What outcomes did stakeholders expect from SSA, and to what extent were they achieved?
SSA was meant to create a holistic record of the patient’s condition and circumstances, which health or social care staff could use to assess care needs. It was expected to reduce the number of times patients were asked for the same information by different professionals, reduce the duplication of records and increase accuracy of information thereby leading to improved quality of care.
We found that progress towards these outcomes could at best be described as ‘limited.’ All areas had adopted paper SSAs, though in several cases these were rarely used, as the normal method was to record the assessments electronically. All but one area used electronic SSAs-though the extent to which this happened varied between locations within the area-some were almost completely electronic, others were still in the process of implementing them. On the key question of the extent to which staff were sharing the assessments electronically (the main intended outcome of the project), answers were mixed, with the 11 DSMs interviewed answering: yes-2 sites; limited-6 sites; no-3 sites. One of the two DSMs whose colleagues were sharing data electronically explained: ‘it has increased sharing compared with paper, as it is much easier to use’. One, in an area where sharing was limited, said ‘other professions can’t add [information] to the SSA, so they send it to social work who enter it’, while one where there was no sharing explained that this was due to ‘the technical challenges of three computer systems and the cultural differences between health and social work’.
As one respondent, who had initially made good progress commented, momentum was now being lost:
‘Management don’t appear to want to get the information. I think staff are feeling that nobody’s interested, so why bother? It’s affected by the eCare framework, which has failed to materialise, so there has locally been a reluctance to maintain what we’ve got, just in case the national one came along’. (DSM1)
A similar pattern was evident in our three case study sites. While one had made more progress than the others, the sense was of a project which had not yet achieved the outcomes expected, and which many felt were now unlikely to be achieved. One respondent said:
‘I don’t think it has had the impact it was meant to. I’d give it about 1 out of 10. I don’t think it has helped in the slightest. We don’t share a lot of them… … they’re probably not a particularly good assessment either. In terms of a joint document it’s pretty pointless really’. (Interviewee 3-health)
Staff were aware of both the positive and negative outcomes of SSA-commenting for example on the advantages of having an electronic record or, elsewhere, on the disadvantages of the bulky paper document. There were also many comments about how staff used SSA-sometimes as a full shared assessment as intended, by others as a tool for securing a specific care service for a patient. Units also varied in the extent to which they stored the assessments on paper or electronically. A common theme was that the SSA would not be implemented successfully until adequate IT systems underpinned the document.
How did structural boundaries affect electronic data sharing?
The structural boundaries likely to be most relevant are those delineating the delivery of health and social care respectively. NHS Scotland delivers services through 14 Health Boards which, though funded by the Scottish Government, have considerable autonomy over the way in which they deliver them. They can decide how much to spend on information systems, and which systems they want to use or develop. Within Boards, each hospital or clinic can also decide on the disposition of IT expenditure-even where national systems are developed by the centre, units can decide whether or not they use them. Care services are delivered by 35 local authorities which, though substantially funded by the Scottish Government, have a high degree of autonomy over policy, including IT provision.
Health boards and local authorities face competing demands for support from those promoting the many services they provide, as does the Scottish Government which supports them. Staff in both areas talked about the difficulties of different services having their own priorities and information needs, for example to monitor their service in relation to national and local performance targets. They also questioned the Scottish Government’s commitment to the SSA and what their priorities are:
‘I’ve a feeling that the Scottish Government’s starting to move away from it (SSA), because we’ve now switched to this enablement model and more of an outcome focused model of working …so I think this, this dawn of the SSA might not . continue … this is about 10
years on and we’re still struggling’. (Interviewee 19-social work)
Competing priorities were described on an individual, professional, organisational and governmental level and were seen as a major problem.
