Assessment in social work: a guide for learning and teaching
Service users and carers: User-led assessment
The growing validation of service user and carer perspectives has gained expression in assessment partly through ideas of ‘user-led’, ‘user-defined’ and ‘self-assessment’, which go well beyond usual notions of ‘involvement’. None of the SCIE-commissioned studies examines these specific ideas closely, but they are the subject of increasing interest in policy, practice and research and deserve discussion in this guide. It is not possible to examine the ideas comprehensively here but two fundamental dimensions of user-led assessment can be distinguished and used to explore aspects of the subject. The two dimensions are found in a consideration of key elements of assessment, which comprise the definition of the process and criteria to be used in the assessment, and the roles played in the conduct of assessment. Hence, a fully user-led assessment consists of:
- user-defined assessment
- user conducted assessment, also known as self-assessment.
An assessment must be ‘defined’ before it can be undertaken. Defining the assessment means constructing the process and criteria. It is not within the scope of this guide to research empirical examples but the chief mechanism by which service users and carers are likely to be involved in defining assessment is via local or wider arrangements for representation and consultation.
Regarding user-conducted or self-assessment, one study defines self-assessment as ‘assessment that is completed by the subject of the assessment without the immediate involvement of professionals’ (Griffiths et al, 2005, p 17).
The authors stress that self-assessment comprises not only self-report (as in describing one’s needs or situation) but especially self-completion or direction of the process and oneself as the potential beneficiary (p 6). They also warn, first, that self-assessment raises complex questions about the accuracy of assessments made, the effectiveness of the process, and the experience for users; and second, that the evidence base in social care for each of these questions is, for the moment, sparse (pp 6, 8–10 and 56).
Nevertheless, user-conducted or self-assessment is a growing feature of both social care and health care. Historically, professional (and bureaucratic) models of the relationship of service providers to service users tended to treat users’ views in assessment as inexpert and subordinate. These models persist in some process-focused approaches (see Section 9) but have been modified in social care by a number of influences. Service users and carers themselves have become more organised, vocal and influential (Beresford, 2006). Social work practice has been additionally influenced by values of self-determination, respect for persons, empowerment, partnership and accountability. And established practices have been modified by the user-oriented strands in government policy.
Examples are found in the recognition of service users’ accounts of their needs under Conservative community care policies of the early 1990s and in the promotion of service users’ perspectives under successive New Labour programmes since 1997. Self-assessment is part of the legacy of these policies along with developments such as:
- direct payments for self-arranged care and individual budgets (SCIE, 2005; PSSRU, 2006)
- the ‘in-control’ programme (www.in-control.org.uk)
- the promotion of self-monitoring and self-management of long-term conditions and the Expert Patient Programme (Griffiths et al, 2005; EPP, nd)
- the participation of ‘experts by experience’ in inspections of local councils by the Commission for Social Care Inspection (CSCI 2006).
Self-assessment methods range from professionally initiated questionnaires, through self-assessment algorithms to web-based systems with feedback (Griffiths et al, 2005). Paper-based assessments have predominated but online examples are multiplying in social care, where some promise ‘an instant decision’ on whether a person is eligible for specific help and equipment (Kent County Council, 2006).
Some of the possible gains of user self-assessment include:
- recognising and using the expertise of service users and carers
- challenging cultural values about the dependency of particular groups
- guiding people to sources of help and clarifying eligibility
- where online methods are used, providing 24-hour access to assessment
- providing an early alert to need
- speeding up provision by removing the wait for professional assessment
- enabling service users to prepare for professionally conducted assessment
- obtaining an evaluative check on services currently being used. (Griffiths et al, 2005; Priestley, 1998; Qureshi, nd)
No single form of self-assessment is suitable for all service users or types of need. Some service users and carers may prefer an autonomous self-assessment, others peer-supported self-assessment (PSSRU, 2006) while still others seek professionally supported self-assessment or assessment led by a professional (Griffiths et al, 2005; Qureshi, nd). Furthermore, there are limits to self-assessment where lack of accuracy may cause harm or where extreme risk to service user, carer or the public requires professionally controlled assessment.
To summarise, user-led assessment comprises two dimensions:
- user-defined assessment, in which service users and carers play a role in constructing the process and criteria for the assessment
- user-conducted assessment, or self-assessment, in which service users and carers undertake the assessment, usually applying predetermined processes and criteria.
Analysis using these two dimensions results in five models of the service user and carer relationship to the definition and conduct of assessment. The models are outlined below and shown in Figs. 3 and 4:
- professional/agency-controlled assessment
- user/carer-conducted assessment, professional/agency-defined
- user/carer-defined assessment, professionally conducted
- devolved user/carer self-assessment
- collaborative assessment.
All the models except the collaborative one represent extreme points on the two intersecting dimensions. They provide a starting point for classifying real-world examples such as those given in the works by Griffiths and colleagues (2005) and Qureshi (nd). Some real-world examples can be expected to match the models closely while others will display characteristics of intermediate points on the intersecting ‘defined’ or ‘conducted’ dimensions.
The movement towards greater user control of services has encouraged innovation in aspects of user-led assessment. Nevertheless, Griffiths and colleagues write that ‘even the most innovative self-assessments require appropriate action by professionals’ (2005, p 7) and Qureshi remarks that ‘it is generally still for professionals to make the final decision about allocation of public resources’. Eligibility thresholds of some kind seem inescapable where public resources are being used but service user groups and others press the case for maximising self-determination within these constraints (Hudson and Henwood, 2006).
Clearly, the developing ideas of user-led assessment do not dissolve questions about the relationship of service users and carers, on the one hand, and professionals and agencies, on the other. They do, however, help to crystallise questions about degrees and types of involvement and make them available for debate and negotiation.
Fig. 3 Matrix of five assessment models distinguished by the extent to which they are user-led.
Fig. 4 Further outline of five assessment models distinguished by the extent to which they are user-led
|Model of assessment||Description||Comment|
|1. professional/agency controlled||fully professional/agency-led assessments in which the agency and professionals control the process, criteria and conduct of the activity.||represents the minimum of user/carer involvement; usually advocated in social work only in cases of significant risk to service user, carer or public.|
|2. user/carer-conducted/td>||partially user-led self-assessment by the service user or carer applying processes and criteria that have been defined and defined by agencies and professionals.||devolves the conduct of the assessment but maintains agency/professional control of other aspects.|
|3. user/carer-defined||partially user-led service users and carers have defined the process and criteria through prior representation and consultation but professionals conduct the assessment of individual situations.||a reversal of model 2 above.|
|4. devolved||fully user-led service users or carers have defined the process and criteria through prior consultation and a user or carer now conducts the self-assessment||reverses the ‘professionally controlled’ model and might be entitled ‘user/carer controlled’ except that where public services are implicated, ‘devolved’ allows for background ‘official’ governance to fulfil duties of care, probity and accountability.|
|5. collaborative||shared occupies a mid-point between the four polarities, combining professional and user/carerdefinition and conduct of assessment.||the other four models characterise the polar extremes of the two dimensions; this model represents symmetrical participation by service user/carer and agency/professional – it is a ‘symmetrical exchange’ model of assessment.|
Questions for educators
- Do students
have the opportunity to explore user-led approaches
to assessment including:
- the nature and implications of user-defined and user-conducted or self-assessment?
- the matrix of models of assessment, from professional/agency-led to devolved user/carer self-assessment, which come into view when assessment is examined for the extent to which it is user-led?
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