On 1 July 2022 an updated version of the National Framework for NHS Continuing Healthcare (CHC) and NHS-funded Nursing Care (FNC) came into use.
Read our article giving a short summary of these updates and explaining their impact.
Below is a more detailed study of these changes.
Transfer of statutory responsibilities to Integrated Care Boards
The revised National Framework recognises legislative changes brought about by the new Health and Care Act 2022, which establishes Integrated Care Boards (ICBs) as the statutory bodies responsible for CHC.
In most cases this means a simple change from Clinical Commissioning Group or CCG to Integrated Care Board or ICB.
The change in statutory responsibility from one authority to the other does not alter the legal obligations on the NHS, and crucially neither does it change the eligibility criteria for CHC, as confirmed by the following two paragraphs:
“This does not change existing legal obligations on NHS bodies to meet health needs, and local authorities are still required to assess and meet people’s needs for adult social care. Nor does it alter the thresholds of eligibility for NHS Continuing Healthcare.”
– (para. 7)
“The National Framework also reflects Section 22 of the Care Act 2014, which preserves the existing boundary and limits of local authority responsibility in relation to the provision of nursing and/or healthcare.”
– (para. 8)
Changes to consent
There is a significant change to the consent sections of the revised National Framework, and this also affects other areas of policy and guidance, such as capacity. Previously, consent had to be sought from the individual being assessed (or their representative) for the whole assessment process, and this was usually done at the Checklist (screening) stage.
In the revised National Framework, consent is no longer required in order to carry out an assessment for CHC. This constitutes a significant change to 15 years of CHC policy.
This means that even if the individual indicates that they do not wish to have a CHC assessment, an assessment can still legally be carried out against their wishes. Whilst we understand the importance of bringing CHC policy in line with the law, we are concerned about the apparent erosion of civil liberties.
The Framework has clarified that consent is not required for care records (personal data) to be shared among health and social care professionals for the purposes of assessment or care delivery. This is unchanged. Under GDPR rules, the individual concerned must be informed about where and with whom their data will be shared.
Where the individual has capacity, consent is required in order to carry out a physical examination of the individual, or to carry out any sort of physical intervention and to deliver care. Consent is also required in order to share records (personal data) with third parties. The Framework suggests that if the individual does not give consent to a physical examination and/or to be involved in the assessment and/or to share records with a third party (such as their advocate, for example), then the quality of the assessment may be affected. However, in our experience, it is extremely unusual for physical examinations to form part of a CHC assessment.
Where the individual refuses to provide consent for a physical examination, for care, for the sharing of records to third parties, and/or to participating in the assessment, ICBs must help the individual understand the potential consequences of their decision. For example, if an individual is found to be eligible for CHC but that individual refuses care from the ICB, the Local Authority are under no obligation to provide care because they have been assessed as a health responsibility.
In all cases, ICBs are expected to make all reasonable effort to seek participation of the individual (or their representative) during each stage of assessment, review and care planning, in the spirit of a person-centred approach.
If the individual concerned lacks capacity to consent to a physical examination, care and/or the sharing of their personal data with third parties as part of a CHC assessment, a best Interest decision taken should be taken and recorded. This may be done by a third party (such as a relative) with valid and applicable Lasting Power of Attorney (LPA) for health and welfare or a Deputy (health/welfare) appointed by the Court of Protection.
If no valid LPA or Deputyship order is in place, the person leading the assessment (often called a ‘Nurse Assessor’) should make the best interest decision, taking into account the views of those with interest in individual’s welfare (e.g. carers). The starting position is that it would usually be in the best interest of the individual to be assessed for CHC.
Hospital discharge
Guidance around the interaction between CHC assessments and hospital discharge has been updated to reflect best practice, including learning from the emergency hospital discharge procedures that were put in place during the COVID-19 pandemic.
