ITEM CA15 - ANNEX 1CABINET – 19 SEPTEMBER 2006National Framework for NHS Continuing Healthcare and nhs-funded nursing care
Department of Health consultation on the National Framework for NHS Continuing Healthcare
Specific questions raised by the Department in the consultation document: Question 1. We recognise that terminology can be complex in this area, and the names given to particular packages of care (for instance ‘NHS Continuing Healthcare’) can cause confusion. We are keen to receive any suggestions for how these concepts could be re-named to better describe the services they provide. Response: It is the use of the word ‘continuing’ that causes the greatest confusion for individuals, families and carers as it implies that any funding will be ongoing and not subject to regular review and re-assessment of needs, which is the reality for most individuals and their families. We would suggest that the phrase ‘fully funded NHS care’ is considered as an alternative. In order to differentiate this from ‘NHS funded nursing care’ we would suggest that the further clarification included in the Consultation Document is used namely - It can be provided in any setting. In a person’s own home, it means the NHS funds all the care that has been assessed as required. In care homes it means the NHS pays the full fees for the person’s accommodation as well as their care. Question 2. Currently, Strategic Health Authorities (StHAs) hold policy responsibility for local Continuing Care policies. Following the introduction of the National Framework, we are considering moving this overall responsibility to Primary Care Trusts (PCTs) as the local commissioning bodies for NHS services. We would welcome your contributions on this proposal, and any particular benefits or potential obstacles to achieving this. Response: We support the proposal that the responsibility for the implementation of the policy is delegated to PCTs so that the impact of decisions made is incorporated in commissioning plans across the services. However in the operation of the policy there must be a clear separation of the decision-making processes for eligibility for NHS Continuing Care and the financial implications. One of the benefits of the StHAs holding the policy responsibility is that there has been a degree of consistency in the implementation of the local policies across different PCTs thereby reducing the ‘postcode lottery’ effect. We strongly recommend that some processes or mechanisms are put in place for StHAs to continue to have an overview and retain responsibility for monitoring the implementation of the National Framework and policy across their localities. This is particularly important and relevant at a time of change in the NHS with different areas amalgamating into new StHAs where there may well be variable interpretations and practice in current use. Oxfordshire uses a panel system to make the decision on continuing care and RNCC funding. The panel includes local authority managers. We strongly support this approach and will continue to use this arrangement even after the new guidance comes into force. The new Guidance should require PCTs to have in place a swift and robust appeals process for individuals, their families and local authorities so that the decision-making process is open, comprehensible and transparent. We are pleased to note that the present system of Independent Review Panels (IRPs) will remain as this provides an opportunity for independent scrutiny on the implementation of the policy and the decisions reached in individual cases. We strongly recommend that this responsibility is not devolved to PCTs but remains with the StHAs to ensure consistency in the implementation and decision making across their areas. As IRPs are fairly far down the process and only a few cases reach this point it is essential that PCTs have robust appeal/review procedures earlier in the process. Question 3. The National Framework sets out to assess individuals on the basis of their need for care, rather than their diagnosis, condition or where the care is provided, as the fairest way to determine eligibility for NHS funding. Does it achieve this or are there other factors that should be considered? Response: We welcome this needs - based approach to determine eligibility, rather than making the prime focus the diagnosis or who provides the care. It recognises and addresses the fundamental issues and judgements in both the Coughlan and Grogan cases where the test for eligibility for NHS Continuing Healthcare is that the individual’s ‘primary need is a health need….and this is based on the both the quantity and quality of care required.’ A needs - based approach should ensure that individuals with a variety of different diagnoses and conditions e.g. people in the later stages of long term neurological and other progressive conditions, as well as people with severe and enduring mental health needs, cognitive impairment and learning disability are assessed on their current overall level of need. However there are likely to be significant national and local financial pressures, as potentially more people will meet the eligibility criteria. Question 4. We assess whether an individual’s primary need is a health need with reference to four key indicators – nature, complexity, intensity and unpredictability. Do you think these are the correct indicators, or are there any omissions? Response: In general these are helpful indicators. We are pleased to note that on Page 8 of the Consultation Document it is made clear that an individual does not have to meet multiple criteria and that ‘some individuals may have a primary health need on the basis of one indicator alone while others may have a number of interrelated needs that combine into a primary health need.…which should be considered in a holistic way rather than separately’. Question 5. Do you have any views on the statements used to describe the key indicators? Response: In general the statements are helpful in clarifying the terms ‘nature, complexity, intensity and unpredictability’. We are pleased to note that under the indicator of intensity ‘a number of apparently low-level needs can result in the combination of those needs bringing the overall intensity to the level of a primary health need.’ Question 6. Assessors will determine whether a primary health need is established by looking at the key indicators in terms of eleven generic ‘care domains’: Behaviour; Cognitive impairment; Communication; Mobility; Nutrition; Continence; Skin (including tissue viability); Breathing; Drug Therapies and Medication; Psychological/Emotional needs; Seizures/Altered States of Consciousness. Bearing in mind that professional judgement is paramount and assessors can add to/overrule these on a case-by-case basis, are these the right core areas of needs to assess? Response: Yes. We are pleased to note the inclusion of the care domain to reflect Psychological and Emotional needs which was lacking in previous guidance. This is particularly relevant in the assessment of people with severe and enduring mental health needs who may not have significant physical care needs. The sections in the care domain on Medication and Drug Therapies also helpfully reflect the issues of non-compliance and the potential consequences. Whilst recognising the importance of professional judgement in reaching a decision, we recommend that clear statements and an emphasis on the importance of assessors considering how different but interrelated needs can complicate an individual’s overall level of need and therefore demonstrate sufficient complexity or intensity to justify a primary health care need is included in any Guidance. (See paragraph 12 of the Decision Support Tool.) Similarly, we