NHS Continuing Healthcare Commissioning Policy (Patient Choice and Resource Allocation)

Transcription

1 NHS Continuing Healthcare Commissioning Policy (Patient Choice and Resource Allocation) NHS Redditch and Bromsgrove Clinical Commissioning Group NHS South Worcestershire Clinical Commissioning Group NHS Wyre Forest Clinical Commissioning Group Page 1

2 Groups/Individuals who have overseen the development of the Policy: Groups/Individuals who have been consulted in relation to the content of the Policy: Jo Galloway, Chief Nursing Officer, NHS Redditch and Bromsgrove Clinical Commissioning Group and NHS Wyre Forest Clinical Commissioning Group. Lisa Levy, Executive Nurse and Director of Quality, NHS South Worcestershire Clinical Commissioning Group. Linda Allsopp, Interim Deputy Executive Nurse and Commissioning Manager for Complex Care, NHS Redditch and Bromsgrove & NHS Wyre Forest and NHS South Worcestershire Clinical Commissioning Groups. Katie Lake, CHC Transformation Programme Manager, NHS Redditch and Bromsgrove & NHS Wyre Forest and NHS South Worcestershire Clinical Commissioning Groups. Redditch and Bromsgrove CCG Clinical Executive Team Wyre Forest CCG Clinical Executive Team South Worcestershire CCG Clinical Executive Team Countywide patient and carer forum for this policy with Lay Representatives Healthwatch Worcestershire briefing and public presentation HOSC briefing Member of the public information and chance for comments and questions on all 3 CCG websites Circulation to 600+ patient contacts Worcestershire Association for Carers briefing Patient focus group held twice for comments and development In addition the policy has been reviewed by the CCGs legal advisors (Mills & Reeve LLP). Equality Impact Assessment completed: Related documents: Yes The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care November 2012 (Revised). NHS Continuing Healthcare and Patient Choice Patient Information Leaflet Date of Implementation: November 2016 Date of Next Formal Review: November 2018 Document Control Date Version Comment /Update 27 March Policy ratified by NHS Redditch and Bromsgrove Governing Body. 01 April Policy ratified by NHS Wyre Forest Governing Body Page 2

3 23 May Amendment to section 5.3. Definition added regarding significantly. 17 June Amendments to fast track, 20% and mental capacity. KL/JG/LA 4 August Amendments and additions to PHBs and patient choice 23 August Amendments made after legal advice from Mills and Reeve LLP 22 September September Policy ratified with further work needed on EIA and 20% by NHS Redditch and Bromsgrove Governing Body. 5.0 Policy ratified with further work needed on EIA and 20% by NHS South Worcestershire Governing Body 4 October Policy ratified with further work needed on EIA and 20% by NHS Wyre Forest Governing Body 14 November November Wording of policy amended and introduction added following patient focus group and comments received during the consultation period. 6.0 Ratified in full by the Governing Bodies of NHS South Worcestershire Clinical Commissioning Group and NHS Redditch and Bromsgrove Clinical Commissioning Group. 6 December Ratified in full by the Governing Body of NHS Wyre Forest Clinical Commissioning Group. Page 3

