Continuing NHS Health Care

1. Continuing NHS Health Care 2007 Training Programme.

2. Aims of the day: • Housekeeping arrangements • Clear understanding of the continuing healthcare policy and legislative background. • Understanding of the importance of the comprehensive assessment process within the whole assessment. • Detailed understanding of how eligibility for Continuing NHS Health Care is determined. • Practical knowledge of the application of the criteria. • Understand the right to appeal via Independent Review.

3. Outline of the Day. • Legal Context and Policy Background • Triggers for CHC assessment and the 3 levels of care • Glossary of terms • The criteria for Continuing NHS Health Care • The Assessment and Decision Making Process • Independent Reviews • Dispute Procedure • Case studies

4. Session 1 - Background • 1990 NHS and Community Care Act • 1995 WHC(95) 7 CHC (5 policies/criteria in Wales) as a result of the Leeds Case (1994) • 1998 Royal Commission on Long Term Care • 1999 Coughlan Judgement • 1999 NWHA Criteria for CHC

5. Session 1 - Background • 2001 NHS Funded Care • 2003 Ombudsman Inquiry into Long Term Care • 2004 WHC (2004) 54 guidance and framework • 2005 New CHC criteria introduced • 2006 Grogan Judgement • 2006 Revision of existing CHC criteria

6. Coughlan Ancillary or incidental Home for life, closure of NHS facility Primary Health Need Grogan Primary Health Need Services lawfully provided by the LA Assessment process Session 1 - The Coughlan and Grogan Judgments.

7. Session 1 – The Ombudsman Report • Primarily derived from complaints relating to local criteria used by Health Authorities to decide whether people were eligible for Continuing NHS Health Care • A special report of the Health Service Ombudsman (2003) concluded that some cases were inappropriately refused funding for Continuing NHS Health Care • LHBs tasked with proactively seeking out cases of injustice.

8. Session 1 - The Ombudsman Report. • Special Review Panels managed by Powys LHB • Pre 2003 – WAG fund the claims, post 2003 the relevant LHB funds the claims. • £8.8 million up to July 2006 in Wales • The majority of claims pre 2003 were approved as there was no evidence of MDT assessment in the notes • Currently – solicitors cite ‘failure to assess’, ‘negligence - failure to exercise due care and attention’.

9. Session 2 - Triggers • All individuals have a right to an assessment and should be informed of this. • CHC should always be considered and excluded first before considering NHS Funded Nursing Care or Joint Funding. Ref Section 5.1

10. Session 2 - Triggers - Process • During overview or specialist assessment • When planning discharge from hospital • When a person is assessed for a care home or before transfer between homes • During or following a major health episode. • During placement panels Ref Section 5.1

11. Session 2 -Triggers – Care needs Does the individual have a Primary Health Need e.g. • Complex, intensive, unstable, unpredictable or considerable health care needs or health needs more than incidental or ancillary to accommodation? • Are they deteriorating rapidly? • Does the individual require significant healthcare input, regular NHS supervision, routine use of specialist equipment • Is the individual near to death? Ref Section 5.1

12. Session 2 – Care Options • What are the care options on discharge?

13. If not CHC – NHS Funded Nursing Care – funded by LHB, SSD and / or Patient Patient Admission Need for comprehensive / specialist assessment identified MDT Members Patient/Family/Carer/Advocate MDT Assessment Other Hospital Care Home Home NHS can be within contract or OAT’s Independent Hospitals May be LHB or HCW funded Nursing Residential No identified needs Home Care CHC funded by LHB Funded by SSD and / or Patient D/N D/N and Home Care Intermediate Care CHC

14. Session 2 - Care Options – the 3 levels of care. • Social Care • Continuing NHS Health Care • Joint Social Care and NHS Care • Private Ref Section 3

15. Session 3 – Care Options • How do you make the decision regarding any of the identified care options? • Who makes the decisions? PATIENTS AND FAMILY MEMBERS MUST BE INVOLVED IN THE PROCESS

