On 1 March 2018, the Department of Health and Social Care published revisions to the National Framework for NHS Continuing Healthcare (CHC) and NHS-funded Nursing Care. Clinical Commissioning Groups (CCGs) have until October 2018 to adopt the new rules.

As the leading independent experts in NHS CHC, here we provide commentary on the key updates to the Framework:

• The Framework has been updated to reflect the implementation of the Care Act 2014. As such, it makes clear that the eligibility criteria must be applied to everyone equally, regardless of where they receive their care. This removes the opportunity for interpreting the criteria differently for people who receive care at home. The Framework’s new wording removes this double standard, which is welcome news for patients whose needs can be met in their own home.
• The definition of a social care need has been updated in alignment with the Care Act 2014, making it clearer and narrower. This should make it easier to make the important distinction of when a care need is ‘social’ or ‘health’, and to judge whether the health needs of the patient are more than incidental or ancillary to their social care needs and therefore count as ‘primary health needs’.
• Guidance on the nature of annual CHC reviews has been significantly improved, which is excellent news for patients and their families. There is now a clear focus on reviews being primarily to check that the patient’s care package is working well, not on reviewing eligibility. Eligibility should only be reviewed if the CCG can demonstrate that the needs have substantially changed. Where eligibility reviews are carried out, they must – like the first full assessment – involve a multidisciplinary team and use the Decision Support Tool.
• There is now welcome clarity on top-ups (when the CCG does not meet the full cost of care so the patient or their family pays the excess). The update makes it clear that it is the responsibility of CCGs to meet assessed health and wellbeing needs in full. It also provides guidance around the very limited circumstances in which patients can legitimately pay a top-up, i.e. for non-needs-based services such as hairdressing.
• The make-up of the multidisciplinary team has been clarified, with very helpful guidance clarifying that the assessment co-ordinator (often referred to as the ‘nurse assessor’) must not dominate proceedings. Instead the whole process must be multidisciplinary throughout.
• The description of the remit of CCG verification of eligibility decisions has been improved, reiterating that ‘Only in exceptional circumstances, and for clearly articulated reasons, should the multidisciplinary team’s recommendation not be followed’ and that verification should not replace proper multidisciplinary panel assessment.
• The Framework strengthens the guidance around CCGs’ commissioning responsibilities in an attempt to deal with the spread of worrying ‘settings of care’ policies. These policies cap funding for people who want to live in their own home, and can have the effect of forcing people to move into a care home or live with inadequate care provision. The Framework outlines the rights of individuals to have their assessed health and social care needs fully met by the CCG, taking into account the person’s preferences and without unreasonable restrictions being in place.
• It has been made clear that where CHC processes are outsourced to Commissioning Support Units, CCGs remain responsible for all decisions of eligibility.
• The obligations on CCGs in respect of local resolution of appeals have been improved. For example, the introduction of a two-step process whereby a first attempt at bespoke, collaborative and genuine resolution should be made by the CCG. If that does not answer the individual’s concerns, the decision can be reconsidered by a panel.

There are some areas in which we believe the update has missed the opportunity to improve practice and has failed to bring clarity to some areas that cause confusion among CCGs and professionals involved in assessments:

• The definition of well managed needs still lacks clarity and uses subjective phrasing that is open to interpretation. We would like policy to enshrine clearly that a person’s needs must not be marginalised or underestimated in the Decision Support Tool simply because they might be well-managed at the time of assessment.
• The central test of a Primary Health Need remains fuzzy. For example, we feel there is still too much opportunity for CCGs to say that if the threshold of 2 x Severe or 1 x Priority levels is not hit in assessment, the person is not eligible. In fact, Primary Health Need is about whether the totality of a person’s health needs are more than incidental or ancillary to their social care needs – regardless of whether arbitrary thresholds are met.
• We are concerned that any health professional – even those with no training and little understanding of the complex CHC criteria – can rule a patient out of having a Checklist completed.
• The toolkits – Decision Support Tool, Fast Track Tool and Checklist – have had only minor tweaks. We believe their wording leaves them open to interpretation. A thorough review of each tool would be preferable.
• A host of best practice suggestions made by ourselves and other expert stakeholder have not been addressed in the Framework. These include the urgent need to raise awareness of CHC with potential recipients, and speeding up the appeal process.

Conclusion

The new Framework represents a welcome tightening-up and clarification of several areas of CHC process, which we hope will reduce the instances of procedural failings that patients and their families experience after October.

However, the update falls short of bringing clarity to the complex concepts involved in making the crucial decision about each patient’s eligibility for funding. This leaves the door open for the postcode-lottery of access to CHC to continue.

Our role in the Framework update

At Beacon – as expert advocates of patients who are navigating the system – we had welcome opportunities to contribute to drafts of the Framework update. We did this by participating in an engagement process during which we fed back comprehensively on a range of issues. We also provided evidence from a focus group with members of the public who have experience of the CHC system. We thank the Department for these opportunities and note that some of our recommendations have been included.

About us

Beacon CHC is a leading UK-wide social enterprise with profits donated to charity to fund vital older peoples’ services.

Our specialist caseworkers provide a comprehensive and ethical advocacy and support service for individuals trying to navigate the maze of NHS CHC funding. We also run an independent helpline – funded by the NHS – for people in England who need free information and advice about to NHS CHC.

Call us on 0345 548 0300

As the leading independent experts in this field, our experienced team regularly deliver bespoke training to public, private and third sector organisations on a range NHS CHC matters. To discuss what we may be able to do for you, please send us an email outlining your requirements to enquiries@beaconchc.co.uk.