4 Definitions Care Coordinator A person who coordinates the assessment and care planning process. The Care Coordinator is usually the central point of contact with the individual/patient. The services of a Care Coordinator may be provided by a member of the CHC team or commissioned by the CCGs from a commissioning support organisation. care package or package A combination of support and services designed to meet an individual s reasonable assessed health and associated social care needs. care plan A document recording the reason why support and services are being provided, what they are and the outcomes that they seek to achieve. care planning A process based on assessment of an individual s needs that involves working with the individual to identify the level and type of support to meet his/her reasonable assessed health and associated social care needs, and the objectives and potential outcomes that can be achieved. CCGs (Clinical Commissioning Groups) Refers to NHS Redditch and Bromsgrove Clinical Commissioning Group, NHS South Worcestershire Clinical Commissioning Group and NHS Wyre Forest Clinical Commissioning Group. CCGs are clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. commissioning The means to secure the best care and the best value for local citizens. It is the process of specifying and procuring services for individuals and the local population, and involves translating their aspirations and needs into services that: Deliver the health and well-being outcomes, including promoting equality; Provide health and social care provision; and Achieve the above with the best use of available resources. Accredited Provider Each CCG s Accredited Providers: Have been assessed and accepted by the CCG as being able to fulfil the NHS Continuing Healthcare requirements of individuals at an agreed cost; and Are registered with the Care Quality Commission (or any successor organisation) as providing the appropriate form of care to meet the individual s needs; and Are not subject to an embargo by the CCG or the relevant Local Authority. home care means care provided in an individual s own home. individual The person who has been assessed for and found to be eligible for NHS Continuing Healthcare. Local Authorities Refers to Worcestershire County Council and any other Local Authority responsible for an individual. NHS Continuing Healthcare Means a package of on-going care that is arranged and funded solely by the NHS where the individual has been found to have a primary health need. Such care is provided to an individual aged 18 or over, to meet needs that have arisen as a result of disability, accident or illness. Preferred provider means the provider most capable of meeting the needs of the patient and who is appointed in accordance with the commissioning policy of the CCGs representative Any family member, friend or unpaid carer who is supporting the individual, as well as anyone acting in a more formal capacity (e.g. welfare deputy or health and welfare attorney, or any organisation Page 4

5 representing the individual). Where an individual has capacity, s/he must give consent for any representative to act on her/his behalf. significantly higher cost (in reference to a package of care) means a package of care that costs more than 10% of the most competitive provider quote. value for money This does not necessarily mean the cheapest option. The CCGs strive for value for money in terms of the quality of care and the level at which a provider can support all of the needs of a patient. The National Audit Office identifies 4 key areas for achieving value for money. These are economy, efficiency, effectiveness and equity. For more information please see Page 5

6 1 Introduction and Purpose of Policy 1.1 This Policy sets out the principles that the CCGs will apply in commissioning NHS Continuing Healthcare. The content of the Policy is in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care November 2012 (Revised) ( the Framework ) and has been developed to provide a common understanding of the CCGs commitments with respect to individual choice and the funding of packages of care to meet an eligible individual s assessed health and associated social care needs. 1.2 As well as improving quality and consistency of care, this Policy is intended to assist the CCGs to make decisions about clinically appropriate care provision for individuals in a consistent way and to support robust financial management by the CCGs. The Policy recognises that the commissioning of care involves actions at both individual patient and strategic levels and is intended to support each CCG to balance its responsibility to commission services for eligible individuals against its responsibility to provide access to healthcare for the whole of its population, whilst also maintaining financial balance. 1.3 The key aims of the Policy are to: Inform robust and consistent commissioning decision making by the CCGs using a locally developed policy; Ensure that there is consistency across the local area as to the services that individuals are offered; Ensure that the CCGs achieve value for money in the purchasing of services for individuals eligible for NHS Continuing Healthcare; Facilitate effective partnership working between the CCGs and other professions and agencies, including the Local Authorities in the area; Support choice to the greatest extent possible in view of the above factors. 1.4 This Policy is applicable to both new and existing patients eligible for NHS Continuing Healthcare. This Policy applies once an individual has received a comprehensive, multidisciplinary assessment of her/his care and support needs, the outcome shows that s/he has a primary health need and the individual has been found eligible for NHS Continuing Healthcare funding by the relevant CCG panel. 2 Key Principles 2.1 Where an individual is eligible for NHS Continuing Healthcare, the package of care to be provided is that which the relevant CCG assesses is appropriate to meet the individual s reasonable assessed health and associated social care needs (see paragraph 167 of the Framework). 2.2 Subject to the factors set out in paragraph 2.4 and within the broader framework of this Policy, the responsible CCG will seek to commission services using models that promote personalisation and individual control and that reflect the individual s preferences. 2.3 An individual s needs may change over time and the person may not remain eligible for NHS Continuing Healthcare. Consequently the CCG may not be responsible for providing NHS Continuing Healthcare services to that person indefinitely. In line with paragraphs of the Framework, regular case reviews will be undertaken in order to reassess an individual s current care needs and eligibility for NHS Continuing Healthcare, and to ensure that the person s needs at that time continue to be appropriately met. 2.4 When commissioning care, the CCGs will look to balance a range of factors including: Page 6