During the emergency period, individuals leaving hospital who required new care or support received interim funding for up to six weeks (latterly four weeks) or until such time as all necessary assessments had been completed following discharge. Government funding for this ended on 31 March 2022 although some localities have chosen to continue the scheme for a limited period, using local funding. This type of funding is no longer national policy.
Summary of hospital discharge position
- Checklist assessments (the first stage of the assessment process) should not be completed in hospital in most cases, full assessments should also not be completed in hospital.
- The need for a CHC Checklist should be identified before the individual is discharged from hospital.
- Where the individual is discharged to NHS-funded sub-acute (step down / rehabilitation) care, it should be established if the individual is eligible for CHC or not, before NHS-funded services are removed.
- If the individual receives a positive Checklist in hospital (Checklists should only be done in hospital now in exceptional circumstances), interim NHS-funding is not guaranteed but will be dependant on local criteria for funding Discharge to Assess placements, even if the individual goes into a new care placement. This is a change to the previous system whereby funding for interim care was expected following a positive Checklist completed in hospital.
- If consideration for CHC is required but the individual is returning to an established, unchanged care package, existing funding arrangement stay in place until CHC eligibility has been established (including individuals who are ‘self-funding’). If found eligible following a full CHC assessment, eligibility should be backdated to the date of discharge from hospital.
- The Checklist and Discharge to Assess paragraphs have been reordered to improve flow, and in our opinion, the new structure is clearer.
- The emphasis is on people continuing to receive interim funding because they are in receipt of interim NHS services, rather than because they have new care and support needs.
Hospital discharge principles
The overarching principle is that until an eligibility decision is made, the individual’s existing care arrangements (including funding) continue. So, people who receive a positive Checklist in the community will not have their care funded in the interim before an eligibility decision is reached but funding will be backdated to the 29th day following receipt of a positive Checklist by the ICB, if you are eligible.
In the case of hospital admissions, eligibility for CHC should normally be considered after discharge, when the individual’s needs are clearer (but not necessarily fully known). For the vast majority this will mean that Checklists are completed after a period of recovery either in a familiar setting or intermediate / rehabilitation placement. This is a slight change to previous policy whereby Checklists were often carried out in hospital prior to discharge.
Full assessments for CHC using the DST should also normally take place in a community setting rather than in hospital and this is a policy which has not changed. The principle is that longer term or end-of-life care needs should be assessed once the individual has reached ‘a point of recovery’.
The revised Framework reflects the recently updated hospital discharge policy by taking care not to be overly-prescriptive about exactly how discharge procedures will operate and who takes responsibility. Each locality (ICB/Local Authority/NHS bodies/partners) should develop its own protocols regarding roles and responsibilities for discharge procedures, intermediate / rehabilitation care arrangements including CHC assessments.
But crucially, local protocols must include identification of individuals who will need a CHC Checklist (and potentially a full CHC assessment using the DST) once they leave hospital so that they can be appropriately followed up.
Interim services
Some individuals may be discharged to therapy, rehabilitation, intermediate care or an interim package of support, as required. This can either be delivered in their own home or another community setting.
If, at the point of discharge, an individual has been identified as needing to be considered for CHC, the Checklist and assessment should only take place when an accurate appraisal of their ongoing needs can be made. This might not be until after a period of interim care and/or rehabilitation.
The funding of such interim services should be covered by the NHS until it is established if the individual is eligible for CHC.
An important principle in the revised National Framework is that individuals should not be transferred from an ‘acute’ hospital setting to long-term residential care unless one or more of the following situations exists:
- They have an existing long-term residential placement which can still meet needs.
- They have already completed a period of specialist rehabilitation (e.g. stroke unit, neuro-rehab, spinal injury service) and following consideration of next options.
- They have had previous failed attempts at being supported at home which were formally assessed (with or without intermediate support).
- A period of residential intermediate care followed by another move is likely to be unduly distressing for them.
Hospital discharge pathways
The following five scenarios have been given to describe what happens when people are discharged from hospital with ongoing care needs, who are not already in receipt of CHC.
