SCIE Guide 9: Implementing the Carers (Equal Opportunities) Act 2004

Assessment of carers - Outcome-focused assessments

Key research and policy findings

Practice points

Assessment

A practitioner's guide to carers' assessments (8) emphasises that:

  • The most important element of the content of the carer's assessment will be the focus on what the carer wants to happen (the outcome).
  • The guide outlines the necessary elements of the assessment (pp16-22), including the need to consider the carer's education, training, employment and leisure needs.

Review

Research and policy

As part of the government's agenda for modernising health and social care, a raft of legislation and policy initiatives have focused on improving the quality and consistency of social care and promoting independence, control and choice for service users themselves. Modernising social services (30) emphasises the need to focus on 'the quality of services experienced by, and the outcomes achieved for, individuals and their carers and families'. Outcomes have been defined as the impacts, effects or end results of services on a person's life (31).

The Department of Health's Green Paper, Independence, well-being and choice (28) and subsequent White Paper, Our health, our care, our say (56), are set around seven key outcomes identified by people who use services:

The Commission for Social Care Inspection (CSCI) has incorporated these into their new assessment framework, A new outcomes framework for performance assessment of adult social care (PDF file).

More specific to carers, Nicholas (31) provides a framework, which is adopted in 'A practitioner's guide to carers' assessments' (8), for the evaluation of outcomes for carers. The framework comprises four dimensions:

A carer's assessment should be focused on what the carer identifies as the best possible outcome. It must focus on the outcomes the carer would want to see to help them in their caring role and maintain their health and well-being (8).

For many carers, flexible, client-centred services are essential to the sustainability of the caring role. Independence, well-being and choice (28) stresses the need to prevent problems as well as support those with high level needs for care:

In future, greater focus should be placed on preventative services through the wider well-being agenda and through better targeted, early interventions that prevent or defer the need for more costly intensive support. Current eligibility criteria allow for early intervention and support. More use of universal services could help people remain better integrated in their communities, prevent social isolation and maintain independence. This will allow social care to play its specialist and essential role in supporting those with specific needs that cannot be met in this way (28).

The White Paper, Our health, our care, our say reinforces this message:

There is also a growing evidence base showing that preventative measures involving a range of local authority services, such as housing, transport, leisure and community safety, in addition to social care, can achieve significant improvements in well-being.

Carers who have time for themselves and flexible services (for example, aromatherapy for relaxation or driving lessons to improve mobility and community access) are more likely to be able to continue as carers. Carers should be offered the same advice and support as care workers in order to protect their own health, for example, with regard to lifting and handling. In the long term, support for carers is likely to save money on costly care packages and residential care.

Previous guidance advocates innovation, stating:

Services for carers are not defined. Any outcome valued by the carer may be a legitimate use of council resources if it genuinely will support the carer in their caring role or help them maintain their own health and well-being (8).

A number of programmes (32,33,34) have supported the development of outcomes-focused practice. These complement the influential work of service-user organisations themselves (35,36) on the processes and outcomes that people want and value.

The work carried out by the Social Policy Research Unit (SPRU) at York University has led to the development of the substantial Outcomes into practice resource pack for managers and trainers (37). Since completion of the SPRU programme, the members of the Outcomes into Practice Network have continued to develop their approaches, providing some examples of current and emerging practice. SPRU was commissioned by SCIE to carry out a knowledge review of the progress on outcomes-focused services for older people. The review shows that progress towards person-centred, outcomes-focused policy and practice is patchy and that agencies are at different stages in their implementation. A lot of development work is therefore required to embed this approach into mainstream practice.

Research and policy shows that progress on carrying out carers' assessments has been slow (12) and that, where they have been carried out, this is often due to well-informed carers or proactive workers (38) rather than structure in policy and procedure. The Audit Commission (12) found that, where local authorities had returned figures on carers' assessments, they did not correspond with the perceptions of service users or case records.

As the Carers' Grant is largely used to provide breaks for carers, some local authorities have tried to find increased assessor resources to facilitate carers' assessments. Without increased resources, it may be difficult for practitioners to meet targets for carrying out assessments. According to the Audit Commission report (12), social workers with existing heavy caseloads did not see themselves as having time to carry out carers' assessments, and carers were angry about the attitudes of social workers towards them. Some local authorities have delegated their responsibility to carry out carers assessments to local voluntary sector organisations. It is clear, however, that the local authority has a statutory duty to assess and make a decision about service provision: “it is not enough for the local authority to simply check, on a complete or partial basis, the outcomes of another organisation's assessments” (REF combined Policy Guidance for the 2000 and 2004 Acts para 45)

Nicholas (31) states that, to implement outcomes-focused carer assessment, the following are required:

Clearly this presents a significant challenge to existing services that are currently working to full capacity. Bearing in mind the consequences of not supporting carers, the measures above should be key priorities for local authorities.

