Single Shared Assessment Indicator of Relative Need: Operational Guidance Users Handbook

Guidance to assist implementation of SSA-IoRN


Process Summary
  • Single Shared Assessment - Indicator of Relative Need should only be completed for people aged over 65

  • The Single Shared Assessment - Indicator of Relative Need is completed following a Single Shared Assessment

  • Single Shared Assessment - Indicator of Relative Need is a questionnaire consisting of 12 multiple choice questions divided into the following sections:

    • Activities of Daily Living

    • Personal Care

    • Food/Drink Preparation

    • Mental Well-Being and Behaviour

    • Bowel Management

  • Answer each question using the information contained within the SSA

  • Add up the scores for each section

  • Use the step-by-step instructions within the Single Shared Assessment - Indicator of Relative Need questionnaire to assign the Single Shared Assessment - Indicator of Relative Need grouping

  • Single Shared Assessment - Indicator of Relative Need grouping to be passed on for local collection


This guidance has been produced to assist the practitioners in implementing the SSA-IoRN. The guidance has been developed and shaped by the practitioners involved in the early implementation of the SSA-IoRN.

Details on the development of the SSA-IoRN can be found in the report titled The Development of a Resource Use Measure for Scotland, which was published by the Scottish Executive Health Department on 24 September 2002. This report can be accessed at the following web address -

The Joint Future Ministerial Steering Group agreed that the SSA-IoRN should be implemented incrementally during 2002-03 in the 5 local authority areas with their health partners. The next steps letter dated 28 February issued by the Scottish Executive confirmed this intention.

We are grateful to these authorities and their NHS partners for their willingness to lead the implementation nationally and to you for your part in using the SSA-IoRN as part of the single shared assessment process.

What is the SSA-IoRN?

The SSA-IoRN is a questionnaire comprising 12 questions that draw on the information a practitioner will already have gathered from an individual's assessment of need. It should be completed following (or as a component part of) a Single Shared Assessment (SSA).

The SSA-IoRN is a tool that has been developed by the Scottish Executive and the Information and Statistics Division (ISD) of the Common Service Agency (part of NHS Scotland) in collaboration with health and social work practitioners to provide a standardised means of grouping individuals according to their relative needs. Its purpose is to promote fair access and equitable distribution of resources for older people.

The SSA-IoRN and SSA

SSA for older people needs to be in place before the SSA-IoRN can be applied. Local authorities and their health partners have been working towards the Joint Future's SSA implementation timetable and have arrangements in place for older people from 1 April 2003.

As outlined above, the SSA-IoRN can only be completed following a needs assessment or SSA. The SSA will provide good quality information on the individual's needs which will allow the practitioners to respond to the specific SSA-IoRN questions. The SSA-IoRN will be best applied by the lead practitioner following the assessment when sufficient information has been gathered to inform the individual's care plan. If the SSA-IoRN is to be effective the SSA must be of a high standard. It is important to emphasise that the SSA-IoRN is only applicable to older people, it is not a substitute for an assessment of individual need, nor should it influence the individual's care plan.

Informing Service Users and Carers

In line with best practice for sharing information it is expected that the practitioner will inform the client and/or carer that the SSA-IoRN will be completed as part of the SSA process and share with them details of the group into which they fall.

How will it be introduced?

The work in early implementation has been staged to suit local circumstances and all of the 5 areas began using the SSA-IoRN by early April 2003. A report reviewing the early implementation and which highlights lessons learned will be published in April 2004.

The process for completing the SSA-IoRN will be linked to systems already in place in your area. Some will be using paper systems and others will be more advanced in developing ways of sharing information electronically. Where paper systems are in place the practitioner will calculate the SSA-IoRN score manually using the scoring card. Where electronic systems are well developed it may be possible to complete the SSA-IoRN electronically. Ultimately the aim is to have the SSA-IoRN incorporated into electronic systems that are being developed for SSA and that the SSA-IoRN score will fall out automatically.

Completing the SSA-IoRN:

It is essential that before you complete the questionnaire you read the guidance notes within it. Please answer all the questions.

The SSA-IoRN questionnaire consists of 12 questions covering the following areas:

Activities of Daily Living
Personal Care
Food and Drink Preparation
Mental Well-Being and Behaviour
Bowel Management

A score card is incorporated in the questionnaire to enable practitioners to assign a SSA-IoRN grouping for their client. Scores for the responses to the questions are listed in the right hand column except for Q11 - Mental Well-Being and Behaviour and Q12 - Bowel Management. Scores for Q11 and Q12 are as per the box ticked, e.g. if box 1 is ticked the client scores 1.

