NHS Continuing Healthcare

1
NHS Continuing Healthcare

• Workshop 1 the basics
• 1. Update

2
Welcome and Introductions

• names of facilitators

3
Objectives

• To get to know your local, regional and national
  partners in continuing care amend as appropriate
  for audience
• To discuss and share
• update on the National Framework
• legal background to continuing care
• key principles of good assessments
• To understand how the tools proposed for the
  Framework are intended to be applied
• To take away your learning from today

4
Reminder - the National Framework
National Framework

• Current system

• Each SHA in England has own rules on eligibility
  for NHS Continuing Healthcare

• One national policy on eligibility for the NHS in
  England.

• Each SHA uses its own assessment process and
  tools

• National assessment process supported by national
  tools.

• PCT
• assesses individuals need for care from a
  registered nurse
• in a separate determination, places the
  individual into one of three nursing bands

• NHS still assesses registered nursing needs, but
• - no banding system ? no requirement for a
  separate assessment to decide the band
• - funding at a flat weekly rate

5
The Consultation process

• Consultation ran from 19 June until 22 September
  2006
• 500 written responses received from individuals,
  NHS bodies, voluntary groups, LAs. (not
  exhaustive)
• Public events involved 640 people

6
Positive feedback ?

• - assessment on the basis of need
• - the concept of a National Framework
• - the idea of national tools to support
  decision-making
• - the suggested care domains
• - the idea of reducing to 1 band for Nursing
  Care

7
Areas for further work ?

• - clarity regarding roles and responsibilities
• - our descriptions of the key indicators
• - the financial implications
• - the legal robustness of the Framework

8
Requests for more input/guidance

• End-of-life and palliative care
• Joint working between Health and Social Care
• Auditing and monitoring
• Training and piloting

9
What weve been doing since the consultation

• Analysing your responses

• Improving the Decision Support Tool
• - more work on pain, getting the levels right,
  getting the balance of mental and physical health
  needs right

• Investigating financial, legal and practical
  implications how long roll out will take

• Turning our attention to helping you commission
  better

10
When will it all happen?

• Still under discussion, but guidance in June
• (?)

• Plenty to do before full implementation possible
  (training, piloting)

11
In the meantime general message

• The direction of travel is hopefully clear

• Following the interim guidelines more SHAs are
  moving towards common sets of criteria that look
  more like the National Framework, which is very
  helpful

• Given the importance attached to joint working we
  hope that partnerships will strengthen over the
  time between now and implementation

• We remain open for further post-consultation
  comments

12
In the meantime what this means for you

• Although date for implementation not yet set, as
  soon as it is, things may have to move quickly
  and we need to be prepared
• Training sessions starting now to bring you up
  to date, to discuss the new draft tools and to
  enable you to take what you have learned back to
  your organisations
• Second wave of training when the implementation
  timetable has been announced

13
NHS Continuing Healthcare

• Workshop 1 the basics
• 2. Legal background and the primary health need

14
The National Assistance Act

• Section 21 of the 1948 Act
• a local authority may make arrangements for
  providing residential accommodation for persons
  aged 18 and over who by reason of age, illness,
  disability or any other circumstances are in
  need of care and attention which is not otherwise
  available to them. It goes on to say that the
  board and other services, amenities and
  requisites should be provided in connection with
  the accommodation.

15
The National Health Service Act 1977

• Section 3
• Duty to provide as necessary to meet all
  reasonable requirements -
• Hospital accommodation and other accommodation
  for the purposes of any services provided under
  this Act
• Nursing services
• Facilities for the prevention of illness, the
  care of persons suffering from illnessas he
  considers are appropriate as part of the health
  service. ETC

16
Policy Context 1

• 1995 Guidance (HSG (95) 8) NHS responsibilities
  for meeting Continuing Health Care Needs short
  or long term basis for inpatient care
• ALTERED 1996 over-restrictive criteria over
  reliance on the needs of patient for specialist
  medical opinion
• SUPERCEDED by 2001 guidance largely because of
  the Coughlan case

17
The Coughlan Judgment 1

• 1999 Court of Appeal the Pamela Coughlan Case
• 1998 moved from Mardon House her home for
  life.
• 1996 HA review - Miss Coughlan ineligible for NHS
  care.
• No place of care was identified. The LA would
  take responsibility for Miss Coughlans care.

