Email your comments

On 26th June, the government published its latest policy regarding continuing health care and NHS-funded nursing care.

The new policy should be welcomed, although leading charities have already claimed the changes do not go far enough. It marks an important simplification to the present system, and has the potential to bring clinicians much closer to the decision-making process.

Background
The issue of funding Continuing Health Care has been controversial, complex, and a postcode lottery for many years. In 1996, following a successful case challenged by the Ombudsman, the Department of Health (DH) required each Health Authority (HA) to devise eligibility criteria. There was a strong call, including from many geriatricians, for a universally applied assessment tool, yet the DH continued to expect HAs to interpret legal guidance in a consistent way without any clearly understood criteria for continuing health care. Since the inception of the National Health Service, the State has always been required to provide services for the care of persons suffering from illness. However, long term care has increasingly been provided in private nursing homes funded in the main privately by home-owners. The Royal Commission into long term care recommended in 1999 that nursing care should be paid for by the State, but the government did not entirely accept this, and created instead a three-banded system to re-imburse patients for the nursing component of their care. The Coughlan case was a legal challenge as to whether nursing care could be provided by the Local Authority in a private nursing home. This led to a restatement of the definition of NHS-funded continuing care in 2001 – where the nursing component of the person’s care can no longer be considered ancilliary to the person’s overall need for care. On behalf of thousands of families, the Ombudsman has been challenging the application of the DH guidance by HAs, and revealed that assessment systems and appeals mechanisms were far from satisfactory. Inconsistencies were shown by a small study by Tony Luxton (Age and Ageing 2006 35: 313-6). More recently, BBC Panorama programmes have sought to engage an even wider public to force a change to the policies.

In June 2006, a consultation document was published. The BGS and around 500 other people and organisations responded. In general, the response to the consultation was very favourable, but some improvements and clarifications have since been made.

Primary health need
The central assessment is whether the person’s primary need is a health need. If it is, then the person should receive NHS Continuing Healthcare; if not, then the nursing care must be considered only ancilliary to the overall social care required, and the person may be eligible for care provided by the Local Authority. Characteristics of the needs of the individual help determine this: the nature, the intensity, the complexity, and the unpredictability of their needs. Assessing the overall needs leads to a decision, and this will be assisted by using the national Decision Support Tool.

The Decision Support Tool is not a validated assessment tool, yet provides a structure for the assessment of eleven domains of health need, based around the four factors described above. The outcome remains descriptive rather than a score. The Support Tool also captures diagnoses and risk assessments including, crucially, what would happen if the current care was removed or reduced. Case studies have not been included, and their reason is the desire to maintain the emphasis on clinical assessment of that individual. The Decision Support tool has been piloted in 1,200 cases, but no results have been published, and as far as I can tell, no formal validity studies have yet been conducted. It remains to be seen whether there will be satisfactory validity and cross-country consistency using the national assessment tool - this is potentially the Achilles Heel of the proposals.

Process for assessment
The assessment must be informed, person-centred, and free of discrimination. The decision must not be based on the setting of care. It is envisaged that everyone in need of care should undergo the screening assessment of the eleven key domains. A checklist has been produced for the purpose. With a system that sounds reminiscent of the driving test, two “majors” or five “minors” are sufficient to trigger a full assessment. This screening is mandatory before a person can be referred for social care, and can be carried out by, for example, a nurse, doctor, occupational therapist or social worker.

If the full assessment is then required, this should be carried out by a multidisciplinary team (MDT) who have received training in the use of the Decision Support Tool. (A training package with Powerpoint slides is expected.) The process should be coordinated by one member of the team. When the MDT has reached agreement, they should make a recommendation on eligibility to the Primary Care Trust (PCT).

Many PCTs have a panel which at present makes these decisions. The new process is that the panel, or PCT officer, ensures consistency and quality of decision-making, but should normally endorse the recommendation of the MDT which is more clinically informed. Finance officers should not be part of the PCT approval team.

Rather challengingly, it is anticipated that the MDT assessment and subsequent PCT ratification, will be completed within 2 weeks. This may be difficult where the patient is outside of a hospital setting.

Review
A regular review process will be similar to that used at present. The first review will be within 3 months, and then a minimum of annually thereafter.

Disputes
Dispute resolution will be broadly similar to the present system, with first a local PCT review panel, and then by an external multidisciplinary team comprising an Independent Review Panel under the authority of the SHA.

NHS-funded nursing care
For those patients ineligible for NHS Continuing Healthcare yet requiring some degree of nursing care in a care home, they will receive a single band of financial support from 1st October 2007. The payment will be around £100 per week currently. This replaces the current 3-band structure. This should hugely simplify the current bureaucracy in the RNCC assessments. It is envisaged that the assessment process including the screening for eligibility for NHS Continuing Healthcare and the Comprehensive Assessment component of Single Assessment Process should make it quite clear whether the patient requires nursing care: it is therefore assumed that no additional or separate “RNCC” assessment would be required.

Previous determinations
Acknowledging that this is a new assessment process, there is to be no backdating of decisions and financial reimbursement. If a patient is found after 1st October 2007 to be eligible for NHS Continuing Healthcare, they will not be able to apply for this to be backdated to the entry into long term care.

Conclusion
I believe we should welcome these new procedures, because it represents a serious attempt to standardise the decision-making process regarding NHS Continuing Healthcare. It aims to bring the location of that decision into local MDTs, which may be seen as an additional pressure for clinicians - these decisions can have a colossal financial implication for a family. Yet clinicians are used to tough decisions, and the emphasis is on a clinical decision as to whether the person has a Primary Health Need. This will be a difficult language for us at first, and training and much discussion will be important. It is likely that the policy will have significant cost implications - not only in raising all RNCC recipients to the single £100 band, but also because I suspect many patients currently given “high band” will in future be classified as NHS Continuing Healthcare. I hope geriatricians get involved with the new processes, and that some of us will organise proper validation of the assessment tool. Click here for details of all these policies and assessment tools.

Ian Donald
Co-chair
BGS Primary Care and Community Care Special Interest Group