The use of outcomes-focused assessment tools has led to more positive outcomes for both service users and practitioners. Guberman et al (15) carried out an evaluation of the impact of carers' assessment tools in four different countries, which 'aimed at promoting partnership with carers and encouraging greater recognition of the complexities of caregiving and its impact on all aspects of life'.

Models from the UK included the framework for outcomes-focused carer assessment developed by Nicholas (39), which incorporates the tool developed by Nolan et al (40). The latter measures the situation of the carer via three indices for an assessment of the carer's experience of difficulty, satisfaction and managing.

Research confirmed that these tools increased practitioners' insight and understanding of carers' needs and the complexities of the caring relationship, including the positive aspects. For carers, the tools led to the provision of new information and a more person-centred approach. Assessors reported a difference in the power balance. Carers were viewed as partners rather than resources, and professionals took the role of facilitators, while the expertise of carers was recognised (31).

Flexibility and innovation in service provision is necessary for an outcomes-focused approach. Practitioners using the assessment tool noted that asking carers how they would like to make use of breaks led to an increase in new or rekindled interests. The Carers' Grant guidance encourages flexibility in suggesting that money could be spent on 'driving lessons, moving and handling classes or a short holiday for the carer' and 'to support carers to move on to new learning and/or work or volunteering opportunities' (26).

Evidence suggests that many carers prefer face-to-face contact to self-assessment, (38) and that being listened to and acknowledged is a valuable aspect of the assessment process and an outcome in itself.

Case study

A disabled woman who cared for her elderly partner wanted to be able to cook him a hot meal in the evenings (lunchtimes were catered for through meals on wheels). This problem was a source of worry for the woman. The assessor simply suggested that the woman buy a microwave and promised to show her how to use it. The woman was willing to buy a microwave herself.

The result was that she felt listened to and had got what she needed from the assessment. The desired outcome was achieved with no extra cost to social services.

Informal, face-to-face contact is particularly important to young carers (38). Preparation forms that help carers plan for their assessment can be useful, but they should not be used to replace the assessment itself (8). Carers can be empowered to use such forms through advocacy or peer support that is culturally suited to their needs. Face-to-face contact is important to ensure that the carer has appropriate knowledge about the purpose and possible outcomes of assessment. If a carer chooses self-assessment and declines face-to-face contact, the local authority will need to make a judgement, based on the information provided, on whether to provide services.

People who use services and their carers should be offered the opportunity to talk separately (See chapter 5-6 'Shiela' in the Listening to carers video). Sometimes there can be tensions between them, and in exceptional circumstances where there are conflicting issues, it may be necessary for the carer's assessment to be carried out by a separate assessor (41). Carers themselves may have other requirements and should be told that they can have someone else present at the assessment - e.g. a friend, advocate, interpreter, signer (8). Training for assessors should include awareness of issues that may necessitate the allocation of separate assessors.

Where the cared-for person refuses an assessment and/or services, it is important that the carer's needs are assessed. Previous practice guidance addresses this issue (2) (pp 20-21). It may be possible to provide services that support the carer in some way or to work with the cared-for person to help them to accept a degree of service. For example, someone who refuses to accept care from another person may accept a sitting service that allows their carer some time for a break. A carer is still entitled to an assessment even where the person they care for is not eligible for or receiving services. The details of this are explained in Carer's and their Rights 9.2 - 9.5

Where a cared for person receives services that are funded by health through Continuing Care local authorities should still offer a carer's assessment. The legal framework for this is explained in detail in Carers and their Rights point 7.30 - 7.34.

If a carer refuses assessment, their views should still formulate part of the assessment process for the cared-for person:

Section 8 of the Disabled Persons (Services Consultation and Representation) Act 1986 requires the local council to have regard to the ability of the carer to provide or continue to provide care when deciding what services to provide to the disabled person (42).

Transition to adulthood for disabled young people can be a difficult time and is likely to bring about concerns for parent carers. Additional support may be needed at this time (42).

Visit the SCIE knowledge review on outcomes-focused services for older people

Ideas from practice

Practice examples are self-reported and have not been evaluated.

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