National Review of Access and Eligibility in Adults Social Care - Overview Report

Transcription

1 National Review of Access and Eligibility in Adults Social Care - Overview Report September 2010

2 Crown copyright September 2010

3 Contents Page Section One: Rationale for the review 2-3 Section Two: What are the thresholds for accessing social services? 4-6 Section Three: Do officers understand and monitor how eligibility criteria are applied? 7-10 Section Four: Where do eligibility criteria fit with the broader issues on access to services? Section Five: Overall, is the application of eligibility criteria fair and consistent? Section Six: What are the issues that impact on access to services? main conclusions Section Seven: Next steps 19 1

4 Section One Rationale for the Review CSSIW undertook this work in response to growing concern from a range of stakeholders, including service users, policy makers, regulators and local government. The purpose was: to review access and eligibility in adult social care; to comment on significant issues ; and to identify the key issues for further consideration by policy makers and practitioners. The key question for the review was what are the issues that impact on access to services, including the application of eligibility criteria? The more detailed questions considered by the review were: What are the thresholds for accessing social services? Do officers understand and monitor how eligibility criteria are applied? Where do eligibility criteria fit with the broader issues on access to services? Overall, is the application of eligibility criteria fair and consistent? The review focused primarily on older people. This reflects the considerable policy interest in eligibility criteria and the impact upon older people s services in particular. Methodology Following a survey completed by all 22 local authorities, inspectors spent one day in each of eight local authorities. Fieldwork took the form of small group, semi-structured discussions with identified officers. CSSIW met between 12 and 53 people in each local authority. Groups included corporate contact staff; social services duty officers; social workers and managers; commissioners; health partners from community nurses to director and consultant level; independent providers and voluntary sector partners; and senior managers to head of service level. These discussions were to test, or give additional information on, overarching or performance issues that arose from the survey. They also allowed inspectors to look further into the approach and understanding of the social services authority. Methodology and resources did not include case file tracking or individual interviews with service users at this stage but we were fortunate in speaking to user and carers representatives in each local authority. This provided useful general feedback on the impact and experiences of older people. 2

5 Specific areas of interest for fieldwork were: The impact and rationale of changes to eligibility criteria. the link to preventative work; how do local authorities ensure services go to people who need them access routes, decision making processes, ensuring quality and consistency of decisions? what else affects access to services? The review was not intended to address the following: individual performance of all local authorities across Wales (though any specific areas of concern will be followed up on a regional basis); assessing the future potential cost of care; a baseline study of models of services available for older people; or fair Access to Care Services (FACS), Unified Assessment (UA), or other assessment processes. 3

6 Section Two What are the thresholds for accessing social services? What are eligibility criteria? Guidance states that in order to manage their resources, local authorities have to identify those people they are able to help and those they are not. The mechanism for this is the process of applying eligibility criteria. These should describe the full range of eligible needs that will be met by local authorities who have taken their resources, local expectations, and local costs into account in the context of the national framework for Unified Assessment (UA) 1. The national framework outlines four criteria: critical, substantial, moderate and low. What are the eligibility criteria in place across Wales? Local authority eligibility criteria in Wales: Eligibility criteria Number of local authorities Critical and substantial 15 Critical substantial and moderate 6 Critical substantial moderate and low 1 Fifteen local authorities currently meet critical and substantial needs only. This is 68 per cent, compared with 70 per cent in England (in ) who met critical and substantial only. No local authorities in Wales currently set their criteria at critical only, compared with two per cent who meet critical only in England (2007-8) 2. It is unclear how many people in receipt of services have been assessed against each band within the eligibility criteria, for example, how many people have been assessed at critical or substantial. There are currently no nationally collated figures. In our survey, some local authorities reported that they could and did monitor numbers assessed at the different eligibility bands, sometimes through regular case file audits or workflow planning. But most reported that their information management and reporting systems were either in the process of adapting to allow monitoring, that their data was incomplete, or monitoring of figures was a manual process, with data being collated from different sources. At first glance, our survey shows a picture of tightening criteria at a time of increasing demand and pressure on resources. Over half the local authorities (12) have changed their criteria since All local authorities who changed their criteria raised thresholds. Four authorities currently set at critical and substantial had moved to those thresholds in the last three years. However, five of the authorities who set their eligibility criteria at critical and substantial had done so since NAFWC 09A/ Health and Social Care for Adults: Creating a Unified and Fair System for Assessing and Managing Care Guidance 2 Cutting the Cake Fairly CSCI October