Pathway 1
The individual has an existing package or placement which everybody agrees can still meets their needs without any changes. The individual is discharged back to that placement under existing funding arrangements and a Checklist assessment takes place within 6 weeks, followed by a full assessment (using a DST) where necessary. If eligible, reimbursement is applied back to the date of discharge. This includes people who may be self-funding their care.
Note that this pathway is not about whether the individual’s needs have changed, but whether the existing package/placement can still meet those needs without changes.
Pathway 2
The individual is discharged to interim NHS-funded services (such as rehabilitation / interim care). A Checklist assessment and (if positive) a full assessment (using a DST) are carried out if required to establish the individual’s eligibility status before interim services are withdrawn and when an accurate assessment of ongoing care needs can be made.
Pathway 3
A negative Checklist is completed in hospital prior to discharge (in exceptional circumstances), so there is no need for further assessments and the individual is not eligible for CHC.
Pathway 4
A positive Checklist is completed in hospital prior to discharge (in exceptional circumstances), and the individual is then discharged to interim NHS-funded services. Then a full assessment for CHC (using the DST) or new Checklist is carried out before those interim services end.
Note where a positive Checklist is completed in hospital prior to discharge and the individual is discharged to a new or changed care package in a care home or their own home, funding responsibilities will be dependent on local Discharge to Assess policies.
Pathway 5
A positive Checklist and full CHC assessment (using the DST) are both completed in hospital prior to discharge (in exceptional circumstances). The individual is assessed as not eligible for CHC and the decision is taken before they are discharged.
Virtual assessments
The revised National Framework acknowledges the shift towards virtual assessments since the CHC-restart in September 2020 following the initial COVID emergency period. There is no operational guidance here but policy provisions for virtual engagement in CHC assessments were already in place in previous versions of the Framework. ICBs are able to continue using a number of approaches to assessment, including face-to-face, video and tele-conferencing amongst others.
Any assessment – whether virtual, in-person or hybrid – must be arranged to ensure that the individual, their representatives, and all member of the multidisciplinary team are able to participate actively. The ICB should meet or speak in advance with the individual (or representative) to ensure that the proposed assessment arrangements will work for them. This should mean that if for any reason the individual is not able to participate effectively in the proposed arrangements, the ICB offers a suitable alternative.
Inter-agency disputes
The way in which Integrated Care Systems (ICSs) have been set up creates the potential for confusion when it comes to disputes over CHC eligibility decisions between agencies. New opening paragraphs of this section aim to provide high-level clarity on the roles of those agencies in CHC disputes.
They set out that the purpose of ICSs is for NHS and local government partners (among others) to collaborate in the delivery of services including CHC. Statutory responsibility for CHC rests with the ICB which will comprise Executive and Ordinary members. Each ICB must have at least one Ordinary Member nominated by the NHS and one from the Local Authority, however as ICBs are ‘unitary bodies’ those members do not act as representatives from their sectors but should use their knowledge and perspective when contributing to decision making, favouring the interests of their local community.
The ICB takes over the role of the CCG and as such, must still work with Local Authorities as a separate authority, including in the resolution of disputes. All other guidance regarding the mechanism and principles of inter-agency dispute resolution remain largely unchanged.
Fast Track
There has been some tightening up on language in the Fast-Track pathway sections of the revised National Framework and the Fast Track Tool.
Fast Track Reviews
Some terminology has been aligned with the CHC Standing Rules.
For example, para. 267 originally read:
“ICBs should monitor care packages to consider when and whether a reassessment of eligibility is appropriate. Where it is apparent that the individual is nearing the end of their life and the original eligibility decision was appropriate, it is unlikely that a review of eligibility will be necessary.”
But in the revised Framework has been changed to:
“ICBs should monitor care packages to consider when and whether a reassessment of eligibility is appropriate. Where it is apparent that the individual is rapidly deteriorating and may be entering a terminal phase and the original eligibility decision was appropriate, it is unlikely that a review of eligibility will be necessary.”
