Continuing Health Care

1. Continuing Health Care Lynne Phair Consultant Nurse for Older People Crawley PCT lynne.phair@crawleypct.nhs.uk

2. The battle for NHS Continuing Care • Changing emphasis of care in the early 1990s • Introduction of eligibility criteria 1996 • Coughlan Judgement July 1999 • It was unlawful to transfer responsibility of patients general nursing care to local authority unless it was merely incidentally or ancillary to the provision of accommodation and of a nature which could bee expected social services to provide

3. The battle for NHS Continuing Care • October 2001 introduction of funded nursing care. 3 levels of RN care for which the government make a RNCC contribution • February 2003 Ombudsman’s Report for long term care • This found some Health Authorities had not been lawful in their continuing care criteria and had not adjusted them in accordance with the Coughlan Judgement

4. The battle for NHS Continuing Care • Recommendations- The DoH should review the national guidance for eligibility for continuing NHS care • This guidance must be much clearer in showing when the NHS must provide funding and those where it is let to the NHS bodies locally. • The guidance may need to include detailed definitions of terms and case examples • The DoH were also required to make efforts to remedy consequent financial injustice

5. The definition • The nature or complexity or intensity or unpredictability of the individuals health care needs (and any combination of these needs) requires the regular supervision by a member of the NHS multidisciplinary team, such as the consultant, palliative care, therapy or other NHS member of the team

6. The definition of NHS continuing Care • The individuals needs require the routine use of specialist health care equipment under the supervision of NHS staff • The NHS has a rapidly deteriorating or unstable condition • Individual is in the final stages of a terminal illness and is likely to die in the near future • The location of care does not determine the eligibility

7. Working definitions of the key words • DoH did not directly provide definitions in the circular of the key aspects of care • Stability, predictability and complexity were all take from the funded nursing care definitions • These terms have also been defined in RCN Assessment tool and previous DoH eligibility criteria

8. How the DoH managed the recommendations • Each SHA had to review their criteria • some also developed assessment tools and scoring methods. • Thus all SHAs have an individual interpretation and scoring system • Potential still exists for variation in interpretation and application

9. The Grogan Judgement January 2006 • The high court ruled that eligibility for NHS CHC used by the Trust was unlawful since the criteria contained no guidance as to the test or approach to be applied when assessing a person • There as no express reference to the “Primary Health Need Approach” or the incidental or ancillary test • There was no decision as to whether Mrs Grogan did or did not meet the criteria

10. The Grogan Judgement • The DoH issued an action statement ( 03 March 2006) identifying that a persons health needs is not just the need for registered nursing, but is overall need and the need for the accommodation is part of that overall need. • All SHA and PCTS had to once again review how they have applied the criteria • CHC is not jut the next step up from FNC

11. Intensity of Care • Working definition described by Bexley Care Trust Retrospective Review Team November 2003 • Health or disease process/ disorder, including emotional physical behavioural and psychosocial needs, requiring extensive levels of care time and or frequent periods of direct care, treatment or observation to achieve/ maintain self- actualisation • ( including the maintenance of life, e.g breathing, swallowing, eating drinking) from one or more professionally qualified health professionals.

12. Intensity of Care • Intense includes high levels of care needing extensive direct handling and or use of invasive techniques and intensive refers to a very thorough/ rigorous type of care to achieve maximum capacity of the patient

13. A practical example • Agnes aged 87 years. Lived in a Nursing Home for 3 years. • Unable to communicate or understand any instruction or language. Legs had become contracted, no sitting balance and no voluntary movement of arms or hands • No recognition of people objects, risks or aids to living • Doubly incontinent

14. Agnes • Thin papery skin, cachectic weight loss. • Inability to recognise food or fluids in her mouth • Becomes agitated when care is delivered • All responses are primative • Lives in a twilight state sometimes opens he eyes to sound stimulation no facial responses • He husband visits daily

