Implementing the Single
Assessment Process across
the South West Peninsula
Basic awareness
What is the Single Assessment
Process (SAP) ?
Originated from the National Service Framework
(NSF)Older People Standard 2: Person Centred Care
-a single agreed approach to assessment for health /social care
-type of assessment is appropriate to needs
-agencies do not duplicate assessment
-effective contribution by range of professionals/agencies
-resulting in a single holistic service or care plan
-contributed to and agreed by all (including the person)
South West Peninsula SAP will cover all adults 18+ except
mental health
Who will be using SAP?
All health &social staff
 South west peninsula partnership
 All organisations using same tools and
eSAP system
 PCTs, Adult social care,acute trusts
 For full list of partners see SAP website
“Don’t you people talk to
each other?!”
National guidance
“Provides a rigorous framework
that will lead to convergence of
assessment methods and results
over time irrespective of the tools
chosen for local use”
What is an
•involves the gathering of information about
the health and social status of the user, analysis
of that data, and the making of a professional
judgement to meet the user’s need
•Within SAP this is carried out with the service user
4 types of assessment
Contact Assessment
Not every contact needs one
 initial contact if needs recording
 multi-agency referral form
 basic personal information
difficulties, risks & significant life events
any staff member who is trained
not necessarily professionally qualified staff
 may be partially completed by one person
More detailed assessment
At any stage in SAP
More complete picture of an individual
Incorporates core information
Includes information on providers/agencies
Risk triggers
Identifies need for further assessment
Specific difficulties identified at contact/overview
One or more specialist professionals
Unstable,unpredictable or complex needs
Specialist tools/scales/measures -each profession
Examples of specialist assessments :
The SAP Health needs assessment (HNA) is the only specialist assessment in
place across the SWP and on eSAP – other specialist assessments will be
carried out on existing tools or using FACE second line tools but not on eSAP) –
eg Care programme Approach for mental health , Housing, Speech & language
( in the SWP a process not a tool)
Contributions from different professionals /
 Co-ordinated by appropriately skilled
 Evidence base for detailed care planning
 Includes all domains of overview / specialist
 Intensive & prolonged level of support /
 Complex care packages
- e.g. intermediate/residential care
Care Plan
Care is joint agency and identifies what care
or treatment is in place and who is
providing this.
 Contingency plan for emergencies
 Diary Sheet
All care plans should have review date set
 A review should take place with the person
and their carer
 The review tool is to record this and set next
review date
Making the links with SAP
across health
& social care
it can impact
on all this
and more….
long term
Mental health and
Fair access to Care
Care/Funded Delayed discharge
nursing care
Person centred
Projecting & Sharing Information
Don’t you people talk to each other!
 Information can be shared providing the
service user has given written or verbal
consent and this is recorded on:
“Consent to share and protect your
information form
 Agreed protocol across the health & social
care agencies in SWP
What is eSAP?
SAP can’t work without IT!
 eSAP enables assessment and care plan
information to be stored electronically ,
shared with professionals across health and
social care and sent to each other
 This is possible using your own computer
and your organisation's IT system
 Web based browser- very safe & secure
Benefits of eSAP
Reduction in delayed transfers of care
-Improved communication and better access to information
Reduction in unplanned admissions
-Better information should lead to improved risk management
decisions and unnecessary admissions to hospital
Better use of workforce
-Reduce duplication and staff time spent in recording.
-Easier and faster transfer of information between agencies.
-More appropriate use of skills
Less faxing , photocopying, storage
Personal held record
This is a folder ( usually yellow) held in person’s
home and issued by PCT
Contains SAP documentation, communication
diary and useful self-care information
Enables professionals to communicate
Service user and carer kept informed
Useful for emergencies
Will be flagged on eSAP so know it is in place
Anyone can suggest one is issued providing meet
the criteria as follows:
Criteria for Personal held
complex care packages delivered in own home
treatment and care by a number of practitioners / agencies
known to request frequent unscheduled care from their GP
(including out of hours services) or their district nurse
have required a number of unscheduled admissions to hospital
at ‘risk’ of needing emergency care
managed for a ‘long term condition’ or ‘complex care pathway’
palliative diagnosis including malignant or non-malignant
Single Assessment Process
For further information contact:
Heather Eardley/Jude Anthonisz/Bruce o’Connor
SAP Programme Team
Tel: 01392 687142
Website address: