Theme no. 3: Checklisting for CHC – this doesn’t seem to be mentioned in the Care Act’s hospital discharge schedule, and so is it on its way out?

Material taken from the National Framework on checklisting

  1. CCGs should ensure that local protocols are developed between themselves, other NHS bodies, LAs and other relevant partners.

 

These should set out each organisation’s role and how responsibilities are to be exercised in relation to delayed discharge and NHS continuing healthcare, including responsibilities with regard to the decision-making on eligibility.

 

There should be processes in place to identify those individuals for whom it is appropriate to use the Checklist and, where the Checklist indicates that they may have needs that would make them eligible for NHS continuing healthcare, for full assessment of eligibility to then take place.

 

  1. Assessment of eligibility for NHS continuing healthcare can take place in either hospital or non-hospital settings. It should always be borne in mind that assessment of eligibility that takes place in an acute hospital may not always reflect an individual’s capacity to maximise their potential.

 

This could be because, with appropriate support, that individual has the potential to recover further in the near future. It could also be because it is difficult to make an accurate assessment of an individual’s needs while they are in an acute services environment.

 

Anyone who carries out an assessment of eligibility for NHS continuing healthcare should always consider whether there is further potential for rehabilitation and for independence to be regained, and how the outcome of any treatment or medication may affect ongoing needs.

 

  1. In order to address this issue and ensure that unnecessary stays on acute wards are avoided, there should be consideration of whether the provision of further NHS-funded services is appropriate.

This might include therapy and/or rehabilitation, if that could make a difference to the potential of the individual in the following few months.

 

It might also include intermediate care or an interim package of support in an individual’s own home or in a care home.

 

In such situations, assessment of eligibility for NHS continuing healthcare should usually be deferred until an accurate assessment of future needs can be made.

 

The interim services (or appropriate alternative interim services if needs change) should continue in place until the determination of eligibility for NHS continuing healthcare has taken place. There must be no gap in the provision of appropriate support to meet the individual’s needs.

 

  1. Where NHS-funded care, other than on an acute ward, is the next appropriate step after hospital treatment, this does not trigger the responsibilities under the Community Care (Delayed Discharges etc.) Act 2003.

 

Material from the national framework on the Checklist

 

  1. The first step in the process for most people will be a screening process, using the NHS continuing healthcare Checklist – unless it is deemed appropriate for the Fast Track Pathway Tool to be used at this stage (see paragraphs 97 – 107) or for other NHS-funded services to be provided (see paragraph 65).

 

In an acute hospital setting, the Checklist should not be completed until the individual’s needs on discharge are clear. The purpose of the Checklist is to encourage proportionate assessments, so that resources are directed towards those people who are most likely to be eligible for NHS continuing healthcare, and to ensure that a rationale is provided for all decisions regarding eligibility.

 

  1. Standing Rules Regulations make it clear that if the CCG is to use any screening tool, that tool must be the NHS Continuing Healthcare Checklist. They may, if they wish, directly move to a full MDT assessment for an individual without using a Checklist. However, a CCG cannot use a different tool or method for screening for NHS continuing healthcare.

 

  1. [Standing Rules Regulations] require a CCG to take reasonable steps to ensure that individuals are assessed for NHS continuing healthcare in all cases where it appears that there may be a need for such care.

 

  1. Where the Checklist has been used as part of the process of discharge from an acute hospital, and has indicated a need for full assessment of eligibility (or where a Checklist is not used, a full assessment of eligibility would otherwise take place), a decision may be made at this stage first to provide other services and then to carry out a full assessment of eligibility at a later stage. This should be recorded.

 

The relevant CCG should ensure that full assessment of eligibility is carried out once it is possible to make a reasonable judgement about the individual’s ongoing needs. This full consideration should be completed in the most appropriate setting – whether another NHS institution, the individual’s home or some other care setting. In the interim, the relevant CCG retains responsibility for funding appropriate care.

 

  1. Whatever the outcome of the Checklist – whether or not a referral for a full assessment for NHS continuing healthcare eligibility is considered necessary – the decision (including the reasons why the decision was reached) should be communicated clearly and in writing to the individual and (where appropriate) their representative, as soon as is reasonably practicable.

 

Where the outcome is not to proceed to full assessment of eligibility, the written decision should also contain details of the individual’s right to ask the CCG to reconsider the decision.

 

The CCG should give such requests due consideration, taking account of all the information available, including additional information from the individual or carer.

 

A clear and written response should be given to the individual and (where appropriate) their representative, as soon as is reasonably practicable.

 

The response should also give details of the individual’s rights under the NHS complaints procedure as enshrined in the NHS Constitution.

 

  1. The time that elapses between the Checklist (or, where no Checklist is used, other notification of potential eligibility) being received by the CCG and the funding decision being made should, in most cases, not exceed 28 days.

