Meeting documents

Tuesday, 19 September 2006


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National Framework for NHS Continuing Healthcare and nhs-funded nursing care

Report by Director for Social & Community Services


  1. Following a number of legal cases including the "Coughlan" judgement, recommendations of the NHS Ombudsman and the Parliamentary Health Select Committee and pressure from patient groups, professionals and the media, the Department of Health has published for consultation a draft National Framework for NHS Continuing Healthcare and NHS funded Nursing Care in England.
  2. The draft Framework builds on previous guidance and aims to amalgamate best practice from across the country. It does not change the underlying legal framework on which current eligibility policies should be based. It has two main purposes. Firstly, to set out a single policy on who should receive NHS funding - either:

    1. Fully funded NHS Continuing Healthcare where the NHS funds the whole care package; or
    2. NHS-funded Nursing Care where the NHS is responsible for funding the nursing required from a registered nurse in a care home setting.

    Secondly, a standard process for assessing eligibility for these services, including national tools to support decision-making by professional staff. Annex 1 sets out details of the specific consultation questions asked by the Department of Health.

  3. The Consultation does not explicitly cover children and young people under 18. The Department of Health is currently working on a framework for the provision of continuing care for children and young people and intends to consult on it between February and April 2007 with a published framework and guidance for implementation by Summer 2007.
  4. Current Operational Policies and Structures in Oxfordshire.

    Strategic Health Authority responsibilities:

  5. Currently each Strategic Health Authority (StHA) in England operates its own rules on eligibility for NHS Continuing Healthcare using various criteria, assessment processes and tools to support local decision–making. The criticism is that this results in a ‘post code lottery’ across the country as to who receives NHS Continuing Healthcare funding.
  6. Work undertaken over the last two years with the 16 PCTs and 9 local authorities within the Thames Valley StHA area has resulted in an agreed set of eligibility criteria and assessment tools adopted across the area. In my view, the newly configured South Central StHA should retain the responsibility to ensure the consistent implementation of the National Framework across the new larger area.
  7. StHAs also have the responsibility of establishing and supporting the Independent Review Panels (IRPs), which provide the opportunity of independent scrutiny of individual cases including local processes, and the decisions reached. The role of the IRP is advisory but recommendations are made to the Chief Executive of the StHA which in practice are usually accepted. This responsibility should remain at StHA level to ensure consistency across the PCTs and local authorities.
  8. Primary Care Trust (PCT) responsibilities:

  9. The Oxfordshire PCTs have a team of specialist nurses who undertake assessments to determine eligibility for NHS Continuing Healthcare drawing on information from all the professionals involved in the care and treatment of the individual. A separate team of nurses assess and determine the level of the Registered Nurse Care Contribution (RNCC) for people in nursing homes. All applications for Continuing Care and RNCC assessments in Oxfordshire go to a panel jointly convened with Social & Community Services to make the final decisions. At present there are three RNCC bands and if the proposal to have a single band is adopted (see Question 11 in Annex 1), staff resources and time may be used to screen individuals and undertake full NHS continuing healthcare assessments more effectively. However, there are some concerns that this will mean that the funding on the one band will not be enough to compensate providers or full fee payers completely for the actual cost of the nursing care.
  10. Local Authority responsibilities:

  11. Social workers and care managers need to be familiar with the various criteria for both the RNCC determination/NHS-funded nursing care and eligibility for NHS Continuing Healthcare so that they can contribute to the assessments, advise on the appeal procedures when appropriate and refer individuals for continuing care assessments. In Oxfordshire, Social & Community Services' managers also attend the panel meetings, which determine the outcome of applications.
  12. The Department of Health guidelines on the IRP state that there must be Local Authority representation to ensure that all aspects of individual’s needs including their social care needs are considered. Two senior managers from Social & Community Services have participated in training by the StHA and sit on IRPs when required.
  13. Definitions and Funding Responsibilities