18
The Coughlan Judgment 2

• This type of nursing care could not lawfully be
  provided by the LA.
• HA broke their promise to Miss Coughlan.
• HAs consultation on the closure of Mardon House
  was flawed.
• HAs eligibility criteria for longer term health
  care were flawed.
• HA did not identify an alternative place of care
  for Miss Coughlan.

19
Post Coughlan

• June 2001 Guidance (HSG 2001/015) replaced all
  previous guidance.
• Emphasis on nature, intensity, complexity and
  unpredictability
• Reference to Coughlan
• Eligibility criteria to cover three scenarios
• Where the Primary need is for health, NHS takes
  sole responsibility
• Where the responsibility can be shared between
  the NHS the council, nursing needs can be
  provided by the council NHS will be responsible
  for other health needs
• Where all social care including nursing (this was
  pre RNCC) can be the responsibility of the
  council

20
Section 49 Health Social Care Act 2001

• The Local Authority cannot provide for any person
  or arrange for any person to be provided with
  nursing care by a registered nurse which includes
  the provision, planning, supervision or
  delegation of that care.

21
Ombudsman Report

• Feb 2003 Ombudsmans report
• - HAs criteria over-restrictive.
• - Retrospective Review process announced.
• Cases would be backdated to 1996
• - DH required SHAs to have a single set of
  criteria.
• Retrospective review has so far involved 12000
  cases

22
Grogan judgment

• Bexley Care Trust used unlawful criteria not
  the primary health need approach
• Did this mean other Trusts might also be using
  similarly unlawful criteria?
• Criticised the lack of distinction between high
  band nursing and continuing care
• DH issued guidance asking all SHAs to re-examine
  their criteria (March 2006)

23
GROGAN PRIMARY HEALTH NEED

• If a persons primary need is a health need then
  the NHS will be responsible for providing for
  that need (and thus for that persons
  accommodation if that is a part of the overall
  need).
• In assessing whether or not he has that primary
  need the totality of his needs and thus all his
  needs for health care need to be taken into
  account.

24
Primary Health Need/ Incidental/ancillary

• nature, intensity, complexity and
  unpredictability have been the NHSs answer to
  the Coughlan judgment (incidental or
  ancillary)
• i.e. where the primary need is for health, the
  NHS should take responsibility
• In your groups, discuss for 10 minutes (consider
  just one term to start off with)
• What you think these terms/phrases mean
• how these terms relate to a primary health need

25
Using the indicators/phrases

• The previous exercise has probably demonstrated
  to you how difficult it is to define the four
  key indicators / incidental ancillary
• The main difficulties are usually
• Is it about needs or interventions?
• The overlaps between the different terms
• Open to interpretation - differences in opinion
  Health vs Social Services colleagues and lay
  versus professional
• what I think complex is might not be what a
  patient thinks complex is

26
National Framework

• Interpretation led to variation both locally and
  nationally, hence the need for a National
  Framework.
• Commitment reinforced in the White Paper 2006
• Need for a standard process to ensure that
  eligibility consideration against criteria is
  carried out robustly and uniformly

27
National Framework tools

• Key to a standardised process nationally
  approved tools to support decision making
• These should help examine nature, intensity,
  complexity and unpredictability of an
  individuals health care needs.
• To use the tools, need good assessment material

28
NHS Continuing Healthcare
Workshop 1 the basics 4. Principles of
assessments
29
Q What do you think are the KEY PRINCIPLES OF
GOOD ASSESSMENTS?
Brainstorming for 15 minutes in your groups.
Please highlight 2 points per group.
30
PRINCIPLES OF GOOD ASSESSMENT

• Principles will hold for any sort of assessment
• However, focus on how to obtain the right sort of
  evidence for making a decision about eligibility
  for NHS Continuing Healthcare
• Think about
• General principles of assessments
• Co-ordination of the process

31
The basics

• Purpose to identify care needs and health risks
• Should be
• coherent process for users and carers
• joint process for the multi-disciplinary
  professionals.
• The NHS Continuing Healthcare decision-making
  process
• DOES NOT ADD EXTRA LAYERS OF ASSESSMENT
• helps ensure a full needs portrayal.
• The Single Assessment Process (SAP)/ other
  comprehensive assessments using validated tools
  are key.