7 Three local authorities stated their intention to change the criteria in the next year, two of them considering moving to critical only. Taken with comments from several local authorities that increasing numbers of people were presenting for the first time with higher levels of need, this suggests that services are increasingly only dealing with the more complex needs. There is a need for caution here. These figures also show that nearly half the local authorities have not changed their criteria. There are a third of local authorities still meeting moderate or low criteria. This picture also does not reflect some of the innovative person centred approaches and preventative work put forward by the local authorities that we met. Two of those authorities who were planning to change their criteria, (including one considering critical only ) have reviewed their decision following consideration by councillors, and are maintaining eligibility criteria at their current levels. The potential savings from restricting eligibility criteria may not always necessarily be as significant as imagined. One local authority had costed raising the threshold and had concluded that this would not deliver significant efficiency savings. This authority was also concerned that raising the threshold to critical and substantial would limit existing preventative work. In addition, their review revealed positive opportunities for more innovative thinking around services and more consistency of decision making within the existing criteria. It is interesting that this one local authority found that savings from changing criteria would be less than anticipated. While this evidence is confined to one local authority, it resonates with the findings of the CSCI study in England 3 which found that FACS policy therefore seems to have only a modest effect on expenditure. In the survey the main reason given repeatedly for past changes and planned changes to eligibility criteria was financial pressures. That is, local authorities said they had less to spend. Local authorities report that they are adopting preventative approaches and indicate that they are reluctant to restrict eligibility at this time. But they report this is against a background of efficiency savings to budgets, increasing demand, increasingly complex or severe levels of need. Thresholds to accessing services Within the process of people approaching social services for assistance and the application of the eligibility criteria, we found several thresholds. By this, we mean transition points where decisions are made about who continues in the process and who does not. The assessment of eligibility against criteria is only one of these points. 3 Cutting the Cake Fairly CSCI October

8 We have identified four points at which people are likely to be screened out of the eligibility process (either by the process or their own actions) they have needs but do not apply for various reasons; at first contact; on assessment; and post-assessment We will approach these in more detail in the following sections, though due to the methodology and the nature of the subject, there is more information on first contact and assessment. But it is clear that decision points and access routes have a crucial part to play in people appropriately accessing services. 6

9 Section Three Do officers understand and monitor how eligibility criteria are applied? We used the fieldwork to pursue our interest in the decision making process and the quality of decision making we asked how local authorities ensure that services reach people who need them. It became clear from discussion and observation that eligibility criteria are applied following assessment but that significant decisions about access are being taken at a much earlier stage. Screening at first contact All local authorities appear to have some form of screening process that assesses presenting needs to see if they are potentially eligible needs. Local authorities often refer to these calls as enquiries, or contacts. We will refer to this stage as first contact. The eight local authorities we visited used a variety of models, including: corporate call centres with no dedicated social care staff; social services specific call centres; social services duty officers (some non-social work posts, some community support staff covering duty); and social services intake teams with team managers leading specialist call centre assistants. Most are based in social services or have social service specific call centres. First contact is generally provided by phone contact with staff who speak to callers to ascertain their needs (though we did visit one authority that provides a walk-in service). First contact staff then decide if the caller has sufficient eligible needs to trigger further discussion leading to an assessment. Not all first contact staff use the term eligible need, although significantly some do. In practice, from the evidence reported to us, staff at first contact are identifying people who are likely to be found eligible at the formal assessment stage. This is supported by the anecdotal evidence from managers that very few cases are turned down at the assessment stage. One social worker commented that, the referral from the contact team is the basis of the eligibility decision. However, some local authorities that we spoke to did not seem to consider this identification of need at first contact to be part of the UA assessment. Indeed some specifically explained that this was not the case, even though the form used by staff was headed contact assessment. Local authorities will signpost to alternative services, often third sector partners, if they do not think the caller s needs are sufficient or if the caller merely wants advice. They use a variety of tools to allow them to identify needs: the Unified Assessment seven key issues, locally devised forms, checklists, and personal knowledge. Some of these tools are very 7