 

In acute services, it may be appropriate for the process to take significantly less than 28 days if an individual is otherwise ready for discharge.

 

The CCG can help manage this process by ensuring that potential NHS continuing healthcare eligibility is actively considered as a central part of the discharge planning process, and also by considering whether it would be appropriate to provide interim or other NHS-funded services, as set out in paragraph 65 above.

 

Practice Guidance note 13.6

Social care practitioners should work jointly with NHS staff throughout the NHS continuing healthcare eligibility process, and should be involved as part of the MDT wherever practicable.

 

Therefore, where the LA receives a referral for involvement in the MDT process for NHS continuing healthcare they should respond positively and promptly.

 

The LA should usually be represented on the MDT completing the NHS continuing healthcare eligibility process.

 

This means that, in most cases, the key assessment information needed for LA support is already available if the delayed discharge process is triggered subsequently.

 

Therefore, where a person is found to be ineligible for NHS continuing healthcare and delayed discharge notices are then issued, the LA should be in a position to respond and action their responsibilities within a short timeframe.

 

PG 13.8 In summary, CCGs should have appropriate processes and pathways in place to ensure that, where an individual may have a need for support after hospital discharge, one of the following scenarios will apply:

 

  1. a) prior to completing a Checklist in hospital a decision is made to provide interim NHS funded services to support the individual after discharge (in which case the delayed discharge provisions would not be triggered). In such a case, before the interim NHS funded services come to an end, consideration of NHS continuing healthcare eligibility should take place through use of the Checklist and, where appropriate, the full MDT process using the DST;

 

[No checklist and no DTOC notices because need for more NHS services of some kind is clear – NHS pays for and arranges those for the short or longer term and CHC is decided at the end of those services having any potential for improvement]

 

  1. b) a Checklist is completed which indicates the person may have a need for NHS continuing healthcare and interim NHS-funded services are put in place to support the individual after discharge until a full MDT NHS continuing healthcare assessment is completed (in which case the delayed discharge provisions would not be triggered);

 

[a positive Checklist but discharge effected because it’s better for the patient – NHS pays until CHC assessment is done]

 

or

 

  1. c) a Checklist is completed which indicates the person may have a need for NHS continuing healthcare and a full MDT NHS continuing healthcare assessment takes place before discharge. If this results in eligibility for NHS continuing healthcare then the delayed discharge procedures do not apply as the NHS continues to have responsibility for the individual’s care;

 

[a positive Checklist followed by a CHC decision before discharge, assuming a proper MDT]

 

or

 

  1. d) a Checklist is completed which indicates the person may have a need for NHS continuing healthcare and a full MDT NHS continuing healthcare assessment takes place before discharge. If this does not result in eligibility for NHS continuing healthcare then the appropriate delayed discharge notices should be issued;

 

[a positive checklist followed by a DST resulting in no recommendation for CHC status: an assessment notice can be served or need not be withdrawn and a discharge notice can follow on, unless (CASCAIDr says) the patient or family says the council is acting illegally]

 

or

 

  1. e) a Checklist is completed before discharge which does not indicate the person may have a need for NHS continuing healthcare in which case the appropriate delayed discharges notices should be issued.

 

[a negative Checklist and (CASCAIDr says) no challenge to the legitimacy of thecouncil’s actions on legal grounds even if they proposals are not welcome].

 

If a local area does not use the Checklist either generally or in individual cases then a full MDT NHS continuing healthcare assessment should take place before delayed discharge notices are issued.

 

[…because no assessment notice can be served without a decision as to CHC]

 

14.1 Intermediate care is aimed at people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute or longer-term in-patient care or longterm residential care. It should form part of a pathway of support.

 

For example, intermediate care may be appropriately used where a person has received other residential rehabilitation support following a hospital admission and, although having improved, continues to need support for a period prior to returning to their own home.

 

It should also be used where a person is at risk of entering a care home and requires their needs to be assessed in a non-acute setting with rehabilitation support provided where needed. This is irrespective of current or potential future funding streams, but is clearly important in the context of consideration for NHS continuing healthcare.

 

  • CCGs should have regard to the most recent guidance in relation to Intermediate Care.

 

14.3 Individuals should not be transferred directly to long-term residential care from an acute hospital ward unless there are exceptional circumstances. Such circumstances might include:

 

  1. a) those who have already completed a period of specialist rehabilitation, such as in a stroke unit
  2. b) those who have had previous failed attempts at being supported at home (with or without intermediate care support)
  3. c) those for whom the professional judgement is that a period in residential intermediate care followed by another move is likely to be unduly distressing.

14.4 The guidance referred to above sets out what intermediate care should look like as well as how to commission it, with an emphasis on partnership working. CCGs should seek to ensure that this pathway is followed prior to any long-term placement apart from exceptional circumstances.