This update aligns the policy with the wording of the Fast Track criteria but changes the meaning slightly, and potentially loses the original policy intent. The change in wording potentially now allows for individuals who are almost at the end of their lives and receiving palliative care, but who are relatively stable and no longer rapidly-deteriorating, to fall out of CHC eligibility or have to go through the ordeal of a full CHC assessment at the end of their life.
Instead, we had hoped that DHSC would have taken the opportunity to clarify that the Fast Track review process should be aligned to the standard CHC review process whereby reconsideration for eligibility should not take place without first identifying a significant change in need, but that did not happen in the main body of the Framework.
However, the new wording in the Framework is actually different to that of the Fast Track Tool which does align the Fast Track review process with the standard process:
“Clinicians completing the Fast Track Pathway Tool should make the individual aware that it will be important to review the individual’s care needs and the effectiveness of the care arrangements. In doing this, there may be certain situations where a change in needs indicates that it is appropriate to review eligibility for NHS Continuing Healthcare. This could potentially affect the funding stream depending on the outcome of the review.”
– (para. 22, revised Fast Track Tool)
Part of this paragraph is in the revised Framework but the ‘change in needs’ part only appears in the Tool. So, this gives rise to the question – could the funding stream (eligibility for CHC) be affected by the individual no longer having a rapidly deteriorating condition, or by a change of care needs? And if the latter, how would this change in care needs be identified if the original Fast Track assessment didn’t actually consider care needs in any detail? Unfortunately we feel DHSC have missed the opportunity to clarify the Fast Track review process.
Completion of the Fast Track Tool
In order to make the tool consistent with those who are completing the Checklist, the following has been added to para. 1:
“All staff who use the Fast Track Tool should be familiar with the principles of the National Framework and have received appropriate training.”
On the surface this seems like a sensible policy and one that aligns the Fast Track Tool with the other CHC tools. However, there is a reason this has not been a requirement for completion of Fast Track assessments and why the policy could be damaging.
Unlike the DST and Checklist, the Fast Track Tool should be completed by an ‘appropriate clinician’ who is responsible for the diagnosis, treatment or care of the individual. Relatively few such clinicians are likely to have need to understand CHC domain levels etc, or will have been trained to do so. The Fast Track Tool only requires the appropriate clinician to use their knowledge and evidence of the patient’s needs to determine whether they have a rapidly deteriorating condition (which may be entering a terminal phase). The knowledge they need is of their patient’s needs, diagnosis and prognosis, and to be able to follow the instructions on the Fast Track form.
By insisting that anybody completing the Fast Track Tool should be familiar with the principles of the Framework and received training, runs the risk of severely restricting the number of appropriate clinicians who are able to complete Fast Track assessments, which further risks slowing down the rapid assessment of individuals who require such an assessment – in turn defeating the purpose of a Fast Track assessment.
Clarification that those who are eligible via the Fast Track route have a primary health need
We were pleased to see clarification in para. 3 of the Fast Track Tool that a completed Tool which shows the individual has a rapidly deteriorating condition which may be entering a terminal phase means that the individual has a primary health need and is sufficient to indicate eligibility for CHC.
We have encountered some misinformed views in the past which claim that individuals who are eligible via the Fast Track route do not have a primary health need because they have been found eligible via a ‘different criteria’. The wording of the revised Framework and Tool clarifies that a person who is eligible via the Fast Track route does have a primary health need.
Carers
We are pleased to see some improvement to guidance regarding the rights of carers at paragraphs 348 – 356. This includes the involvement of carers at the earliest opportunity in discharge planning from hospital and the carer being made aware of their rights to assessment and support of their own needs. The CHC assessment process provides an opportunity to capture and record the impact that caring for the individual being assessed has on the carer and where referral to the Local Authority for a carers’ assessment may be needed.