16. Session 3 – Glossary of Terms Match the definition to the word.

17. Session 3 – Glossary of Terms • Amount Total of combined health and social care needs • Ancillary Subordinate, subservient or auxiliary • Ancillary Need Is one that is subordinate to a primary need, but can arise from it. • Assessment The process whereby the needs of an individual are identified and their impact on independence, daily functioning and quality of life is evaluated, so that appropriate action can be planned. Assessment involves both professionals and those with the needs thinking through different explanations of how needs have arisen and how different needs interact with each other. Further information is contained in the guidance “Creating a Unified and Fair System for Assessing and Managing Care” (NAFW 2002)

18. Session 3 – Glossary of Terms • Care Co-ordinator An identified NHS clinical professional or social care professional who takes the lead in ensuring that an individual’s package of care is properly managed and monitored. In addition the care co-ordinator ensures that the individual is kept informed of the process and involved in discussions about their care. • Carer Someone over the age of 16 who may or may not be a relative and who may or may not be living with the person they are looking after, this excludes paid care workers and volunteers. • Complex When an individual’s needs are complicated due to the interaction of multiple factors that require frequent reassessment.

19. Session 3 – Glossary of Terms • Comprehensive Assessment This refers to assessments in which most or all of the domains of the UA process have been triggered and explored trough the use of specialist/in-depth assessments (see “Creating a Unified and Fair Assessment” NAW 2002). All people entering care homes or likely to be eligible for continuing healthcare services should have received a comprehensive assessment. This will include medical assessment. • Continuing NHS Healthcare This describes a package of healthcare arranged and funded solely NHS. • Frequent Means occurring or happening often. Frequent or frequency cannot be rigidly defined.

20. Session 3 – Glossary of Terms • Health Commission Wales (HCW) An executive agency of The National Assembly for Wales, which became operational in April 2003. HCW commissions tertiary and other highly specialised services for the residents of Wales. • Incidental Occurring as a minor part or an inevitable accompaniment or by chance. • Incidental Need Is a separate need or level of support that arises as a direct result of the primary need already being catered for. • Intensity Intensity relates to the quality and quantity of care required to manage or maintain health-related needs, with the implication that without this care a person’s health needs would increase. For example, a chronic health condition may require a high degree of intervention to minimise health risks.

21. Session 3 – Glossary of Terms •  Intensity –cont’d • There may be one or more symptoms that are so severe, persistent or intractable that they require a timely response to minimise health risks. • In relation to some conditions, intensity will present a significant risk of aggressive, resistive or disinhibited behaviour which is likely to cause physical injury or significant risk to self, others or the wider community and requires regular risk assessment, possibly by a NHS multi-disciplinary team. • 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.

22. Session 3 – Glossary of Terms • Multi-disciplinary team Involving more than one discipline. MDTs are likely to include medical, nursing, occupational therapy, physiotherapy, speech and language therapists, social workers, psychology or a combination of the above. • Nature Nature can describe either the character of a particular condition (e.g. symptoms which are unstable, episodic, intractable, chronic, persistent, involuntary etc) or the type of interventions required to manage that condition (e.g. invasive treatment, palliative care, responsive medication etc). In both cases the ‘nature’ of condition or intervention can be described in terms of both the quality of care provided – i.e. the type or quantity of care provided – i.e. the level.

23. Session 3 – Glossary of Terms • NHS Funded Nursing Care This refers to the funding by the NHS of the care by a registered nurse in a care home providing nursing. • Nursing Care The Health and Social Care Act 2001 defines nursing care by a registered nurse as meaning any service provided by a registered nurse involving: • §The provision of care or • §The planning, supervision or delegation of the provision of care other than any services which, having regard to their nature and circumstances in which they are provided, do not need to be provided by a registered nurse. It does not include any time spent by any other personnel such as care assistants, who may be involved in providing care although it would include any nurse time spent in monitoring or supervising the care, the provision of which has been delegated to others.

24. Session 3 – Glossary of Terms • Palliative Care The active holistic care of patients with advanced progressive illness, including the management of pain and other symptoms and the provision of psychological, social and spiritual support. • Personal Care Care to help meet personal needs such as bathing, dressing or eating. • Primary Health Need Assessment of whether an individual meets the qualitative and quantitative requirements of a primary health need is to be made by reference to four key indicators, namely nature, complexity, intensity and unpredictability (alone or in any combination) of an individual’s physical, mental, psychological or end-of-life care.

