– 19 SEPTEMBER 2006
Framework for NHS Continuing Healthcare and nhs-funded nursing care
Director for Social & Community Services
- 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.
- 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:
- Fully funded
NHS Continuing Healthcare where the NHS funds the whole care package;
- NHS-funded Nursing
Care where the NHS is responsible for funding the nursing required
from a registered nurse in a care home setting.
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.
- 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.
Current Operational Policies
and Structures in Oxfordshire.
Health Authority responsibilities:
- 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.
- 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.
- 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.
Care Trust (PCT) responsibilities:
- 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.
- 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.
- 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.
and Funding Responsibilities
- Under present
legislation there are different arrangements for funding health and
social care services that can have financial implications for individuals
and their families.
- 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.
- 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.
- 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
- 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.
Consultation on the National
- 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.
- Staff in adult
social care will require ongoing training on the implementation of the
National Framework so that:
and timely advice is provided to individuals and their families;
- staff contribute
to assessments and decision-making processes as appropriate; and
- senior managers
participate in the panel process, in appeals and the IRP as required.
- 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.
- 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.
- 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.
- 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.
- The Cabinet
is RECOMMENDED to:
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;
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
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.
Social & Community Services
Background papers: Nil
Sandra Stapley, Operations Manager, Tel: (01865) 854482;
Head of Social Care for Adults, Tel: (01865) 815828