Practitioners should complete the front of the questionnaire consisting of client details, date of completion and the SSA-IoRN grouping for the client.

  • When responding to the questions, practitioners must ensure their client's mental health needs as well as their physical needs are taken into consideration.

  • When responding to the questions, if unsure which option to select, always choose the higher category.

Section 1 - Activities of Daily Living/Mobility: Q1-3

Q1 relates to a person's ability to obtain adequate nutrition, the question does not refer to a person's ability to cook/prepare meals (these aspects are covered in food/drink preparation). Think about the person's mental health needs and if they require prompting and encouragement to eat but require no physical help, select option D.

Q2 relates to a person's ability to transfer position. If a person is at risk or has a fear of falling and therefore requires observation, refer to the guidelines and select option D.

Q3 refers to transferring on/off the toilet, adjusting clothing and maintaining perineal hygiene. The question does not refer to continence and bowel function; these aspects are covered in Q12.

Score the responses to the questions and write the scores in the boxes relating to the questions.

Add the scores to Q1, 2 and 3 to calculate the ADL score. The ADL score is the most important score when allocating the SSA-IoRN grouping therefore it is important to ensure responses to the questions are accurate, in particular taking account of the client's mental health needs in respect of the questions in this section.

Section 2 - Personal Care: Q4-7

Relate to a person's ability to wash (hands and face, complete wash, wash hair) and dress.

If a person can only do one aspect of the task but not the other, e.g. can dress but not undress, refer to the guidelines and select option C.

If a person has difficulty performing tasks due to mental health or cognitive impairment, consider selecting option D.

Score the responses to Q4-7 and record on page 7 of the questionnaire.

Section 3 - Food and Drink Preparation: Q8-10

Relate to preparing food and drinks to obtain sufficient nutrition and hydration. Again, if a person has difficulty undertaking these tasks due to mental health or cognitive impairment refer to the guidelines and consider selecting option D.

Score the responses to Q8-10 and record the scores at the bottom of the page 7. To calculate the personal care/food and drink preparation score, calculate the total score for Q4-10.

Section 4 - Mental Well-Being and Behaviour: Q11

When responding to Q11 consider whether the person has exhibited any of the behaviours in the previous 4 weeks only. We acknowledge there may be a subjective judgement when assessing if the behaviours have occurred. If a behaviour presents itself but does not cause a problem to the person or others, it should still be recorded as having occurred.

Q11 D, E and F - if the initial response to the questions is "sometimes", then record as "yes".

The scores for the questions are simply the value of the box ticked, either 1 or 2. Calculate the total score for Q11 A-F and record at the bottom of the page.

Section - 5 Bowel Management: Q12

Relates to assistance with bowel management and constipation.

No scoring is required for this question. The person is allocated to either a no/low bowel management group or a high bowel management group as detailed in the box on page 11.

Assigning Client to SSA-IoRN Grouping

The scoring of all responses is essential. Follow the guidance on page 12 of the questionnaire.

There are 2 stages involved:

Step 1 - allocate the ADL group, based on the ADL score on page 3.

Step 2 - go to the relevant box depending on the ADL group, e.g. medium ADL group, go to box 2.

The diagram on page 13 will assist when assigning the SSA-IoRN grouping.

Please remember...

Read the guidelines in the questionnaire to assist in responding to questions.

Answer all the questions.

If you have any queries, please refer to your local SSA trainer in the first instance.

Quality Assuring the Data

A Quality Assurance Framework has been developed in partnership with the early implementation areas. This will aim to ensure the effectiveness of the SSA-IoRN by ensuring that all teams are able to use the SSA-IoRN correctly, accurately and consistently.

Aim of QA Exercise

The main aim of the QA exercise is to support the implementation process. The QA programme will seek:

  • To identify problems early on

  • To assess data quality at partnership level

  • To help specify arrangements to ensure quality data in the longer term.

The QA program is not designed to assess the performance of individual members of staff in completing the SSA-IoRN forms, but to identify problems with the interpretation of the SSA-IoRN questions and the arrangements for collation of data and completion of the SSA-IoRN.

Elements of QA Strategy

The quality and completeness of the data should be assessed using the following methods used during the initial SSA-IoRN implementation program:

  • Inter-rater checks - different scorers of same person

  • Documentation checks - to ensure the responses within the SSA-IoRN are consistent with SSA documentation

  • Feedback - ranked listings of clients by SSA-IoRN group to practitioners/teams and inter-rater results

  • Calculation of SSA-IoRN Groups - ensure that scoring of the SSA-IoRN questionnaire is correct

  • Completeness - Comparison of number of SSA-IoRNs against number of SSAs completed

The inter-rater test is designed to pick up problems of differing interpretation of questions and between different staff members. The problems may relate to the availability of written case documentation to staff completing the SSA-IoRN. Issues may need to be resolved by further training and discussion.