Minor changes
There are a number of minor changes to the text which do not have a significant or detrimental impact on policy. An example of a minor change that does not affect policy in the new Framework comes at para. 127 in the 2022 version:
“The Checklist requires practitioners to record a brief description of the need and source of evidence used to support the statements selected in each domain. This could, for example, be by indicating that specific evidence for a given domain was contained within the inpatient nursing notes on a stated date.”
Changes to…
“The Checklist requires practitioners to record a brief description of the need and source of evidence used to support the statements selected in each domain. This could, for example, be by indicating that specific evidence for a given domain was contained within any relevant patient care records on a stated date.”
Glossary
One final change that we’re somewhat bewildered by, comes in the glossary of the revised Framework. The definition of NHS Continuing Healthcare is described as such:
“A complete package of ongoing care arranged and funded solely by the NHS, for adults with the highest levels of complex, intense or unpredictable needs, who have been assessed as having a ‘primary health need’.”
– (page 167)
This definition contrasts with the definition of CHC given in the Key Definitions section at pages 9-10 and is very much at odds with the description of the Primary Health Need test and associated Quantity and Quality test given in the main Primary Health Need section of the revised Framework, at paras 55 – 67. It is also out of step with the guidance around how to apply the Key Characteristics at section PG3 of the Practice Guidance which does not provide ‘levels’ of those characteristics.
Given that so many other updates to the revised National Framework have centred on bringing policy and terminology in line with legislation, it is difficult to know why the glossary definition was changed in such a way as to bring it out of step with the National Framework’s own definitions and policies regarding CHC, the eligibility criteria, the legal test (quantity and quality) and the key characteristics.
How Beacon can help
Our expert advisers can answer your questions on any aspect of NHS Continuing Healthcare in England. We have helped thousands of people to understand the eligibility criteria, navigate the assessment process, understand the Decision Support Tool and your assessment, review a decision, or begin an appeal. We can also talk to you about funding policies and issues in your area.
Contact us by visiting our Talk to Us page and completing the contact form, or call 0345 548 0300 during office hours.
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In detail: July 2022 updates to the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care
On 1 July 2022 an updated version of the National Framework for NHS Continuing Healthcare (CHC) and NHS-funded Nursing Care (FNC) came into use.
Read our article giving a short summary of these updates and explaining their impact.
Below is a more detailed study of these changes.
Transfer of statutory responsibilities to Integrated Care Boards
The revised National Framework recognises legislative changes brought about by the new Health and Care Act 2022, which establishes Integrated Care Boards (ICBs) as the statutory bodies responsible for CHC.
In most cases this means a simple change from Clinical Commissioning Group or CCG to Integrated Care Board or ICB.
The change in statutory responsibility from one authority to the other does not alter the legal obligations on the NHS, and crucially neither does it change the eligibility criteria for CHC, as confirmed by the following two paragraphs:
Changes to consent
There is a significant change to the consent sections of the revised National Framework, and this also affects other areas of policy and guidance, such as capacity. Previously, consent had to be sought from the individual being assessed (or their representative) for the whole assessment process, and this was usually done at the Checklist (screening) stage.
In the revised National Framework, consent is no longer required in order to carry out an assessment for CHC. This constitutes a significant change to 15 years of CHC policy.
This means that even if the individual indicates that they do not wish to have a CHC assessment, an assessment can still legally be carried out against their wishes. Whilst we understand the importance of bringing CHC policy in line with the law, we are concerned about the apparent erosion of civil liberties.
The Framework has clarified that consent is not required for care records (personal data) to be shared among health and social care professionals for the purposes of assessment or care delivery. This is unchanged. Under GDPR rules, the individual concerned must be informed about where and with whom their data will be shared.
Where the individual has capacity, consent is required in order to carry out a physical examination of the individual, or to carry out any sort of physical intervention and to deliver care. Consent is also required in order to share records (personal data) with third parties. The Framework suggests that if the individual does not give consent to a physical examination and/or to be involved in the assessment and/or to share records with a third party (such as their advocate, for example), then the quality of the assessment may be affected. However, in our experience, it is extremely unusual for physical examinations to form part of a CHC assessment.
