Needs-led assessment: the challenges and the reality.

The NHS & Community Care Act 1990 heralded a new era in community care in the UK. Needs-led assessment and case management were to form the cornerstone of high quality care. Practitioners were challenged to alter their attitudes and practice to accommodate the needs-led approach. Previously they had assessed need to ascertain eligibility for statutory services, now they were required to identify "need" per se. The pivotal role given to assessment meant the success, or otherwise, of the reforms lay in part on the ability of practitioners to make this transition. However, to make needs-led assessment a reality, practitioners would have both to overcome conceptual barriers--need being an unclear concept, with no clear framework existing to assess need--and also to deal successfully with the conflicting requirement to ration services. In order to investigate whether the shift to needs-led practice had been possible, the opinions of social and healthcare practitioners providing services for older people in North Wales were sought through semi-structured interviews in 1994-1995 and 1998-1999. Supports and constraints to practice were also explored. Practitioners indicated that whilst they welcomed the needs-led philosophy, putting it into practice was difficult, if not impossible. The main constraints were a lack of resources (financial, service provision and staffing) and the conceptual difficulty of separating "need" from the "need for a particular service". Ever-tightening budgets and service eligibility criteria over the period of the study indicate that a shift of focus from assessment of need to rationing has taken place.