10 comprehensive, with one example reported of a form which took 20 minutes to complete. The quality of this decision to refer or not is therefore crucial to people s chances of receiving services. This is particularly significant given the number of people not referred on for a formal assessment of need. There is a former performance indicator that shows the percentage of enquiries that trigger an assessment. In 2008 this showed that an average of 46 per cent of enquiries across Wales triggered an assessment. Those local authorities in the fieldwork that reported the numbers of people referred for assessment or not at first contact, consistently showed that between half and two thirds of all calls to first contact were not referred. For a large authority that may mean over 1500 calls a year not referred for assessment. Many of those calls may be simple requests for services. But it does beg the question as to how local authorities know if people are screened out inappropriately at this stage. From information in the survey and fieldwork, no local authorities appeared to be monitoring the decision not to refer for example through case file audits or by sampling calls to contact centres. Not all local authorities we spoke to could collate figures on people who called but were not referred for assessment, though some actively did collate these figures. Only one of the local authorities in the fieldwork sample required managers to agree the decision when there was no further action at contact stage. We asked how the local authority ensures that identification of eligible needs is accurate and effective. Manuals and guidance appeared to be available. Training appeared to be available but patchy. There seemed to be a reliance on the knowledge of existing staff. Many of the staff in specific social services contact centres came from a social services background, though few were qualified social workers. Most, though not all, local authorities we spoke to ensured qualified staff were available at first contact to respond to complex cases or to provide advice. The quality of the information given out by staff at first contact is important, both to identify need and to signpost people appropriately. Capacity was raised as an issue in ensuring quality of identification of needs at this stage some teams carried vacancies or struggled to handle the sheer volume of enquires. Staff reported rushed calls, or conflict with the day job where they were social service staff who formed part of a duty team rota. Social workers in several local authorities reported that the quality of referrals was mixed. It is also worth noting that even where screening processes are strong, it can depend on individual skills and approach: there was evidence of cases where staff dealt with requests for low level services at face value even though the interview had highlighted other more pressing underlying needs. Processes and performance of staff at first contact are therefore important to people's access to services. We also found that the timing of the call, ease of access and potentially the local authority s approach to preventative work can 8

11 all have impact at first contact. We develop these points further in section four. Decisions about eligibility criteria Decision making processes about whether people met eligibility criteria were consistent across local authorities: they followed the UA process. All said that social workers did assessments. We did find that financial assessments, to assess if someone will contribute to their care, were consistently done following an assessment of need. This compares well with the CSCI study [2] which found that in England people were screened out of the process following financial assessment before assessment of need. We found that within the process there was an element of discretion. A significant number of local authorities we met reported that services outside their criteria could be provided for preventative reasons. Staff spoken to commented that people with moderate needs but who may become more substantial if not addressed, would come into system ; or [we meet need] if there is a likelihood of it becoming substantial or critical. We also heard there is flexibility; critical and substantial have a lot of latitude. Some local authorities believed they pitched their threshold low at first contact then used the assessment itself to offer a service to everyone whether that was signposting or referral to prevent deterioration. Social workers showed a very inclusive approach to assist as many people referred to them as they could in order to prevent deterioration in circumstances. There were significant amounts of monitoring of decision-making at this stage, in contrast to earlier stages. The reasons for checking consistency and accuracy included: the appropriateness of the referral; the relevance of the care plan (this is particularly true in local authorities that are trying to move from traditional approaches to more independence-led approaches and use this process to monitor that); and a very few looked at resource issues. We found that consistency of decision making within teams was more commonly checked than consistency of decisions across social work teams or locations. However, overall methods cited included manager sign-off, cross team or multi-agency panels, case file audits, supervision and workload mechanisms. Delays within the process Delays between referral at first contact and assessment are a potential barrier to access, though the main barrier does appear to be getting past first contact. However there is no doubt that once through, there are still obstacles to be overcome. We did not examine individual cases nor waiting times within local authorities, but most are working to national performance indicators on time taken to assessment, providing services and monitoring against that. Within this context, most reported capacity and resource issues as having an impact on allocation for assessment. The longer it takes to allocate a case for 9

12 assessment, the less time is available for assessment and some social workers reported a very short timescale to make a decision. All reported constant prioritisation of cases to ensure that crises were dealt with immediately and complex cases were addressed most promptly. Some social workers expressed concern that delays between first contact and their first approach to a service user might be measured in weeks and that by then the crisis may have happened between call and assessment. 10