Where the individual refuses to provide consent for a physical examination, for care, for the sharing of records to third parties, and/or to participating in the assessment, ICBs must help the individual understand the potential consequences of their decision. For example, if an individual is found to be eligible for CHC but that individual refuses care from the ICB, the Local Authority are under no obligation to provide care because they have been assessed as a health responsibility.
In all cases, ICBs are expected to make all reasonable effort to seek participation of the individual (or their representative) during each stage of assessment, review and care planning, in the spirit of a person-centred approach.
If the individual concerned lacks capacity to consent to a physical examination, care and/or the sharing of their personal data with third parties as part of a CHC assessment, a best Interest decision taken should be taken and recorded. This may be done by a third party (such as a relative) with valid and applicable Lasting Power of Attorney (LPA) for health and welfare or a Deputy (health/welfare) appointed by the Court of Protection.
If no valid LPA or Deputyship order is in place, the person leading the assessment (often called a ‘Nurse Assessor’) should make the best interest decision, taking into account the views of those with interest in individual’s welfare (e.g. carers). The starting position is that it would usually be in the best interest of the individual to be assessed for CHC.
Hospital discharge
Guidance around the interaction between CHC assessments and hospital discharge has been updated to reflect best practice, including learning from the emergency hospital discharge procedures that were put in place during the COVID-19 pandemic.
During the emergency period, individuals leaving hospital who required new care or support received interim funding for up to six weeks (latterly four weeks) or until such time as all necessary assessments had been completed following discharge. Government funding for this ended on 31 March 2022 although some localities have chosen to continue the scheme for a limited period, using local funding. This type of funding is no longer national policy.
Summary of hospital discharge position
Hospital discharge principles
The overarching principle is that until an eligibility decision is made, the individual’s existing care arrangements (including funding) continue. So, people who receive a positive Checklist in the community will not have their care funded in the interim before an eligibility decision is reached but funding will be backdated to the 29th day following receipt of a positive Checklist by the ICB, if you are eligible.
In the case of hospital admissions, eligibility for CHC should normally be considered after discharge, when the individual’s needs are clearer (but not necessarily fully known). For the vast majority this will mean that Checklists are completed after a period of recovery either in a familiar setting or intermediate / rehabilitation placement. This is a slight change to previous policy whereby Checklists were often carried out in hospital prior to discharge.
Full assessments for CHC using the DST should also normally take place in a community setting rather than in hospital and this is a policy which has not changed. The principle is that longer term or end-of-life care needs should be assessed once the individual has reached ‘a point of recovery’.
The revised Framework reflects the recently updated hospital discharge policy by taking care not to be overly-prescriptive about exactly how discharge procedures will operate and who takes responsibility. Each locality (ICB/Local Authority/NHS bodies/partners) should develop its own protocols regarding roles and responsibilities for discharge procedures, intermediate / rehabilitation care arrangements including CHC assessments.
But crucially, local protocols must include identification of individuals who will need a CHC Checklist (and potentially a full CHC assessment using the DST) once they leave hospital so that they can be appropriately followed up.
Interim services
Some individuals may be discharged to therapy, rehabilitation, intermediate care or an interim package of support, as required. This can either be delivered in their own home or another community setting.
If, at the point of discharge, an individual has been identified as needing to be considered for CHC, the Checklist and assessment should only take place when an accurate appraisal of their ongoing needs can be made. This might not be until after a period of interim care and/or rehabilitation.
The funding of such interim services should be covered by the NHS until it is established if the individual is eligible for CHC.
An important principle in the revised National Framework is that individuals should not be transferred from an ‘acute’ hospital setting to long-term residential care unless one or more of the following situations exists:
Hospital discharge pathways
The following five scenarios have been given to describe what happens when people are discharged from hospital with ongoing care needs, who are not already in receipt of CHC.