32
Person centred

• The person being assessed should always be
  treated as an individual. To ensure consistent
  access, assessments should be
• culturally sensitive,
• user centred
• equitable
• Users, carers and advocates where appropriate
  (bear Mental Capacity Act in mind) should be
  fully involved in the assessment process.

33
Further principles

• Duplication of assessments should be avoided
  balance of professional trust and ability to
  query evidence where necessary.
• The timing and location of an assessment is
  important. In almost all cases, assessments
  should be undertaken only after any
  rehabilitation is completed and the outcome of
  any treatments or medication which may affect
  ongoing needs is known.
• The risks and benefits of a change of location or
  support should also be considered.

34
COORDINATING THE PROCESS

• Ownership of process beginning to end
• Identify individuals who should be assessed
• Identify if an individual needs to be
  fast-tracked
• Identify all professionals involved in the care
  of the user who may contribute to the assessment
• Complete documentation accurately, clearly and
  comprehensively
• Ensure appropriate care plan put in place
• A Care Coordinator can help this process run
  smoothly

35
Local adaptation

• Local processes to be signed up to by all parties
  and widely communicated. Take account of any
  national guidance, and think about
• Documentation - to incorporate final versions of
  national tools
• Timescales for assessments and eligibility
  considerations, including initial and ongoing
  reviews.
• Communication channels/responsibilities to keep
  user and carer informed.
• Training ongoing multidisciplinary programme for
  staff involved in assessments.
• Audit process - to assure quality and keep track

36
3 take-home messages

• Assessment/eligibility consideration considers
  the individuals needs, not diagnosis or
  available resources.
• Consideration for NHS Continuing Healthcare is
  NHS-led but should include Local Authority
  partners wherever possible.
• No eligibility decision is made unilaterally
  without reference to a multi-disciplinary team
  assessment.

37
NHS Continuing Healthcare
Workshop 1 the basics 5. The Draft Decision
Support Tool (DST) and Referral tool
38
What is it?

• Draft Framework for the MDT to
• set out the evidence in a detailed needs based
  format
• analyse the evidence to make a recommendation
• justify how and why the recommendation was made
• clarify the evidence used to make the decision

39
What its NOT

• An assessment
• A decision MAKING tool
• Suitable for every individuals situation
• A substitute for professional judgement

40
How did we get here?

• Based on good practice
• LONG development process involving practitioners,
  stakeholders, consultants..
• 3 months consultation
• FURTHER refinement post consultation
• 2nd draft on line since end January
• PCTs now carrying out a 3 month study using blind
  cases. LOCAL PILOT SITE insert

41
How does it work?

• 1. INFORMATION SECTION (p 10-13)
• Minimum information required
• Expect some local variation in this part
  according to need
• Expand information boxes as required

42
How does it work? (Cont.)
2. The Care Domains

• Continence
• Skin
• Breathing
• Drug Therapies Medication Symptom control
• Altered States of consciousness

• Behaviour
• Cognition
• Psychological Emotional needs
• Communication
• Mobility
• Nutrition

43
Terminology

• Consistency central to understanding
• In line with recommendations from Ombudsman and
  others, very few with new draft, no references
  to professional/ specialist
• Although, once provided, NHS Continuing
  Healthcare will involve monitoring and
  supervision by an NHS professional, care might be
  provided largely by skilled carers or care
  workers at time of consideration

44
Levels

• Each domain is divided into levels describing a
  hierarchy of need
• Each level is given a weighting (not score)
• no needs, low, moderate, high, severe, priority.
  