13 Section Four Where do eligibility criteria fit with the broader issues on access to services? We have seen that eligibility criteria are important as the threshold for accessing services. But there are also other issues that affect people s access to services. Access routes We have mentioned that first contact has the potential to be a barrier, depending on the quality of decision making. Other issues about access routes came through our fieldwork and survey. Almost all local authorities, partner organisations and some social workers consistently reported that older people were reluctant to engage with social services for example, they do not like calling someone called a duty social worker. It is acknowledged that some people choose to support their own needs rather than approach social services. This was confirmed by partner organisations who told us people approach them rather than social services. Partner organisations reported that some older people do not understand the eligibility process, or that they do not apply because they think they will not be eligible or that they will not receive services. This may mean that by the time people do approach social services, their needs may be more severe. But if there is a barrier stopping people getting the support that they need and want, what is it and how do we address it? The method of access might be one issue. Most first contact points only use the telephone. In an emergency or in areas where transport is an issue, that is a practical solution. But partner organisations reported that people needed help to make these calls and we had reports of people approaching day centres and corporate advice points seeking face to face help. Timing is also an issue: if people only phone when they are in crisis, (and they may be reluctant to admit that), then a process that consists of taking their number and calling them back later may miss an opportunity for early intervention. Another barrier might be that people simply do not know how to make contact. We were repeatedly told by partner organisations and other professionals that people (including professionals) did not know where to apply. Our own research showed that information on eligibility and access available on websites was patchy, and one could question if this is the best route to inform older people. One partner from the voluntary sector did a 'fairly random sample' of 50 older people in preparation for our meeting and these older people did not know how to access services. The voluntary sector partner then tried to get leaflets as a member of the public and none were available. 11

14 We saw that the way local authorities organise contact and identify needs can be a barrier. As indeed might an approach intended to support independence, however well intentioned. First contact is there to identify needs. But if someone rings saying they need a community alarm and the reasons why they need a community alarm are not explored, then their true needs might be masked. A caller s needs are being screened from the moment they first call and the evidence suggests it is unclear whether all callers understand the implications of that or indeed the whole assessment process. Callers with potential social care needs ring the same number they would call to get their dustbin emptied. They might be reluctant to speak about personal care problems until they meet a social worker; but if they do not articulate their needs adequately at that point they might not get to meet a social worker. In one specific example social workers reported that if information is not presented in a certain way to meet triggers, people will be presented with alternatives to assessment. One authority with a focus on prevention said it assisted people to make a choice about their own arrangements. In practice this sometimes means that people when asked say they can manage. Preventative work Given the local authorities focus on people with eligible need and the numbers not being referred for assessment, we were interested in the preventative work or strategies undertaken by local authorities. We also asked what support they can or do offer for people who are not found eligible and what that means in practice. All local authorities we spoke to said they signposted people who were not eligible or who made a simple request for service. Some had formal arrangements with providers to provide certain low-level services. By and large though, signposting usually meant giving people detail of providers in the voluntary sector. Some local authorities said they had access to comprehensive databases of information and services provided by the council, independent and voluntary sector. While most had some sort of list, contact centre staff and partners from voluntary organisations provided mixed comments about the comprehensiveness and accuracy of the information that it contained. It did appear that unless the caller makes contact with an advocacy service or a voluntary service who actively pursues their case, signposting can mean finding your own solution. All local authorities we spoke to, however, showed a commitment to preventative approaches. For some this was in the form of an inclusive culture trying to support as many people as possible through the eligibility criteria. Most had some form of strategy which took account of preventative work. Two authorities reported that they had funded voluntary partners to provide low 12