Documentation checks will be carried out locally within each site to check how much of the information required to complete the SSA-IoRN is documented.

Feedback to practitioners should include:

  • lists of anonymised client data in SSA-IoRN group order. This will allow staff to see if the order in which the SSA-IoRN places their clients reflects their own interpretation of the clients' level of need

  • results of the inter-rater test

  • results of documentation checks.

Completeness - checks will simply require a count, for each participating team, of the number of clients receiving an assessment within the relevant time period and a count of the number of SSA-IoRN forms completed within the same period.

A person should be identified within the local area as being the person responsible for carrying out QA.

Using the Data:

The main aims of the SSA-IoRN data collection are to support service delivery at the level of the individual practitioner and the local team. High quality information for planners, policy makers and managers in local authorities and the Scottish Executive should flow from a system that delivers for front line staff.

The linkage of SSA-IoRN data, both internally and externally to other related data gives the potential to describe patient/client pathways of care, the flows of patients/clients along those pathways, the impact of particular conditions and events on needs, and, ultimately a comprehensive picture of patient/client care services for the elderly and their relation to need.

The availability of such information allows comparisons of service levels between local teams and partnership areas to be made which take into account variations in client/patient circumstances, prior history and dependency and overlapping inputs from other agencies providing care. Such information would support:

  • The individual practitioner in managing their case load

  • Local managers in prioritising and workload allocation.

  • Council and NHS partnerships in planning and budgeting.

  • Scottish Executive service monitoring and policy development, including information on access to services and equity of provision.

Frequently Asked Questions (FAQs)
  • Question - Can you define the care providers that will apply the SSA-IoRN in relation to private residential nursing homes?

  • Response - Anyone over the age of 65 who has a single shared assessment (SSA) and/or review should automatically have a SSA-IoRN applied thereafter. Care providers will not be expected to apply the SSA-IoRN because it is unlikely they will be carrying out the SSA.
    However, the SSA-IoRN team will be working with the Care Commission on how the SSA-IoRN might be developed to inform staffing levels. The small pilot undertaken to test the applicability of the SSA-IoRN in care homes as part of Phase 2 development was inconclusive. Further work requires to be undertaken in collaboration with the Care Commission.

  • Question - Can you expand on how you collected the data on recording "unmet" need via the practitioners applying SSA and the SSA-IoRN - in order to accurately collate this information?

  • Response - During the development of the SSA-IoRN, part of the exercise was to gather information on unmet need. That is practitioners were asked to record the number of hours of unmet need per older person per week. This information was aggregated and assisted in the process of informing the SSA-IoRN groupings of relative need.
    In order to manage unmet need and plan services for older people systems will need to be in place for aggregating the SSA-IoRN scores locally and recording unmet need and for collecting data nationally. Work is underway with the first five implementation sites which will inform national information requirements.

  • Question - How is the SSA-IoRN going to be analysed locally?

  • Response - Health/LA statistics will be based on local information requirements and information sharing. Local teams need to agree what information is meaningful locally. It is important this is addressed during the early implementation phase. Planning information could be aggregated by teams/areas. A decision would need to be made at a local level how best to use the information.

  • Question - What will be done nationally?

  • Response - National information will provide a Scottish picture and there will be different need profiles in different areas. National data will allow comparison and possible information sharing/shared learning between areas.

  • Question - Need to collect information on carers. What if need is met by carer - won't be reflected in resource requirement, but included in SSA-IoRN score?

  • Response - Yes there is a need to collect information on carers and to what extent their needs are being assessed and met. This work is being taken forward through the Joint Performance Indicators Assessment Framework. The SSA-IoRN scoring and grouping process has been designed to take into account input from carers thereby reflecting the older person's relative need. The fact that a person's need is met by their carer will not alter their "relative need" grouping.

  • Question - What if carer arrangements change?

  • Response - Any change in the older person's needs and/or circumstances may trigger a re-assessment or review which could also involve a re-application of the SSA-IoRN. The care plan and care package will be determined by the person's needs assessment - not the SSA-IoRN.

  • Question - How frequently should the data be analysed?

  • Response - The assumption is that information would be analysed locally as and when needed. At a national level data would be collected regularly.

  • Question - The introduction of SSA, free care and SSA-IoRN has an impact on resources. These policy developments highlight services are inadequate but it is the front-line staff that are faced with issues of stretched resources.