‘… unfortunately they’ve got ministers saying no you need to deliver on this, this and that, and that’s a priority and that’s not. I think SSA is probably left to us to get on with now … But … we need national support. We need national networks where … anybody that has got some sort of remit for SSA, you can share experience of good practice or bad practice, or just having a sounding board and because it’s a very isolating place to be’. (Interviewee 22, management)
IT systems and infrastructure
There are significant differences in IT infrastructure between health and local authority organisations. Local authorities have one system, called CareFirst, that can be easily connected to the eCare framework, but NHS Scotland, with multiple IT systems, cannot. Respondents talked about how clumsy and time consuming it was to complete the SSA on paper and expressed frustration that the technology could not support the successful implementation of the SSA.
One respondent noted that health and social care appeared to be at different stages in the use of IT as well as the infrastructure:
‘Probably the biggest [obstacle] is the lack of IT infrastructure in health. Most social workers were using computers regularly, often laptops, mobile devices. This was just a new application we had to teach them how to use. A lot of the health professionals we dealt with hadn’t come across mobile devices before. I think they found it in some ways quite challenging’. (Interviewee 12-health)
Even if health boards and local authorities were at similar stages of IT use, these have developed independently, and so required an interface to link them. This interface was to be achieved through the ‘e-Care framework’, but several respondents claimed that this system was not able to meet the needs of users, and required significant work to put right:
‘The e-care framework can currently [only] allow a system to publish and view SSAs. Its implementation has been fraught with problems because of a change of government, a change in leadership, a lack of leadership and just a poor implementation plan from the Scottish Government’. (Interviewee 2-health)
The pressing need for more system interoperability was also a recurring theme.
‘So you have got systems that can’t link up, that won’t link up and I think there is a huge call for a system that did marry up’. (Interviewee 29, health)
Positive examples of sharing information were reported in spite of the lack of IT infrastructure, but it was widely acknowledged that data sharing would be much easier if it were supported by electronic systems.
Implementing an electronic SSA has initial and ongoing financial implications. The Scottish Government provided £150,000 over three years to each area to implement the SSA electronically as part of the eCare system. Towards the end of the second
year there was a change in government and funding was reduced. When that funding ceased, councils and health boards had to decide on their local priorities:
‘We were getting financial help from Scottish government to take forward SSA… That funding is no longer there so we’ve had to absorb it within our own organisations. That will have had an impact-there’s [part of] my post…and also we did have admin support and things. Whether it’s financial costs or just implications for staff having to try and catch up when they go back’. (Interviewee 4-social work)
Respondents suggested that future developments in IT may also depend on the willingness of local Health Boards and councils to provide funding; which might not be prioritised in times of financial constraints. Since 2009, there has been no funding at all dedicated to SSA with councils or health boards having to commit their own funding to taking this forward.
How did professional boundaries affect electronic data sharing?
The professional groups most involved in SSAs are social workers (within which there are further specialities such as mental health) and the health professions (especially community nurses). Professional boundaries between these groups affected their respective understanding and acceptance of the aims of SSA, the information they require to do their jobs, and whether they see SSA as consistent with their culture.