25. Session 3 – Glossary of Terms • Quality The sort, kind or type of care, often a nationally or professionally recognised standard. • Quantity Large or considerable amount, being more than ancillary or incidental. • Regular In this context, this normally means weekly or more frequently, by an NHS MDT Manager. • Respite Care The provision of care (in a care home, the person’s own home or elsewhere) to enable the carer to have a break form their normal responsibilities.

26. Session 3 – Glossary of Terms • Review Re-assessment of an individual’s needs and consideration of the extent to which services are meeting the needs and helping to achieve the desired outcomes. • Risk The evidence based chance or likelihood of an occurrence which will result in harm to the individual or others. • Specialist Undertaken by an NHS clinical professional who has undertaken post-basic education and training and/or specific expertise and experience in the relevant area of healthcare. • Specialist Healthcare Equipment Equipment not normally provided in care homes with nursing or on prescription.

27. Session 3 – Glossary of Terms • Specialist/In-depth Assessment Where the information that is required to be gathered within the assessment process needs to be gathered by a professionally qualified person to give a more in-depth look at any domain or sub-domain; this is called either a specialist or in-depth assessment. Examples of specialist or in-depth assessments might be a social circumstances report” for discharge from section 3 MHA 1983; the measuring of a person’s blood pressure; welfare benefits check of an assessment of mobility where the person has complex needs. • Terminal Care The care an individual receives at the end of their life, usually the last 6-8 weeks, that is related to a diagnosed life limiting illness.

28. Session 3 – Glossary of Terms • Unified Assessment Person-centred approach to assessment, which emphasises the need for agencies to collaborate and respond to individuals in a joined up manner. Assessments are proportionate to an individual’s needs and will not be repeated because information is shared across agencies. • Unpredictable When changes to the individual’s condition cannot be anticipated with certainty and requires ongoing assessment/monitoring. • Unpredictability An individual with unpredictable needs will have a fluctuating, unstable or rapidly deteriorating condition which cannot be reliably anticipated. Unexpected or irregular fluctuations in physical or mental or psychological health of the individual and/or their behaviour will require prompt intervention by a health professional or an appropriately informed carer to manage risk to themselves or others.

29. Session 3 – Glossary of Terms • Unpredictability –cont’d • Severe and continuously deteriorating physical condition resulting in rapidly increasing dependency or a short-term life expectancy. • The individual has a rapidly deteriorating or unstable physical or mental condition that requires timely intervention to manage symptoms, avoid deterioration or distress and minimise risk. • Unstable When the individual’s condition results in alternating or irregular variations in health states requiring frequent intervention or treatment.

30. Session 4 – the CHC Criteria • The fundamental basis for decision making is the Primary Health Need Approach AND • The ancillary or incidental question – the services a local authority could lawfully provide in connection with the provision of accommodation. Ref Section 3.1.1

31. Session 4 – the Primary Health Need Approach There are 4 key indicators which must be considered • Nature • Complexity • Intensity • Unpredictability Ref – Glossary of terms

32. Session 4 – the Primary Health Need Approach In addition consideration must be given whether thenursing or other health services required by the individual is • more than incidental or ancillary to the provision of accommodation which Local Authority Social Services are under a duty to provide AND • are they of a nature beyond which a Local Authority whose primary responsibility is to provide Social Services could be expected to provide?

33. Session 4 – the Primary Health Need Approach • If the patient has a Primary Health Need then they should qualify for Continuing NHS Health Care. •  If the patient does not have a Primary Health Care Need but has needs which are more than incidental or ancillary to the provision of accommodation which Local Authority Social Services are under a duty to provide and the needs are of a nature beyond which a Local Authority whose primary responsibility is to provide Social Services could be expected to provide, then they should qualify for Continuing NHS Health Care. (Interim Guidance)

34. Session 4 – the CHC Criteria • If the patient has a primary health need, refer to which criteria is met e.g. • Criteria 1 - complexity, unpredictability, etc • Criteria 2 - specialist equipment • Criteria 3 - rapidly deteriorating, unstable • Criteria 4 - end stage, terminal Ref – Section 4

35. Session 4 – the CHC Criteria • Criteria 1 The nature, or, complexity or intensity or unpredictability of the individual’s health care needs, (or any combination of these needs), or the risk to themselves or others means that regular input (such as assessment, intervention or monitoring) is required by one or more members of the NHS multidisciplinary team, such as a doctor, nurse, therapist or other NHS member of the team. Ref – Section 4.4.0