  • Response - The team recognises the impact of new policies. Part of the Joint Future Agenda is to ensure localities work towards having joint budgets/management. In time the resources available will be more suited to the needs of the local population.
    The SSA-IoRN is a planning tool that could help to inform resource allocation.

  • Question - How will the inter-rater test be of benefit to ensure equity of service provision?

  • Response - The inter-rater test is not about ensuring equity of services. The test will be used as part of quality assuring that the data from the questionnaires are of good quality.

  • Question - What is involved in the inter-rater test?

  • Response - Two practitioners, who know the client well, will be asked to complete a SSA-IoRN questionnaire. This is to ensure there is compatibility in the response to the questions contained in the SSA-IoRN.

  • Question - Once the SSA-IoRN questionnaire is completed; the SSA-IoRN grouping is to be used for planning purposes across teams to better target provision of services. Is the SSA-IoRN an eligibility tool?

  • Response - The SSA-IoRN is not be used to determine eligibility for services.

  • Question - Could you clarify the timescale for early implementation? Are we starting now?

  • Response - The purpose of today's seminar (28 November 2002 at COSLA, Haymarket, Edinburgh) is to kick-off early implementation. Individual meetings will be arranged with the 5 sites to discuss implementation with a view to completion of the SSA-IoRN starting in January 2003. We recognise the need to work with local areas at their pace, taking into account what they can achieve.

  • Question - Will the SE be providing additional resources for implementing the SSA-IoRN and training and admin/clerical support "for inputting" and managing data, etc.?

  • Response - Joint Future Agenda is about better use of resources not more resources. Nonetheless, the Executive made available in 2001 settlement for amongst other things implementing the Joint Future Agenda - but its not specifically for SSA-IoRN or SSA. Partnerships will have their own plans for using it for joint future in their area. Developing electronic solution is the longer-term outlook. Funding is available under Modernising Government Fund to that end. At the end of the day, however, it will be up to local partnerships as to how they incorporate the SSA-IoRN into their systems whether it be manually or electronically.

  • Question - More paperwork?

  • Response - Only in the short term until electronic systems are developed. Long-term goal will be simple electronic solution.

  • Question - When do you apply and reapply the SSA-IoRN?

  • Response - The SSA-IoRN should be applied following the initial SSA/needs assessment and thereafter at review stage.

  • Question - What happens when peoples' needs change after 6 weeks do you re apply the SSA-IoRN?

  • Response - During the development of the SSA-IoRN, one of the pilot teams was an Early Supported Discharge Team and they applied the SSA-IoRN at 2 intervals, the first when the person was referred and discharged from hospital then a few weeks later when needs had changed. This was useful in those circumstances when someone had been in acute care, e.g. following a stroke. However, local circumstances will determine whether someone needs a re-assessment or review and therefore re-application of the SSA-IoRN. When someone goes in to care they are often reviewed at 6 weeks or 3 months and annually thereafter - so the SSA-IoRN would apply consistent with this, provided it is the practitioner/professional who is carrying out the SSA whether it is assessment or review process.
    The SSA-IoRN should be completed following every SSA for older people but there are some issues to tease out and learn from the first 5-implementation sites. Particularly as definitions for levels of and SSA differ across the country, e.g. a simple assessment in one authority might be a self assessment in another. This will have implications as to how information is collected for planning purposes.

  • Question - SSA-IoRN to be completed for over 65s only. Women aged over 60 are OAPs and some clients are referred to Older People's teams who are under 65.

  • Response - If a client is referred for an older people's needs assessment or for clients who are under 65 with advanced dementia then it would be okay to apply the SSA-IoRN. Practitioners are asked to use their judgements sensibly. The SSA team is comfortable with the application of the SSA-IoRN for those aged 60+ but not for clients aged under 60. SSA-IoRN is not designed for other care groups at this stage.

  • Question - Question 6 within the questionnaire relates to a person's ability to give themselves a complete wash. What option should be selected if a client is unable to wash their feet, for some clients the ability to wash feet maybe more important than to others.

  • Response - The guidelines will help answer this question, e.g. Select option 3 - the person is able to perform the task with difficulty or the person has difficulty with one aspect of the task.

  • Question - What about clients who are in for example, a hospital setting, when assessed yet whose behaviour in such settings is different from that when at home?

  • Response - If an assessment on the client is done then it should pick up that their behaviour can depend on the setting.

  • Question - Can clients have a copy of the SSA-IoRN?

  • Response - Yes, if clients receive a copy of the SSA

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