History of co-operation
How people act is influenced in part by historical factors and, in this context, this means the extent to which they have worked collaboratively with colleagues in other agencies. There has been a long history of attempts to bring health and social care services closer together with limited success, as the following respondent highlights:
‘SSA was a naïve political vision [based on] the idea that we had a joint future, and as a joint future has never taken place, SSA has always struggled…we’ve never worked closely together particularly at the management level with our Social Work and Local Authority colleagues. [Barriers include] trust, budgets, management structures, councillors trying to control services, health board members not elected, not wishing to share funds’. (Interviewee 3-health)
This was a significant theme throughout the interviews with health and social work staff. Respondents talked about distinct professional boundaries being maintained by each agency with an acceptance that that’s the way it’s always been and that it is unlikely that it will change. The following interviewee gave a typical view:
‘I think there is still an underlying trend that, oh well that’s health and that’s social work and never the twain shall meet which is a real pity but that’s how staff are’. (Interviewee 4-social work)
Importantly, there was evidence that such barriers to joint working could be overcome. For example, one area instigated an initiative called ‘virtual teams’ which was a joint programme designed to improve communication and understanding of professionals’ roles. They used creative media to raise awareness of communication issues and professional boundaries. The following respondent talks positively about the scheme:
‘Because there were limited communications between the two groups of people and it was leading to a sort of blame culture well this is social work’s paperwork or, or health aren’t complying with this and that wasn’t the case, so they did a em, it was a like actors came in and did a wee scenario, but very comically showed us what we looked like in a sense, you know blaming each other and things and that was really useful as well, because everybody could relate to it and then we sat, sat down in group works and actually started to look at paperwork and look at how we used it and it was, it was really useful’. (Interviewee 17-social work)
Understanding and acceptance of aims of SSA
There were a range of views about the aims of the SSA. Many described the aims in terms of theory and practice, explaining that they were different. Typically, staff would outline the theoretical aims of the SSA in terms of holistic care, joint working and reduced duplication and then talk about how it works in practice. In practice, many professionals were using the SSA as a referral document to secure services for patients. The following respondent articulated a common view:
‘…if you’re gonna get a service from social work then this is the ticket’. (Interviewee 8-health)
One manager wondered if the management team was partly responsible for staff perceiving the SSA as a referral document. Because the professionals were reluctant to use the SSA, managers made the decision to make it a necessary part of the referral process. The following comment describes the unintended consequence of this decision:
‘because the decision was made that you had to do a SSA to access other services, then it was never seen as, you know, the full assessment, it was seen as a way to get into another service as opposed to what it should have been …’ (Interviewee 12-social work)
While some who were responsible for the implementation of the SSA expressed their frustration with professionals, others did describe positive examples of how the aims of SSA were accepted yet still proving difficult to enact in practice.
‘I think it’s fairly well understood in theory. I’m not sure that they, they see it the same when they’re actually in practice and doing all these things but they see that yes, it’s useful. And they certainly come back to us when we’ve done training or when we’ve gone back out and yes it is a really good document but I don’t have time to do it, they’re just not seeing the whole picture. Em, so I mean it has fallen down as far as that goes where, yeah, the theory of it is great but in practice it’s just not hitting the mark’. (Interviewee 4-social work)
Professions often have different beliefs about the information they need to do their work. All staff assess a system’s ability to meet their information needs by its usefulness and ease of use. Commonly practitioners found it neither useful nor easy to use:
‘I think they are not all that happy with the assessment because it is very time consuming and as I say it doesn’t always give us the results that we want to get’. (Interviewee 25, health)
Many of the health staff criticised the SSA document for not having enough clinical information and for covering more ‘social’ than ‘health’ information:
‘It’s more a social work document than a health document, and there’s still this huge gap between Social and Health’. (Interviewee 5-health)
Health staff also suggested that much of the information in the document was not important or not appropriate, for example, ethnic origin, religion and first language. There was dissatisfaction about the information needed to meet the Scottish Government minimum data standards, which was contrary to what practitioners think they need to give care to their patient. In addition to the type of information required, practitioners questioned whether it was necessary to undertake a full and often unwieldy assessment for what they considered a relatively simple need like a ‘helpcall’ which is a push-button device that they wear around their neck:
‘Why do a whole 14 page assessment when actually the person needs a helpcall? What is it we need to know about the person for them to have a helpcall? We don’t need to know all their background and how many times they’ve been married’. (Interviewee 8-health)
There was variation and some confusion about how much information assessors should collect. What they collected was dependent on many factors including personal choice and management support.
Finally, staff evaluate a system’s ability to provide them with information in terms of how it fits with established working processes-a close fit is likely to encourage readier acceptance than one which requires costly changes to present methods.
Professions have different views about what is important in their work, what they value, and their willingness to share information. Health service professionals work in a system where delivery is free at the point of access-and are sometimes reluctant to conduct an assessment that supports the delivery of means-tested services:
‘The social care component is means tested-if you’ve got the money you pay for it-and ethically we’ve always gone for service being free at the point of access. Doing a financial assessment might affect a nurse’s relationship with their patients-asking to see their bank book, or asking how much their house is worth’. (Interviewee 3-health)
Social workers, in contrast, are familiar with a range of services whose delivery depends in part on someone’s income-so the SSA does not conflict with their values.