 

 

Proposals for reform of the CHC system

The CHC Alliance published a report in November 2016 highlighting a number of issues, including with the CHC assessment process. Additionally, in July this year the National Audit Office (NAO) published an investigation into CHC.

Key facts and figures

Continuing Healthcare – 2016/17

  • Almost 160,000 people received or were assessed as eligible for CHC
  • Almost 77,000 referrals for a full CHC eligibility assessment process
  • Around 88,000 Fast Track Pathway Referrals received
  • Around 25% of individuals assessed for standard CHC were found eligible
  • Approximately £3.2 billion spent on CHC
  • 609 Independent Reviews took place, 122 of which resulted in an eligibility recommendation for at least some period of care

Funded Nursing Care – 2016/17

  • Approximately 132,000 people received or assessed as eligible for FNC
  • Approximately £625 million spent on FNC

Summary of Issues: in general, inconsistent experiences and variation, including…

  • High number of assessments and screenings being conducted that do not lead to eligibility for CHC – In 2016/17 77,000 people were assessed for CHC. Of those assessed, around 25% were eligible. It may be possible that some of these assessments were unnecessary, even if we account for people who receive NHS funded nursing care. Our analysis has shown a number of factors could be influencing this, such as the location in which screening and assessment is carried out.
  • The level at which the Checklist threshold is set – When the Checklist was designed the threshold was deliberately set low to ensure individuals who may be eligible for CHC receive a full assessment. A staff survey data collected by a group of Commissioning Support Units (CSUs) for DH and NHS England and analysis of this data showed that 86% of respondents thought the Checklist threshold was too low, resulting in full assessments that were unnecessary and patients’ expectations being raised.
  • The impact of the location in which individuals are screened for CHC – That same data shows that 80% of respondents thought that the setting of the screening has an impact on the outcome. At that point, around half of CHC screenings, and a third of assessments, were being carried out in an acute setting at a time when patients may not have benefited from a period of recovery. Delays in hospital discharge can lead to a high risk of deconditioning – for patients over 80 years old, every ten days spent in hospital is equivalent to 10 years of muscle ageing – which is entirely preventable.
  • Disparity in approaches to training across the country – Around 87% of staff reported having done e-learning or face-to-face training, Data shows that staff think training is not well co-ordinated by the CCGs, which in some local systems may to lack of practitioner confidence. This has also been referenced in the CHC Alliance report.
  • Issues with the “challenges to individual decisions” process – There is evidence of variation at CCG level in terms of the local dispute resolution process, a lack of clarity around process, and distress being caused to individuals and their families or carers as a result. These are also highlighted in the NAO report.
  • A lack of clarity around the three and twelve month review purpose and processes – There is evidence of variation in the review processes and inconsistency, also highlighted in the NAO report and CHC Alliance report.

 

As we understand it the position from the DH, is that they have decided not to put the proposals out to public consultation. Instead, DH are going through a short stakeholder engagement process. DH will only accept submissions from stakeholders (for example a CCG or organisation in the CHC stakeholder group), and only one response per stakeholder.

200 expressions of interest were received via Beacon, from which they selected 25 people to attend an event and constitute a group.

Even though CASCAIDr’s Belinda Schwehr was not selected to attend the focus group, Beacon asked for feedback on the powerpoint so that it could inform Beacon’s final response to the Department of Health.

We have no idea whether the powerpoint may or may not be shared, but we think that aspects of it should be shared in the public interest, so that people can lobby their MPs as to why there is no public engagement.

The formal stakeholders were only given a couple of weeks to respond with a deadline of 31 October. Permission was given from DH to share the slides with the formal stakeholders and a short extension was given.

In 2006 when the National Framework was first worked on, it took CASCAIDr’s Belinda Schwehr three whole working days to critique the last consultation on CHC and the current document is no easier.

Is this not a bit like information prior to the Referendum on reminaing in the EU, CASCAIDr would have to ask?

The DH’s proposals for reform of CHC guidance (of course there is no suggestion that the law or the line would move, on the process for getting to the decision making….) said this

  • Should CHC checklists always be done in a community setting (this would allow for stabilisation and management of hospital beds, but would depart from the fundamental perspective that the next liability should not be determined without a decision about CHC – no problem if interim discharge to assess beds are free, of course)
  • Should CHC DSTs occur ONLY in a community setting?
  • What should the considerations for who gets checklisted in the first place, be?
  • Should the rules on review be changed?
  • Should the rules for training be changed?
  • Should the rules for roles within the NF be changed?
  • How should the rules for local resolution be changed to get rid of the immense variations that occur?
  • Whether there should be a 6 year rolling limitation period for restitution of retrospective claims?
  • What people think of additional fees arrangements (top ups) for CHC care?Proposals for clarifying the meaning of Primary Health Need?
  • Whether the domain wording should be clarified
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