15 level services when they changed their eligibility criteria threshold to substantial. We did find some divergence between the perception of preventative work by local authorities and their partners. On the ground, in some local authorities, there was a perceived lack of cohesion. Strategic approaches were not immediately visible to partners and preventative work in places seemed piecemeal rather than coordinated. Voluntary sector partners consistently raised the perceived missed opportunity by authorities to link their preventative strategies with the way in which they fund and work with the voluntary sector. In particular the failure to move to longer term funding arrangements for voluntary bodies was reported as a barrier to planning and establishing effective preventive work. A view made more acute by the perceived growth in the numbers of people being referred or signposted on to the voluntary sector from local authority contact centres. Partners reported confusion about cohesion in services with some voluntary services appearing to be duplicated, slow or late funding decisions affecting their ability to respond to need, and a lack of accessible information. Some of these groups said they did not feel like partners in the process, that the local authorities talked about partnership but were preoccupied with funding. The partners also reported that eligibility criteria have an impact on their own work. It was noted that most voluntary services supported people who fall into three groups: people who chose not to approach social services; people who had been found ineligible and signposted to them; and people who had been found eligible and supported as part of a commissioned service. They reported increasing numbers approaching them directly as well as being signposted by the local authority. Some had introduced their own rationing processes as a result. Most reported concerns about continued funding. This was echoed in our survey, where several local authorities raised the point that funding restrictions were also putting pressure on preventative initiatives and some had ceased to fund certain preventative services. Much of this might be around communication and ongoing development of working practice. But if local authorities are relying on voluntary organisations and providers to support their preventative work and support the numbers of people who will not approach local authorities or are not eligible, then they need to consider how best to support that preventative framework. Other issues There was some anecdotal evidence of charging being a barrier to access. Contact centres reported that some people asking for services decide against continuing with the process when they hear about charging. A few local authorities reported tensions in reablement and joint services where health 13

16 care or social care might be free for a certain period of time but where charges are introduced later and people may then refuse any further service. It was reported to us that one barrier to access is that some services simply are not available for a number of reasons, such as rural or isolated locations, limited range of services or delays in accessing specialist services, for example occupational therapy. In the survey many local authorities reported financial pressures or availability of resources as the biggest issue affecting access and eligibility. For some this was seen not simply having less money available, but as the pressure on existing resources from meeting higher dependency and complex needs. Some providers reported that services which previously had a preventative or monitoring role had changed dramatically. One example given was that day services are now supporting people with more critical needs in the community. This can include offering intensive personal care, such as toileting, bathing, and monitoring fluid intake. This can mean fewer places available for people needing social care. There was concern expressed about those in-between who do not get day care any more. A significant number cited health and corporate partners lack of understanding of eligibility criteria and the constraints eligibility criteria can bring. There also seemed to be an issue with other access routes whilst local authority processes and eligibility criteria meet all client groups, Health have separate clinical criteria for provision of integrated services. Several local authorities commented on the application of clinical diagnoses to people with mental health issues or learning disabilities and that this could affect their access to mainstream services. We did note in our fieldwork that there are routes that bypass eligibility criteria, for instance services provided under Protection of Vulnerable Adults (PoVA) in cases that would not meet the relevant eligibility criteria thresholds; or complex care teams ( for example multi-agency team preventing hospital admission) where services can be accessed without eligibility criteria. There may be good reasons for these decisions but they do undermine the concept of equity and consistency of eligibility criteria. It also highlights the inherent tension between eligibility criteria which seek to meet the highest needs first and the increasingly preventative early intervention agenda local authorities seek to pursue. 14

17 Section Five Overall, is the application of eligibility criteria fair and consistent? Without comparing individual decisions it is hard to tell whether application of eligibility criteria in individual cases is fair and consistent. What we can say from our study is that although there is little monitoring of first contact stage, local authorities put large amounts of effort and resources into monitoring the assessment against eligibility criteria stage. However, this includes monitoring the appropriateness of the resulting package as much as it does the quality of decision making. They are also more likely to monitor consistency of decisions within teams or by an individual, rather than monitor consistency across teams or locations. We do know that there are different eligibility criteria in different local authorities. This is in line with the eligibility criteria guidance. Different local authorities are not required to make identical decisions about eligibility. Guidance does not prescribe the way in which the needs of service users who are in similar circumstances should be met, nor does it prescribe what services should be available to service users who have similar needs. It expects that people in broadly similar situations have broadly similar outcomes, to reflect the person-centred approach that assesses an individual s specific problems, circumstances and related risk. It also accepts that in setting their eligibility criteria local authorities will take account of their resources, local expectations, and local costs. In some respects, local differences are therefore built into the system. The equity in the guidance comes from all local authorities using one eligibility framework for all service users though as noted earlier we did see that there can still be different routes into services for different client groups. This said, most local authorities have set their eligibility criteria at the same level. Fifteen of the 22 have eligibility criteria set at critical and substantial, with a further six set at critical substantial and moderate. What we do not know is what that means is one local authority s moderate the same as another s? (We also do not know if criteria are applied consistently across client groups: this was outside this study s remit, but relevant in light of some of our findings). Certainly some local authorities we spoke to, when they undertook case file audits, found inconsistencies within their own bandings, for example whether a particular set of needs are assessed as moderate or substantial. We also do not know for sure, as we have seen, if the right people are being assessed, or if people are being inappropriately screened out at an early stage due to processes, quality of decision making and training or lack of monitoring of first contact. We do know from the survey that there are few recorded appeals against the decision about eligibility though this might reflect the anecdotal evidence from our fieldwork that few people are turned 15

