain in ‘easy to fix’ territory, where our standard home care or residential solutions can be quickly prescribed, or our doors can be closed if not quite enough boxes are ticked.

Assessing needs

“we lose the person in the very process designed to find them.” Liz Sargeant [7]

Our social care assessment is an assessment of need. We focus on what people struggle with and can’t achieve. We see problems, not people. We’re so caught up in screening and assessing and labelling and processing that we believe if we’ve met basic safely and survival needs we’ve done our job and we can move on to the next ‘case’ on our waiting list. But in focusing just on needs (and usually just on basic, functional, personal care needs) we fail to see the bigger picture and fail to really listen to or understand the person and those close to them: those who know the most about what they need the most.

We also fail to talk about what really matters: to have conversations about pursuing hobbies, finding work, developing friendships, building relationships, falling in love, living life. These conversations require a significant amount more time. Time to establish the trust required for the person to tell their story. Time to listen. Time to understand what’s happened to make them who they are now, and what needs to happen to enable them to be who they want to be. Time to explore how we can be most useful. Time to stick around and see the difference. And the reality is that in our current social care system, time is scarce.

But it’s not just time that’s the issue. These conversations also require us to be interested in people and their lives, not just their problems, and increasingly it seems that we’ve just lost interest.

The assessment process

“And after years of these assessments, I know that the final outcome will bear no relation to our reality. The social worker is great, so this is no reflection on her. It’s the knowledge that, (a) it’s a form filling exercise and the form is astonishingly narrow in its reach, and (b), whatever is written is completely at the mercy of Panel. That anonymous bunch of people for whom the £ is king.” Mark Neary [8]

At the end of the day the assessment is just that: a process. A “document and a stage in the IT system that is needed to unlock other stages”. [9] A cog in the social care machine.

The assessment process is our process. The assessment form is our form. It’s completion and approval allows us to progress to the next stage, but it holds little value to the people and their families who are desperate for us to put down our pens, look up from our checklists, listen to what really matters to them and act on what we hear.

All too often the assessment is recorded in great detail for a decision by a manager far removed from the person and their life. And even then, who actually reads the reams of detail poured into the boxes on the form? Maybe the panel – where the assessor has to justify their decision and the associated cost. Maybe the senior manager, conjuring up a response to a complaint. Maybe the judge unpicking events. Maybe the coroner investigating a death. When things go wrong, the assessment is scrutinised, and the assessor in turn becomes the assessed, judged from afar and awaiting a verdict of their own.

Replacing assessments with conversations

I’ll admit it, I’m impatient. I’ve got a short attention span when it comes to endless discussions and deliberations about whether or not we can make a change. I’m the one pushing to ‘just get on with it’, and have a go – after all, what could be worse than the bureaucratic, dehumanising tangle of our existing social care system? But I’ve come to realise that to get from here to there – broken old world to shiny new world – requires small steps, not one giant leap. Once such step is the shift from assessments to conversations.

The theory is good. An assessment is prescriptive and narrow in its reach, whereas a conversation is open-ended. A conversation can be led by the person – with support, where necessary, from their family, friends or an independent advocate. “It can help people to explore their own aspirations, the things they’re good at, the experiences they’ve had, the people they care about and what matters to them, as well as their support needs.” [10] It can be written up on a record with free-text space for reflections, rather than a form with set questions, categories to select and boxes to tick.

And yet, however open and honest these conversations are, they take place within a system full of assessments and tests. Yes we have conversations – but we still judge whether or not people are ‘vulnerable’ enough and their needs are significant enough to meet our entry criteria. We still assess risks. We still determine eligibility. Our assessment forms may have been replaced by conversation records, but we still write for panels, to justify our decisions and their associated costs. And if we decide that people have sufficient needs for us to proceed, we apply a means-test to their finances and determine how much they’ll pay.

I genuinely believe that conversations count, but conversations in social care are nothing more than assessments with a shiny new name if they aren’t accompanied by an associated shift in values and behaviours and relationships at all levels, including nationally. As long as we have a system based on entry criteria and eligibility thresholds and means-tests and risk assessments the power dynamic remains. We are still assessors. We are still judging people. Our function is still to process people through our system – if we permit them to enter at all. We still hold the keys to the social care door.

A better, brighter social care future
“So, let’s embrace our humanity and the humanity of the people we serve… That’s our role. Let’s stop wasting time spending days in the office typing up pages and pages of assessment forms and case notes which no one will read.”

Elaine James [11]
Assessments don’t exist in our better, brighter social care future. There is no place for tests. Instead we build relationships of trust where we recognise and respect people as experts in their own lives. We listen to what they, and those who know them best, say about the support they know they need to get on with living the life they want to lead. We shift the power, so instead of us judging people, we let people judge how we can be most useful – the barriers we can help to remove, the rights we can uphold, the connections we can make, the doors we can open, the opportunities we can bring their way. We respond to people’s stories and their hopes for the future, rather than expecting people to respond to the questions on our forms about what’s wrong.

Without an assessment, we focus instead on the plan. A single plan for a good life well lived, owned by the person and developed in collaboration with a team of people who genuinely care about them. We’re in that team. We’re on their side. We’re by their side. And what matters most to us is what matters most to them.

Compassionate social care requires a compassionate system – right from the top and all the way down. A government that values people and families and communities, and finds a fair and sustainable funding solution for social care. Local authorities that listen to, and are guided by, the aspirations of all those who live within their jurisdiction. Social care departments that work with community groups and collaborate with health and housing colleagues (rather than fighting about how needs are defined and which organisation should step up to meet them). Managers who trust and support their staff. Social care workers who have the time and the motivation to get to know people in their families and their communities, and work out together how things could be better.

So let’s revisit the Care Act, and shift our attention away from the sections on assessing needs and determining eligibility, and back to the start – to the fundamental principle of promoting wellbeing. Let’s reclaim our purpose as social workers of promoting social change and development, social cohesion, and the empowerment and liberation of people [12]. Let’s liberate people from the dehumanising constraints and judgements of the assessment process, and liberate ourselves too. Rather than setting the tests and asking all the questions, let’s focus on the answers, and let’s be part of the solution.