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t
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ryantunnardbrown
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development : children and families
Assessment models - the contribution of the paper work practice tool
This paper describes Paperwork, one of the alternative models to the Department of Health assessment forms. It explains how the model has been implemented in four local authority areas, and draws out some of the emerging themes. As with any practice tool, there are countless things that have been said and could be repeated today. Many are about practicalities and process, and all are very important. But what I'm going to focus on are just a few of the key lessons that are emerging about professional practice, because these pose challenges that are relevant for all of us, no matter which assessment tool we have adopted, or adapted, to help comply with the requirements of the Assessment Framework.
I'm drawing on four main sources for the presentation:
· First, the feedback we have given to the local authorities over the past two years about what social workers say and do. The "we" here refers to the small group of consultants who were employed by the Dartington Social Research Unit to develop and implement the tool.
· Second, the internal audits and evaluation of the work, conducted by the individual local authorities.
· Third, comments about Paperwork from external examiners, and
· Fourth, what we have learnt about other assessment tools from our work in a range of other local authorities. The "we" that I'm referring to here are colleagues at RTB. By now we have read hundreds of other assessment forms, when helping with Best Value reviews, leading audits of need, reviewing mental health services for children and adolescents, and scrutinising the operation of thresholds in child protection and looked after work.
WHAT IS PAPERWORK?
This assessment tool was not developed as a direct response to the Assessment Framework. Rather, it's part of a wider endeavour to explore the potential for a common language for children in need. It's the product of ongoing work at Dartington that takes the language and tools of research and tries to apply them to policy, management and practice with children and their families. The overall intention is to improve communication, and consistency of judgment, between those involved in the work:
· between researchers, policy makers, managers and practitioners
· between health, education, social services and other professionals
· between those working at different levels in the hierarchy of children's services
· between professionals and service users
· and between different countries - there's an international perspective to the work.
So Paperwork is part of a package of tools that is being developed. A familiar one to many people is the Matching Needs & Services audit methodology. Each tool can be used on its own, but it is intended - over time - that they are seen and used as part of a set.
This work on developing the common language rests on four concepts. They are about:
Need - the needs of children and families in all areas of their life
Threshold - measuring how serious is the child's situation
Outcome - what can be achieved realistically, and what actually happens, and
Service - what response offers the best chance of enabling families to achieve the outcomes, given the needs identified and the severity of those needs.
These same concepts underpin Paperwork. What Paperwork offers is a way of recording and analysing information that is compliant with the Assessment Framework.
What does it look like and how does it work?
There are forms for Initial and Core Assessments, and others too – for reviews, for multi-agency work, for child protection conferencing and for pathway planning.
The forms differ slightly between the four local authorities implementing Paperwork, but the core features are the same – you build up information about each of the concepts, about risk and protective factors, about unmet needs and about family views.
In relation to the layout of the forms, the key point is to work down the dimensions (the LAC ones), from top to bottom of each form, and then across the concepts, from left to right, completing the form column by column. A sample form can be viewed at the end of this paper.
Implementation has been preceded by training courses that focus on completing forms from real cases, followed by office-based coaching for teams and individuals, and with periodic refresher sessions for practice supervisors and team managers. In one authority an induction pack has been produced, to bring together in one file the Paperwork forms, examples of completed forms, tips for recording in each column, links to the Assessment Framework dimensions and domains, and local authority policy and procedures for assessment. The packs are used as a training tool and are available in each office.
The Paperwork process provides a structure to help people think about the meaning of information, rather than just collect information. The tendency in social work has been to say “here's the problem, what's the solution?” What's needed instead is an approach that starts with the question “this is the situation, what does that tell me about need?” But then goes beyond that:
· analysing risk and protective factors,
· making a judgment about what's possible,
· thinking about possible service responses,
· reaching a conclusion,
· and being clear about how and why you got there.
Thinking and analysis are the key activities here.
There are three observations to add to this general view about assessment.
The first is about what happens in between judgments about need and service. The Assessment Framework is rather vague about this. It rolls concepts together, with plenty of references to "moving from needs to services" and "moving from needs to a plan of action" without spelling out that, between those stages, there's some important thinking to be down about outcomes.
The second point is that some practitioners find the concepts of need and outcome particularly difficult to grapple with. So, for need, there's a tendency to identify services instead - counseling, day care and assessment often crop up on forms. Our response is to say: take a step back - what is the need that gives rise to that possible service response? Is it the need to cope with loss or trauma? Is it the need to understand the adverse impact of adult conflict on children? Is it the need for greater stimulation for a pre-school child? Think need not service at this stage.