18 down at assessment stage. There is no evidence available here about how many people complain or appeal if screened out at first contact (where the volume turned away is more significant). We do know that only five local authorities in our survey said that they monitor the number and reasons for rereferrals. 16

19 Section Six What are the issues that impact on access to services? Main Conclusions The overall picture is of tightening resources, with increasing demand, people presenting with increasingly complex or severe levels of need, and changes to eligibility criteria due to financial pressures. It is important to note that we also found a commitment to preventative approaches and some development of innovative person-centred working. Most local authorities (15 out of 22) set their eligibility criteria at critical and substantial. However, this does not mean that eligibility criteria are always applied equitably or consistently across, or within, local authorities or across client groups. There are some indications that this is not always the case. Local authorities are trying to meet as many eligible needs as they can within the framework, within their limited resources. There are thresholds within the process where key decisions are made and some of them are barriers to people trying to get services. People with immediate evident significant needs tend to get through the process and be found eligible because that is what eligibility criteria framework was established to facilitate. The issue is what happens to people whose needs may be more borderline, less evident or less well articulated. By and large if you get through to assessment, it appears that you will usually get some form of support. The barrier can be getting through to assessment. It often depends on the first contact. Processes and performance of staff at first contact is therefore important to people getting services. This means that the quality of questioning and the decision making is crucial. People need to know how to apply, and the way that they then express their needs in conversation is a key factor in determining what happens next. The timing of the call, ease of access and potentially the local authority s approach to preventative work can all have impact at first contact. The UA 4 guidance says that everyone is entitled to an assessment. In practice everyone gets an interview at first contact to identify their needs but this will probably not be considered the actual UA assessment by the local authority. Local authorities might wish to consider how to make the best use of the often considerable time spent on this process, to assess needs and better shape any preventative or signposting advice that may be offered as an alternative to referral. 4 NAFWC 09A/ Health and Social Care for Adults: Creating a Unified and Fair System for Assessing and Managing Care Guidance 17

20 Apart from the application of eligibility criteria, there are a range of alternative access routes to services including through health services, through initiatives such as the PoVA process, joint preventative hospital admission schemes, and inclusive approaches to prevention. It was reported that these can provide an alternative access route to the published eligibility criteria. There is perhaps an inherent tension between an eligibility framework that targets the highest needs as priority and a preventative approach. The study found a perceived lack of cohesion between providers and local authorities. Providers identified missed opportunities in strategic planning and confusion about funding. This must be tackled if service providers are to deliver early intervention to support the independence of people in need of support. Better cohesion to provide packages and support for people found not eligible, perhaps as a form of early intervention, could support a preventative approach. 18

21 Section Seven Next Steps CSSIW will incorporate the evidence from this review into its analysis of the strengths and areas for improvement in local authority social services. It will be used to help inform the development of our activity and work plans for 2011 and beyond. We will continue to monitor the effectiveness of access to services for people in Wales. This task will assume even more significance as demand and constraints on public spending grow in the coming years. Recommendations Local authorities should ensure that better information on how to access services is readily available in a format and locations appropriate to potential service users. Local authorities should also ensure that access routes are clear and transparent; readily understood by users, carers and partners; are appropriate to the needs of users; and seek to support people to approach for assistance and to articulate their needs. Local authorities should review their contact and screening arrangements to ensure that engagement with people to identify their wider needs and subsequent decision making is of good quality; that training and expert social care advice is readily available to staff; and that decisions are appropriately monitored to ensure that people with needs are accessing services appropriately or receiving effective advice. Given the amount of time taken to screen at first contact and preassessment, local authorities should look at how they make the best use of this time as part of the actual assessment process, not just a pre-assessment screening process. Local authorities and key partners should ensure that there is better cohesion in preventative services to support the actions above and to support those people found not eligible. Issues were raised about whether the unified assessment process and Fairer Access for Care Services are still fit for purpose as local authorities actively move towards outcome focused working, joint teams and preventative early intervention approaches. It is suggested that the impending review of Unified Assessment should consider this question along with the other findings of this review. 19