36. Session 4 – the CHC Criteria • Criteria 2 The needs of the individual require the routine use of specialist health care equipment involving supervision of NHS staff Ref – Section 4.4.1

37. Session 4 – the CHC Criteria • Criteria 3 The individual has a rapidly deteriorating or unstable medical, physical or mental health condition (or is detained in accordance with Section 17 of the Mental Health Act) and requires regular input (such as assessment, intervention or monitoring) by a member of the NHS multidisciplinary team Ref – Section 4.4.2

38. Session 4 – the CHC Criteria • Criteria 4 The individual is in the final stages of a terminal illness and is likely to die in the near future Ref – Section 4.4.3

39. Session 4 – the CHC Criteria • Section 3.2 The patient needs a joint package of services from both the NHS and Social Services. It applies where the patient DOES NOT meet the criteria for CHC. Health and Social care needs are often difficult to separately identify.

40. Session 5 - Assessment • The assessment process is the most important element in making decisions about an individual’s eligibility for CHC • The MDT must assess and recommend a package of care • This must involve the patient and family in the decision making process • This must be fully documented • CHC assessments form part of the UAP and are not separate to UA. Ref – Section 5

41. Session 5 - Assessment process. • Contact assessment indicates high level of needs and possible triggers for CHC. • Referral to other agencies and professionals as appropriate and Care Coordinator identified. • MDT assessments undertaken – minimum nursing, medical and social work. • MDT meeting or case conference to discuss care needs and CHC eligibility. • Patient and family involved. • Eligibility for CHC considered and care plan proposed • Decision documented

42. Session 5 - Documentation Standards All assessments must be • Current • Consistent • In accordance with professional guidance for documentation • Provide details and costs of the proposed care package • Care Manager identified (for reviews) • Provide evidence of clinical effectiveness (for specialist treatment) • Provide evidence that alternatives have been explored.

43. Session 5 -Decision Making Process The MDT • Determine eligibility for CHC and provide rationale if not eligible for CHC. • Recommend a suitable care package • Determine whether these needs be met from within existing contracts or is additional funding required?

44. Session 5 - Decision Making • The MDT will determine eligibility for Continuing NHS Healthcare and recommend a package of care. • The designated LHB CHC panel will review the decision and • The panel will decide on the appropriateness of the care package and consider value for money and choice issues.

45. Session 5 - LHB CHC panel meetings – customise for each area • Every Tuesday/please specify • Application to be received by previous Thursday/please specify • Panel members – please specify • Role of the panel - Evidence of eligibility, best value, consider the appropriateness of the care package, choice of placement, preferred providers NHS professionals can attend these panels by prior arrangement.

46. Session 6 -Independent Review • A patient and/or their representative, has a right to appeal against the decision making process. • If there is a disagreement all avenues of local resolution should be exhausted before progressing to an Independent Review. • If this is not possible or following discussions at local level not being resolved then the complainant has a right to request an Independent Review. • Consider the role of Advocates and the new Independent Mental Capacity Advocates (IMCAs)

47. Session 6 -Independent Review • Requests for reviews will be allowed where the complainant is dissatisfied about either the procedure followed or the application of the criteria by the LHB • Patients are entitled to have someone act on their behalf during the Review Process including direct representation at the panel meeting • This does not extend to the use of a lawyer acting in a professional capacity. Ref – Section 6

48. Session 6 -Independent Review • The panel must uphold the patient’s confidentiality. • The panel acts in an advisory capacity, however there is an expectation that the panel’s recommendations will be accepted by the relevant LHB. • Requests for a review must be made within 28 days from notification of the outcome of the decision being made.

49. Session 6 -Independent Review • The purpose of the review is to check that the proper procedure has been followed in reaching decisions • Eligibility has been fairly and consistently applied • No new information can be introduced by any party at Independent Review.

50. Session 6 -Independent Review • The review procedure does not apply when patients or their families wish to challenge • The content rather than the application of the criteria • The type and location of any offer of Continuing NHS Health Care • The content of any alternative care package which they have been offered • Their treatment or any other aspect of the services they are receiving or have received