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For many years, geriatricians, the general public and several high profile media campaigns bemoaned the inequity of the system across the country for awarding continuing NHS care to the fortunate few.

Following considerable involvement from the Ombudsman, and a series of` legal challenges, the Department of Health first instructed a major retrospective review of all disputed cases to be judged against the principle of “Primary Need”. At the end of that process, the Department finally agreed to provide a national assessment process designed to deliver greater consistency, which was published in 2007. Now after a further 2 years, new guidance has been published:.

What has changed?
The new guidance demonstrates a maturity to the revised procedures which provides greater clarity. However, the process is essentially unchanged. All patients being discharged with substantial care needs must be assessed using the NHS Continuing Healthcare Needs Checklist [see “National Framework Decision Support Tools”. This will usually be in conjunction with the assessment form used locally for complex care packages and long term care. Those completing the checklist should have received training in its use. The new checklist details the levels of need more explicitly than before, and so appears as a longer document.

Where the checklist indicates the possibility of qualifying for Continuing Healthcare (CHC), the full Decision Support Tool (DST) should be completed, under the direction of the CHC nurse lead.

“The DST should be completed by a multidisciplinary team, following a comprehensive multidisciplinary assessment of an individual’s health and social care needs and their desired outcomes. The DST asks multidisciplinary teams (MDTs) to set out the individual’s needs in relation to 12 care domains. Each domain is broken down into a number of levels, each of which is described. For each domain MDTs are asked to identify which description most closely matches the individual’s needs. MDTs are then asked to make a recommendation as to whether the individual should be entitled to NHS continuing healthcare.”

The intention of the process is to determine whether the person’s primary need is health care, while the assessment takes into account the intensity, predictability, and instability of the health care needs. The full guidance includes details about how to involve the patient and their family, issues around capacity and advocacy, and appeals procedures.

Geriatricians and the new guidance
I am aware that many geriatricians across the country have, or believe they have, little or no involvement in the decision-making process, and may also have concerns that this new process prolongs decision-making, resulting in delays to discharge to nursing homes. It would be a shame, however, if our overall reaction to this policy is one of criticism, given that the BGS was one of the voices which helped to bring about a national policy for this difficult area. Geriatricians whose families have experienced the financial burden of long term care will appreciate the huge difference when 100% NHS funding is awarded. I believe that all lead geriatricians should make it their business to understand the policy guidance, and then to meet with their local NHS Continuing Healthcare lead at the Primary Care Trust to review whether the guidance is being followed, and how the process might be improved in line with the policy. Since 2007, there has been a considerable increase in the number of people awarded CHC. However, there has been a lack of any consistent monitoring procedure across the country to indicate whether ‘postcode lottery’ has diminished, although national benchmarking is being introduced from Autumn 2009.

Ian P Donald
Consultant in Old Age Medicine
Gloucestershire Hospitals NHS Foundation Trust

BGS Newsletter, September 2009
Issue 23 ISSN 1748-634000 23