Pathway 1
The individual has an existing package or placement which everybody agrees can still meets their needs without any changes. The individual is discharged back to that placement under existing funding arrangements and a Checklist assessment takes place within 6 weeks, followed by a full assessment (using a DST) where necessary. If eligible, reimbursement is applied back to the date of discharge. This includes people who may be self-funding their care.
Note that this pathway is not about whether the individual’s needs have changed, but whether the existing package/placement can still meet those needs without changes.
Pathway 2
The individual is discharged to interim NHS-funded services (such as rehabilitation / interim care). A Checklist assessment and (if positive) a full assessment (using a DST) are carried out if required to establish the individual’s eligibility status before interim services are withdrawn and when an accurate assessment of ongoing care needs can be made.
Pathway 3
A negative Checklist is completed in hospital prior to discharge (in exceptional circumstances), so there is no need for further assessments and the individual is not eligible for CHC.
Pathway 4
A positive Checklist is completed in hospital prior to discharge (in exceptional circumstances), and the individual is then discharged to interim NHS-funded services. Then a full assessment for CHC (using the DST) or new Checklist is carried out before those interim services end.
Note where a positive Checklist is completed in hospital prior to discharge and the individual is discharged to a new or changed care package in a care home or their own home, funding responsibilities will be dependent on local Discharge to Assess policies.
Pathway 5
A positive Checklist and full CHC assessment (using the DST) are both completed in hospital prior to discharge (in exceptional circumstances). The individual is assessed as not eligible for CHC and the decision is taken before they are discharged.
Virtual assessments
The revised National Framework acknowledges the shift towards virtual assessments since the CHC-restart in September 2020 following the initial COVID emergency period. There is no operational guidance here but policy provisions for virtual engagement in CHC assessments were already in place in previous versions of the Framework. ICBs are able to continue using a number of approaches to assessment, including face-to-face, video and tele-conferencing amongst others.
Any assessment – whether virtual, in-person or hybrid – must be arranged to ensure that the individual, their representatives, and all member of the multidisciplinary team are able to participate actively. The ICB should meet or speak in advance with the individual (or representative) to ensure that the proposed assessment arrangements will work for them. This should mean that if for any reason the individual is not able to participate effectively in the proposed arrangements, the ICB offers a suitable alternative.
Inter-agency disputes
The way in which Integrated Care Systems (ICSs) have been set up creates the potential for confusion when it comes to disputes over CHC eligibility decisions between agencies. New opening paragraphs of this section aim to provide high-level clarity on the roles of those agencies in CHC disputes.
They set out that the purpose of ICSs is for NHS and local government partners (among others) to collaborate in the delivery of services including CHC. Statutory responsibility for CHC rests with the ICB which will comprise Executive and Ordinary members. Each ICB must have at least one Ordinary Member nominated by the NHS and one from the Local Authority, however as ICBs are ‘unitary bodies’ those members do not act as representatives from their sectors but should use their knowledge and perspective when contributing to decision making, favouring the interests of their local community.
The ICB takes over the role of the CCG and as such, must still work with Local Authorities as a separate authority, including in the resolution of disputes. All other guidance regarding the mechanism and principles of inter-agency dispute resolution remain largely unchanged.
Fast Track
There has been some tightening up on language in the Fast-Track pathway sections of the revised National Framework and the Fast Track Tool.
Fast Track Reviews
Some terminology has been aligned with the CHC Standing Rules.
For example, para. 267 originally read:
But in the revised Framework has been changed to:
This update aligns the policy with the wording of the Fast Track criteria but changes the meaning slightly, and potentially loses the original policy intent. The change in wording potentially now allows for individuals who are almost at the end of their lives and receiving palliative care, but who are relatively stable and no longer rapidly-deteriorating, to fall out of CHC eligibility or have to go through the ordeal of a full CHC assessment at the end of their life.