15. The Care needs of Agnes • Staff needed to anticipate all her needs. • Skilled abilities to read non verbal communication and marry up requirements with history from family ,for all aspects of care including pain • Anticipatory skills re pain, hunger, thirst, • Ability to manage and monitor dietary intake without invasive techniques. support of dietician • Remedial Physio re contractions • Manage risks

16. Risks • Intrinsic risks from total incapacity • Pressure risk, falls, DVT, Oral Thrush constipation, dehydration, contractions, chest infections UTIs. • Total environmental risks due it advanced cognitive impairment • Health risks associated with old age

17. Why is this not just basic personal care? • Complexity of the interrelationship between all fundamental functions of life • Intensity of needs as Agnes would die with a few days without total compensatory action • Overwhelming risk of complications • Needs for specialist involvement to balance physical and emotional needs

18. Is this health care? • Nursing is… • The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death ( RCN 2003) • Nursing can be carried out by people other than registered nurses ( RCN 2003 & Ombudsman 2003)

19. Is this health care? • She deserves the regular review and support of a specialist Registered Nurse who has advanced skills in the physical and mental health of old age who has the skills to offer palliative care which of course can empower other care staff to deliver her health care needs • Who has the skills to be able to assess and prescribe care in a non clinical setting and who can support the family and Agnes • She requires the involvement of SALT Dietician and OT • She needs specialist equipment to assist her healthcare needs

20. Is this health care? • Agnes’s needs are complex, every simple action or inaction can have a number of consequences • Her life depends on the intervention of others she has no capacity even to recognise water or understand her need for it. • She requires daily review and reassessment but of a subtle nature but if not carried out will have catastrophic consequences • Her problem is that she is receiving pure nursing, she requires no tubes, the tools of the staff are within themselves, hidden from view

21. The skills required to assess • Competent but not Expert assessors may view the needs of Agnes in a positivist way - over simplistic interpretation of seeing the situation on face value • Expert assessors would use use critical theory techniques to reveal hidden factors and different perspectives on a complex situation Thomas (2006)

22. The skills required to assess • Using the term “basic care” can be likened to the term “common sense” both of which are not common or basic but a dance between different beliefs priorities and needs and an ability of the assessor to use positivist and critical theory to feed the judgement. Thomas (2006) • The danger is that many nurses cannot articulate what the depth of care is and so leaps to use the term basic thus diminishing the complexity of care required to maintain the status quo

23. A practical dilemma • All people leaving hospital are entitled to a CHC assessment before referral to SSD • Development of a trigger tool in West Sussex • Pilot as only partly successful as discharge nurses said it was very difficult to assess against the criteria • Ordinary Ward nurses did not have time to learn it and they would only assess those who they thought might be eligible • The Section 2 referral was made as soon as the person came is and so the process of CHC assessment could not be done when the person was considered stable. • The SHA and SSD are encouraging hospitals to find ways of implementing it • The worry is the lack of understanding of the legal right of older people to have the assessment

24. A practical Dilemma • The SHA and SSD are encouraging hospitals to find ways of implementing it • The worry is • The lack of understanding of the legal right of older people to have the assessment • The lack of acceptance that assessing for CHC is a highly skills activity • The lack of understanding that RNs must document a rationale for their decision making

25. Useful literature • Defining Nursing RCN 2003 • Anderson W Bungay H ( 2004) Assessing patients’ eligibility for fully funded nursing care. Nursing times 100;2,38-41 • Steed A ( 2004) Compensation still in the pipeline money telegraph .co.uk 24.4.04 • The Health Service Ombudsman NHS funding for long term care 2nd report 2003 • Continuing Care NHS and local councils’ responsibilities • HSC 2001//015: LAC(201)18 • Essence of Care (2001)- patient focused benchmarking for health care practitioners DoH • NHS Funded Nursing Care Practice guide & workbook (2001) DoH • Thomas P ( 2006) Integrating primary health care Routledge London • DoH(2006)NHS continuing Care action following the Grogan Judgement www.dh.gov.uk