Another aspect of a culture is the willingness of members to share information. While it is fundamental to the success of the SSA there was some evidence that health service staff were more protective of the information they held than the local authority staff. Some of this appeared to be judicious but some staff projected a heightened sense of ownership and possession of information which was not easily understood as necessary for information governance. This may be more consistent with health service culture:
‘One reason we don’t add much detailed information to the form is that we don’t want to give out too much medical information-the perception is we don’t want to give out any more information than we have to’. (Interviewee 3-health)
Commonly, respondents from health and social work considered culture to have a significant impact on how well they worked together and how well the SSA was accepted and integrated as a joint document. Nurses were more likely to say that the SSA did not fit with their perception of their role, culture or the work they do:
‘When we were evaluating the new SSA, I had quite a lot of comments from nurses saying I will not be filling in this section around employability, house care and finances because I’m a nurse and that’s a social worker’s job’. (Interviewee 22-management)
How did geographical boundaries affect electronic data sharing?
Geographical challenges were noted at all sites and had the potential to affect the ability to share information easily. The SSA was seen as a solution to overcome the challenges of joint working at a distance. Co-location, remote and rural practice and primary/secondary care settings emerged as significant issues.
The study sites had significant experience of working in integrated teams whereby members from several different disciplines worked in the same room. This was particularly useful for completing SSAs because practitioners could access each other’s computer systems in a way that was impossible to do otherwise. Commonly, practitioners were positive about working together in integrated teams as in the following case:
‘There were 30 of us all in the one room and so I found you were able to see some of them and you knew they were there and you could talk to them and sometimes they would come up and sit next to you and you would type a new SSA, you know, what the transfer was. I think all being in the one room was a big help’. (Interviewee 7-health)
Commonly, there were several SSAs completed for the same patient as practitioners were unaware if one had been started. Having access to each other’s systems meant that practitioners could check if an SSA had been started and locate it, if that was the case.
In two cases, practitioners had been working in co-located teams and were disappointed when the teams were disbanded as part of restructuring.
‘It’s quite a difficult time at the moment … the ICAS [Integrated Community Assessment Service] team is actually been disbanded at the moment so we’re going through quite a lot of change within social work’. (Interviewee 16-health)
Remote and rural practice
Some practitioners did identify that joint working and sharing information was more successful in geographically defined places.
‘There was much more of a cohesive team, if you like, even although they weren’t maybe centred in the same place, but because of the nature of some of the rural areas for instance, all the professionals relied on each other to get something to happen. You didn’t have, you know, the choice of six or seven professionals to go to. You either knew who the social worker was in that area, you knew who the policeman is or the policewoman is, you knew the GP. So there was that kind of sort of hub, if you like, of people that worked really well together’. (Interviewee 8-social work)
In addition, there were issues around IT infrastructure and connectivity which were particularly pertinent in remote and rural areas as outlined in the following quote.
‘We have tried other pilots, … to do with tablets … and a lot of the time we just can’t get a decent enough signal to be able to transfer information via a wireless connection or a broadband connection’. (Interviewee 4-health)
Primary/secondary care setting
Boundaries between primary and secondary care were evident in fundamental ways. In one of the areas, the practitioners were convinced that most of the staff in the main referring hospital would not have heard of an SSA. So staff in the hospital were neither initiating SSAs nor using them as sources of information on admission as explained in the following quote:
‘From a hospital point of view, we’d never used it. I’d heard of it and that was all. So going out in the community last year, when I worked with augmented care at home, it was very much a part of their, assessment and criteria. (Interviewee 1-health)
However, in other areas, the practitioners highlighted that it was easier to complete an SSA if you were working on the wards because the patient, relatives and professionals were all more accessible.