Instead, we had hoped that DHSC would have taken the opportunity to clarify that the Fast Track review process should be aligned to the standard CHC review process whereby reconsideration for eligibility should not take place without first identifying a significant change in need, but that did not happen in the main body of the Framework.
However, the new wording in the Framework is actually different to that of the Fast Track Tool which does align the Fast Track review process with the standard process:
Part of this paragraph is in the revised Framework but the ‘change in needs’ part only appears in the Tool. So, this gives rise to the question – could the funding stream (eligibility for CHC) be affected by the individual no longer having a rapidly deteriorating condition, or by a change of care needs? And if the latter, how would this change in care needs be identified if the original Fast Track assessment didn’t actually consider care needs in any detail? Unfortunately we feel DHSC have missed the opportunity to clarify the Fast Track review process.
Completion of the Fast Track Tool
In order to make the tool consistent with those who are completing the Checklist, the following has been added to para. 1:
On the surface this seems like a sensible policy and one that aligns the Fast Track Tool with the other CHC tools. However, there is a reason this has not been a requirement for completion of Fast Track assessments and why the policy could be damaging.
Unlike the DST and Checklist, the Fast Track Tool should be completed by an ‘appropriate clinician’ who is responsible for the diagnosis, treatment or care of the individual. Relatively few such clinicians are likely to have need to understand CHC domain levels etc, or will have been trained to do so. The Fast Track Tool only requires the appropriate clinician to use their knowledge and evidence of the patient’s needs to determine whether they have a rapidly deteriorating condition (which may be entering a terminal phase). The knowledge they need is of their patient’s needs, diagnosis and prognosis, and to be able to follow the instructions on the Fast Track form.
By insisting that anybody completing the Fast Track Tool should be familiar with the principles of the Framework and received training, runs the risk of severely restricting the number of appropriate clinicians who are able to complete Fast Track assessments, which further risks slowing down the rapid assessment of individuals who require such an assessment – in turn defeating the purpose of a Fast Track assessment.
Clarification that those who are eligible via the Fast Track route have a primary health need
We were pleased to see clarification in para. 3 of the Fast Track Tool that a completed Tool which shows the individual has a rapidly deteriorating condition which may be entering a terminal phase means that the individual has a primary health need and is sufficient to indicate eligibility for CHC.
We have encountered some misinformed views in the past which claim that individuals who are eligible via the Fast Track route do not have a primary health need because they have been found eligible via a ‘different criteria’. The wording of the revised Framework and Tool clarifies that a person who is eligible via the Fast Track route does have a primary health need.
Carers
We are pleased to see some improvement to guidance regarding the rights of carers at paragraphs 348 – 356. This includes the involvement of carers at the earliest opportunity in discharge planning from hospital and the carer being made aware of their rights to assessment and support of their own needs. The CHC assessment process provides an opportunity to capture and record the impact that caring for the individual being assessed has on the carer and where referral to the Local Authority for a carers’ assessment may be needed.
Minor changes
There are a number of minor changes to the text which do not have a significant or detrimental impact on policy. An example of a minor change that does not affect policy in the new Framework comes at para. 127 in the 2022 version:
Changes to…
Glossary
One final change that we’re somewhat bewildered by, comes in the glossary of the revised Framework. The definition of NHS Continuing Healthcare is described as such:
This definition contrasts with the definition of CHC given in the Key Definitions section at pages 9-10 and is very much at odds with the description of the Primary Health Need test and associated Quantity and Quality test given in the main Primary Health Need section of the revised Framework, at paras 55 – 67. It is also out of step with the guidance around how to apply the Key Characteristics at section PG3 of the Practice Guidance which does not provide ‘levels’ of those characteristics.
Given that so many other updates to the revised National Framework have centred on bringing policy and terminology in line with legislation, it is difficult to know why the glossary definition was changed in such a way as to bring it out of step with the National Framework’s own definitions and policies regarding CHC, the eligibility criteria, the legal test (quantity and quality) and the key characteristics.
How Beacon can help
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