endorse the statements in paragraphs 30-33 in the Consultation Document that emphasise the responsibility of assessors to consider the information in the care domains holistically and take account of the particular issues and inter dependence and impact of one care domain on others when making decisions about eligibility for people who have dementia, mental health needs, acquired brain injury or a learning disability. Question 7. What are your views on the process shown in the Assessment Framework? What are the potential implementation issues? Response: We are broadly in favour of the process outlined in the Assessment Framework that incorporates both the principle of proportionate assessments and the key elements of the single assessment process (SAP), the Care Programme Approach (CPA) and person-centred planning. We support the process of fast tracking individuals who have rapidly deteriorating conditions and unpredictable needs so that they receive appropriate services for their end of life care. It will be essential to have the input from senior clinicians in making these decisions at the right time. However, the challenge for all staff working in hospital settings, particularly acute hospital settings, is to ensure that all staff are aware of this process and work to the arrangements in a timely way so that it does not impose any unnecessary delays in the discharge planning process. This will require ongoing awareness raising and training programme for social and health care staff. Question 8. Do you agree with the concept of a screening tool to help promote proportionate and appropriate assessments and to direct resources where they are most needed? Response: Yes. We welcome the concept of a national Screening Tool. It will identify individuals who require different levels of assessment under the common assessment framework and ensure that those who have more complex needs are assessed by the appropriate members of the multi-professional team, thereby targeting resources effectively. We welcome the statements that the principle of the Screening Tool will be inclusive, will consider a wide range of needs and will set a low threshold for referral for a comprehensive assessment for NHS Continuing Healthcare. Staff undertaking these screening assessments should be trained in the use of the tool and audits should be regularly undertaken to ensure the application meets the objectives outlined above. Question 9. We would welcome views on the concept of the national Decision-Support Tool to promote greater clarity and consistency in decision making nationally. Response. We welcome the development of the national Decision-Support Tool (DST). It provides a very useful framework for the assessment of needs across a wide range of physical, behavioural, cognitive and psychological domains. It highlights the different levels of need along a continuum and will support professionals in reaching a decision about eligibility for different levels of interventions and funding and provide a transparent rationale for the decision. In determining primary health care need we would recommend that in paragraph 19 of the DST there is a more precise statement about the number of domains with high and moderate levels of need. The current statement is too vague and is open to wide interpretation. We would also recommend that a glossary of terms is included in any final guidance to ensure the statements within the care domains are interpreted consistently across the country. Question 10. Do you think the care planning process is the best place to establish whether an individual requires care from a registered nurse? What are the alternative processes for determining eligibility for NHS-funded Nursing Care? Response: Yes. This supports good multi-agency and multi-professional working for people who will, by definition, have a range of health and social care needs requiring a joint package of care. Question 11. What are your views on the principle of removing the banding system for payments of NHS-funded Nursing Care? Response: It has the superficial attraction of simplifying the present arrangements. However, as people entering a nursing home have a range of nursing needs, from those with relatively low level needs to those with more complex needs but do not meet the criteria for NHS Continuing Healthcare, we have some concerns about the degree of flexibility within the proposed single rate of £97.00/week and how clinical and financial decisions will be made. We would want to ensure that there is not a financial disincentive to care home providers to accept people with more complex nursing needs. Locally in Oxfordshire the proposed change will have an impact on contracts and fee levels with providers as fee levels are currently related to the three RNCC bands of Low, Medium and High. On balance therefore, we would prefer to see the current 3-band arrangement remain. We feel it would allow for a more accurate funding of the actual cost of nursing care, which would be important for both providers and full fee payers. Question 12. We would welcome your views on the following supporting documents: a. Core Values and Principles This provides a coherent context and rationale for introducing a National Framework and the principles that will underpin the implementation of the new policy including clarifying the rights of individuals and their families to an open and transparent assessment and decision-making process. The section on governance arrangements is welcomed. b. Public Information Leaflet. This needs re-writing in language that is comprehensible to lay people. In spite of best efforts it is does not give an explanation of the complexities and differences between the types of NHS funding and the implications for individuals and their families. Some illustrative examples may help to expand the definitions, make them more comprehensible and related to real life situations. c. Consultation Presentation There is more detailed explanation of the issues and definitions in the presentation than in the leaflet, which makes it more comprehensible. d. Partial Regulatory Impact Assessment This provides a clear legal and policy context to explain the rationale for Government intervention in this area. The second of the three options considered, provides useful national information, which can be used in a local context to model the overall impact of the new national Framework. Additional Comments: a. Independent Living Fund (ILF). Individuals with a physical or learning disability who are in receipt of ILF have expressed real concerns about the withdrawal of this funding stream. If they are awarded NHS Continuing Healthcare they lose their right to this alongside other benefits. The concern is that the ILF is used to improve the individual’s quality of life and integration into the community and potentially many of these aspects of their lives might be curtailed through the loss of this benefit to the considerable detriment of the individual. There is a real danger that the cost of these unfunded parts of the package would fall to local authorities to fund at a time when their budgets are very stretched. We urge the Department of Health to urgently review the implications of this. b. Equipment in Care Homes. We would welcome more detailed clarification of what items of equipment should be provided by care homes as part of the registration process to meet the ‘fit for purpose’ criteria and what the NHS should reasonably fund. Disputes regularly arise in relation to ‘specialist’ beds and chairs for very frail, dependent or obese individuals and there is no clear national guidance on who has the responsibility to provide these items of equipment.
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