• Not all domains have the same weighting based
  on principle that some domains reflect health
  needs more than others

45
Establishing a Primary Health NeedComplexity,
intensity, unpredictability
L
E
V
E
L
S
COMPLEXITY
INTENSITY
D O M A I N S
46
Completing the DST

• Appoint care co-ordinator to
• liaise with MDT
• gather evidence
• complete DST

47
Before proceeding

• Has there been a comprehensive assessment?
• Does the assessment contain enough detail?
• frequency and intensity of need
• fluctuation in need
• complexity of interventions where relevant ?
• Has all the evidence been gathered?
• Have the appropriate risk assessments been
  undertaken?
• Is there any variation between day night time
  needs?

48
Eligibility 1

• Complete DST liaise with MDT (patient, family
  etc) and make a recommendation
• Clear recommendation of eligibility when
• - a priority need in one of the 4 domains which
  carry this level
• - 2 or more incidences of severe needs
• Clear recommendation of ineligibility when all
  domains are either Low or no need

49
Eligibility 2High Moderate Needs

• A number of domains with high and/or moderate
  needs can also indicate a primary health need.
• Consider
• Overall needs
• How the interaction and interrelationship between
  the needs affects the overall impact
• Risk assessments.
• Focus on the evidence and use professional
  judgement
• Is there a primary health need?
• Or are health needs incidental and ancillary to
  the provision of accommodation?

50
Recommendation and Justification

• How and why you reached a recommendation should
  be clearly set out and explained to patients and
  carers so that everyone can follow the rationale
• A pen picture
• helps illustrate how each aspect of need either
  did or did not contribute to a primary health
  need.
• may form the basis of the panel discussion and
  correspondence with the individual and/or their
  representative
• could be summarised in DST
• may be used if the case goes to review.

51
Decision

• Once a recommendation is made, the PCT should
  only disagree for very good reasons which they
  should explain clearly to the individual. That
  decision should never be made unilaterally

52
Referral Tool

• DRAFT
• Title under review (previously screening tool)
• In two parts note new version will be 2 separate
  documents
• Fast tracking individuals who have a rapidly
  deteriorating /terminal condition
• Identify individuals who are potentially eligible
  for NHS CC.

53
Fast track pathway

• Only for those individuals who have a terminal
  condition that is deteriorating rapidly
  characterised by an increasing level of
  dependency.
• They need an immediate decision on eligibility
  to be made so that their immediate needs can be
  met.

54
Supporting Information

• Brief outline of reason for fast tracking
• Care plan describing how immediate needs will be
  met.
• Full assessment should follow at earliest
  opportunity if not already completed.

55
NHS Continuing Healthcare Referral tool

• Same domains as DST
• Mid line (high) descriptors used as baseline
• 3 options for completion
• meets or exceeds described level
• Borderline or close to described level
• Does not meet level

56
Refer those for full assessment

• Two or more ticks in column A
• Five or more ticks on column B or one tick in A
  and four in B
• Less ticks in columns A and B, but in your
  opinion a full assessment is still necessary
  (give reason)

57
Benchmarking trial

• Do we need a fast track approach?
• Do we need a referral tool for NHS Continuing
  Healthcare?
• If so at what level should we refer those for
  full assessment?
• What title should it have?

58
Homework

• Your pack contains
• Two brief case studies, one intended to use to
  practise mapping evidence onto the decision
  support tool and one to the referral tool
• An example of a good pen picture so you can start
  thinking about what the important considerations
  are
• Please, over the next week or so, take the time
  to go through these materials and then try out a
  couple of real cases with the tools, remembering
  to write the justification carefully.

59
Identifying training needs

• How can you take home the learning from today?
• What are the other skills that need to be met?
• How can you improve links with Acute trusts and
  MH trusts?
• What sort of materials are useful to aid training?

60
Next Steps

• Review how the local process fits in with the
  principles you have heard today
• Identify what will need to be done to bring
  things in line with the proposed National
  Framework
• Make arrangements to ensure that training is
  cascaded to all relevant staff in your patch, to
  ensure that all relevant staff are aware of the
  Continuing Healthcare process and the changes
  proposed under the National Framework
• Identify where links need to be strengthened
• Acute Trust and MH Trust
• PCT
• Local Authority

61
?
?
?
Any questions?
?
?
?
contact details for facilitator