The difficulty with outcomes is about language and understanding. Often outcomes are phrased as more needs, rather than where the child or parent will have got to if the needs identified are addressed. It might be that a mother understands how her past trauma is affecting her child. It might be that she understands which bits of behaviour she needs to change. Or the outcome might be that she has changed her behaviour. It depends on where she's at now. It's a matter of professional judgment, and it's an essential part of assessment.
Paperwork encourages practitioners to take this approach. It gets them to check that they are thinking about outcomes that are SMART:
· Specific,
· Measurable,
· Agreed with families,
· Realistic, and with
· Timescales.
A third point about analysis is how well assessment forms enable workers to analyse change over time. The layout of the forms is helpful here, with their flow from left to right through the different concepts of need, threshold, outcome and service. In one coaching session a worker was preparing for the revocation of a care order. The advantage of the Paperwork form was that she could lay two side by side, putting the two needs columns alongside each other. The first form set out the needs before the care order was made, the second set out needs now. She got a graphic, and immediate, picture of what had changed between her two assessments. And she commented on how easy it would be for the parents to get a measure of how things were different, which needs they had worked on in the intervening period.
CASE MANAGEMENT, DECISIONS, PLANS
This section is about the contribution of Paperwork to deciding what needs to happen next.
In relation to case management, the attention that is required to recording timescales for achieving outcomes can be helpful.
So what about the "plan of action" that the AF refers to as coming at the end of assessment. How much thinking goes into this part of the work? Assessment using PW means that your task is not complete until you end up with a summary analysis to date, giving as much weight to outcomes and services as it does to circumstances and needs.
In another coaching session a worker explained that she needed to record, and keep track of, three different timescales for her case - three days to liaise with housing to avoid eviction, two months to see the benefit for the child of stimulation from a nursery place, and six months for the mother to begin to reduce her substance misuse if she managed to attend her group meetings every fortnight. The worker was clear that she didn't want to record only the longest timescale because work on the other needs might have fallen behind what could realistically be achieved in those areas.
The process can help with decisions about the transfer of cases to other teams. One advantage comes from the work that goes into completing the services column. Here again the message is about being clear and specific. The tool requires practitioners to make and record their judgment about what should be provided, by whom, for how long, from what venue, and for which family members.
Sometimes that thinking can help justify keeping the work a little longer in the assessment team, allowing direct work between family members and the social worker they have come to know and trust. A girl of 12 was in serious conflict with her mother, and vulnerable because of mixing with an older group and staying out late at night. One need was for mother and child to find ways of communicating better. The social worker was on the brink of suggesting a referral to a specialist local mental health service. But the waiting list was at least six months’ long, and the social worker thought the work could be done in six weeks. She had already started that work, and wanted to complete it. So, in the service column of the form, she put down herself as the person to do the work – and prepared to meet her manager!
Coaching for the long-term teams has highlighted the wide range of situations where Paperwork can help take stock of the next steps. As, for instance, when planning the final stage of social work involvement with a child newly de-registered. At the end of a coaching session the worker commented that the link between need and outcome was really important and had helped her conclude that school was going to be the best focus for work with the child.
Or, for a child newly looked after, the social worker commented that doing the form had made him realise that the plan he had been working to was unrealistic. Doing the outcome column had clarified that the parent was not able to set routines for the child and so he needed to think about who else to involve in that aspect of parenting.
Or, taking stock before a quarterly multi-agency network meeting, a worker said: “This list of needs is a good summary of my view. I must go through it with the parents to show them what I'm worried about, and check whether we can agree some realistic outcomes.”
The tool has also been helpful in enabling colleagues in other teams to move more quickly to providing a service. A Family Support Team have found it helpful having the assessment team set out clearly what is needed by way of services, once they got over their initial resistance to thinking they were being told what to do by the Referral and Assessment Team. In turn, the Family Support Team is now demanding greater specificity when taking referrals from the long-term team for time-limited pieces of work. The obvious advantage here is that people are becoming more confident about trusting the judgment of colleagues. And repeat assessments are being avoided - a bonus for professionals and families alike.
Paperwork has also been found helpful when transferring cases out of the department. A worker commented that the form looks at the past, the present and the future all in one, providing useful summary information about the case, without the need for an additional transfer report.
PRACTICE THAT IS EVIDENCE BASED
Each section and each concept of the forms benefit from, and help promote, the value of research and other evidence in children and family work.
For need – you don’t know what evidence to apply if you are not clear what the need is. It sounds obvious, but the fact is that practitioners misuse evidence if they lack a clear analysis of need.
For threshold – this section challenges practitioners to think about the research basis for their prognosis. To ask what is the evidence about the risk and protective factors in families lives. To be clear about how they will justify their opinions to supervisors and to families? To understand the likely impact on children of domestic violence or depression, of racial abuse, poverty, inconsistent parenting? To know what influences practitioners when they make a judgment about whether impairment is significant or not?