  14. Under present legislation there are different arrangements for funding health and social care services that can have financial implications for individuals and their families.
  15. NHS Continuing Healthcare describes a complete package of care arranged and solely funded by the NHS where it has been assessed that the individual’s primary need is a health need. To determine this the assessment needs to conclude that nursing care is more than incidental to the provision of accommodation by a council and that the nursing care is of a nature beyond what it is reasonable to expect a local authority to provide. It can be provided in any setting – for example in a person’s own home where the NHS funds all the care that has been assessed as required or in a care home where the NHS pays the full fees for the person’s accommodation as well as their care. Individuals are not subject to charging if they are assessed as eligible for NHS Continuing Healthcare.
  16. Health and social care joint packages include services funded and provided both by the NHS and the local authority to support individuals whose needs are not primarily health but who require levels of support in their own home or in a care home.
  17. NHS-funded nursing care funds the nursing care in a care home setting and is not subject to charging. Other healthcare services e.g. access to a General Practitioner or other NHS specialists are also free at the point of delivery. The social care elements of a joint package of care are subject to a financial assessment and this means there may be a charge for all or some of these services.
  18. Social care funding purchases a range of social care services to meet the person’s assessed needs. Individuals will be charged for all or some of these services based on a financial assessment. Where a person is placed in a care home and does not require 24 hour registered nursing care they will be assessed for a financial contribution for their accommodation and social care needs. Any identified health care needs will be met through the provision of community and primary health care services for which there is no charge to the individual.
  19. Consultation on the National Framework

  20. The new proposals set out by the Department of Health address many of the issues and inconsistencies in the current policies and their implementation. As well as standardising the eligibility criteria and assessment tools, the recommendations to improve the assessment framework and process should be broadly welcomed. They should provide a more open and transparent process for individuals and their families, and support staff in reaching decisions based on clear evidence of needs. This is essential as some of the well publicised cases show that in parts of the country patients and their families are being asked to pay for care, which in other regions are being met under continuing care agreements. However Annex 1 details some specific comments and significant concerns.
  21. Staff Implications

  22. Staff in adult social care will require ongoing training on the implementation of the National Framework so that:

    1. appropriate and timely advice is provided to individuals and their families;
    2. staff contribute to assessments and decision-making processes as appropriate; and
    3. senior managers participate in the panel process, in appeals and the IRP as required.

  23. Local protocols based on the National Framework will need to be agreed with NHS staff to ensure the initial screening and subsequent appropriate levels of assessment in hospital settings take place in a timely way to avoid unnecessary delays in discharge arrangements.
  24. Financial Implications

  25. The main financial implication is the potential impact on the fee levels for people admitted to a nursing home. As the current fee structure for older people is based on the existing three bands of RNCC funding, the move to a single band for NHS-funded nursing care will mean changes to the current fee structure. Discussions are underway with the care home providers to reach an agreement in the event that this proposal is implemented. However, the response to question 11 in Annex 1 to the Department of Health is that they should not move away from the current 3 bands.
  26. Preliminary work undertaken to model the financial impact on the pooled budget for older people and adults with physical disability estimates a potential pressure on the pool of approximately £500,000 each year. Early indications seem to suggest that this will be a cost pressure that the PCT will have to meet. I consider that changes to the guidance for RNCC funding or continuing care should not result in extra costs to this local authority.
  27. A number of people under 65 who have a physical or learning disability are in receipt of Independent Living Funding (ILF) to support their care package in the community. As with other benefits this is withdrawn if the individual becomes eligible for NHS Continuing Healthcare. Not only is this potentially detrimental to the individual’s quality of life but there is also a potential loss of income to the local authority. Although the number of people in these groups meeting the eligibility criteria is likely to be small, the implications of any potential loss of income to the Council needs to be accounted for. Work is underway to estimate the potential cost to the Council and the need for the Government to urgently review the implications of this has been emphasised in the responses in Annex 1.

  29. The Cabinet is RECOMMENDED to:
          1. endorse the detailed response to the Department of Health on the consultation on the new National Framework for NHS Continuing Care whilst noting the caveats and concerns relating to a number of areas as set out in Annex 1;
          2. request a more detailed report on the financial and operational implications of the outcome of the consultation once new Department of Health Guidance has been issued; and
          3. request that the Directorates for Children, Young People & Families and Social & Community Services work jointly to ensure that the Frameworks for NHS Continuing Healthcare enable a smooth transfer from children to adults services.

Director for Social & Community Services

Background papers: Nil

Contact Officers:
Sandra Stapley, Operations Manager, Tel: (01865) 854482;
Paul Purnell, Head of Social Care for Adults, Tel: (01865) 815828

September 2006

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