For outcomes and services - practitioners need to draw on available evidence about what works, and for whom, and in what circumstances. This will sometimes be helpful in setting timescales. For a difficult 4 year old, a cognitive behaviour course for parents lasts up to 14 weeks and has a good chance of working. But for a difficult adolescent, the evidence suggests that a programme of at least 6 months, with several points of contact each week, is more likely to be needed, but may produce only small changes in behaviour.
AGGREGATION OF DATA FOR PLANNING PURPOSES
How well do assessment forms enable you to aggregate data? This is a struggle for everyone at present. Here, too, Paperwork has something to offer.
First, through a small insert to the Initial and Core Assessment form. Information from the circumstances and need columns can be transferred to that insert and the data then coded and computerised, to give a profile of the needs of families being assessed and/or receiving a service. This work is still in its infancy, but does offer a way forward, including the possibility of teasing out need groups by applying statistical cluster analysis to the data inputted.
Other parts of the form are just as important to aggregate. There's little point in busy social workers diligently recording information about unmet need if that information doesn’t feed into service planning. This, too, is work for the future. It is about analysing data in order to produce baseline information and then using this to measure progress year on year.
MULTI-AGENCY PROGRESS
The Assessment Framework is clear that the assessment of need is the responsibility of all agencies. But it's rather weak on how they might all discharge this responsibility. I'm reminded here of all that work after the implementation of the Children Act in 1991. There was a massive push from the Department of Health on the importance of multi-agency training, and a great flurry of activity until the central funding ran out. I think the time is probably right for a repeat performance.
The multi-agency form developed by one of the Paperwork authorities is really helpful. It's to be used by health, education and the voluntary sector, either to refer in to social services or to contribute to an assessment. It has led to multi-agency briefing meetings, demands for training, training courses and coaching sessions.
All that is good news and will ring bells for staff in other places where a similar form has been introduced. It makes other agencies think and analyse too - they have to apply the same concepts, as the form follows the same format as the ones used by social workers. It helps boosts social work morale - they can't so easily be dumped on any longer, especially as the form requires agencies to record what they can contribute to address the needs they identify. And it's likely to get people talking more about how they understand and describe need, and that’s a useful step towards acknowledging and resolving the difficulties about terminology which can and do hamper fruitful discussion and planning for and with children and families.
IN CONCLUSION
These are some of the lessons emerging from one particular approach to assessment work. I think the overriding message to take from the work is that it is both exciting and daunting.
What's daunting is the change involved in all of this. For many practitioners and managers, it does require a different way of thinking. The focus on analysis is perhaps the biggest shift. You can't escape into writing long essays on contact sheets when Paperwork requires you to be concise. You can't slip into giving more background information when you are required to move on and analyse need, severity of need, outcome and service. You can’t so easily assess people away from services when you have identified those who will benefit from early intervention and your evidence is clear to see.
The same applies to supervisors and managers. They need to be just as familiar with the concepts. They need a strong senior management team with a shared vision and a systemic conceptual framework (evidence based/outcome led) which informs and drives all aspects of business. Those with little money would say this makes this need all the greater!
Managers, and elected members, need to be ready and willing to engage in the debate with staff at all levels, and the community, about how resources are to be used - which needs can be addressed now and which will have to wait until later. At an individual case level, they have to engage with workers who say they do thorough assessments and have them knocked down in favour of cheaper alternative services that don't match the needs identified.
And what's exciting? Paperwork does offer the real possibility of being more focused in direct work with families. What would you want from your local services, for a sick or elderly relative or a child in need?
For a start you'd probably want to know what it means to be assessed. Social workers sometimes ask us who's going to help families understand the assessment forms they get. And the answer is that they are, of course. They need to be saying to families:
· I have to understand your family's situation
· and what that tells me about what your child needs
· and about what you, too, might need
· and about what will happen if nothing is done
· and what we can hope to achieve for you and with you
· and who will do what
· and how we will all know if we've got there.
That, in essence, is what the Paperwork approach to the Assessment Framework provides.
Other things are exciting too. One of the project areas said that the local team that has sent out a copy to families of every assessment completed has, since the project began, received no complaints and one letter of compliment - something unheard of previously. On a larger scale, there has been praise for Paperwork from two joint reviews. The reviewers said that the tool is promoting a more thoughtful and holistic approach to the assessment of children in need. They quote a social worker as saying “now, with every case, I think what is the long-term plan rather than what do I have to do to avoid getting into trouble”. They quote a senior manager as saying “staff are thinking more and writing less”.
Jo Tunnard
Paper presented at the Making Research Count Policy Forum “The Assessment Framework: One Year On” in April 2002