7 Individual safety; Individual choice and preference; The Individual s right to respect for their family life; Value for money; The best use of resources for the population of the CCG; Ensuring that services are of sufficient quality; Ensuring services are culturally sensitive; Ensuring that services are personalised to meet individual need (see section 13 for further information regarding personal health budgets). 2.5 In line with paragraphs 64 and 65 of the Framework, where a person is in a hospital setting, the CCG will consider whether an assessment of eligibility for NHS Continuing Healthcare should be deferred because, with appropriate support, that person has the potential to recover further in the near future. The CCG will in all such cases consider whether the provision of further NHS-funded services is appropriate while an assessment is awaited. 2.6 Equality Statement The statutory duties on CCGs under the Equality Act 2010 are, in so far as relevant to this policy, (1) a duty not to discriminate in the provision of a service to the public because of a protected characteristic and (2) a duty to have due regard to the need to eliminate discrimination, advance equality of opportunity and foster good relations (the public sector equality duty) The CCG endeavours to challenge discrimination, promote equality and respect human rights, and aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others All staff are expected to deliver services and provide care in a manner which respects the individuality of patients and their carers and as such treat them and members of the workforce respectfully, regardless of age, gender, race, ethnicity, religion/belief, disability and sexual orientation Every CHC Nurse Assessor will ensure that assessments and reviews take place with all of the support the patient needs to have a fair, equal and dignified assessment process. An assessment for CHC will not commence until other appropriate professionals are able to attend. For example, if a patient needs a translator, the CHC Nurse Assessor will invite a translator to the assessment to support the patient. 3 Mental Capacity 3.1 When an individual becomes eligible for NHS Continuing Healthcare, important decisions must be made about meeting their care needs in the appropriate environment. This raises the question of agreement to the care package offered and, sometimes, consent to move out of their home, to a care home or independent hospital. An individual must have capacity in order to provide valid consent. 3.2 People must be assumed to have capacity to make their own decisions and be given all practicable help before anyone treats them as not being able to make their own decisions. A person s capacity must be assessed specifically in terms of their capacity to make a particular decision at the time it needs to be made. If there is concern that a person does not have capacity to make a specific decision regarding a particular aspect of provision of their care, this will be determined in accordance with the requirements of the Mental Capacity Act 2005, the Mental Capacity Act Code of Practice and any subsequent national or local guidance. Page 7

8 3.3 Where an adult is found to lack capacity to make a decision, then any action taken, or any decision made for, or on their behalf, must be made in their best interests. 3.4 Professionals and other staff need to understand and always work in line with the Mental Capacity Act 2005 (MCA). 3.5 The Supreme Court ruling in Cheshire West (March 2014) held that a deprivation of liberty will occur when an individual is: under continuous supervision and control; and not free to leave. This can occur in any setting, including domestic settings where the State is responsible for imposing such arrangements (e.g. CHC funded package of care). This includes placements in supported living in the community as well as domiciliary arrangements. Where a care package amounts to a deprivation of liberty, the CCG will consider the need to apply to the Local Authority for a Standard Authorisation (where the placement is in a care home or hospital) or, in the case of other care packages, apply to the Court of Protection. In such cases the CCG process for making an application to the Court of Protection must be followed. 3.6 If the individual does not have the mental capacity to make decisions him/herself, unless there is a health and welfare attorney or deputy, the CCG will take the lead on making a best interests decision in respect of residence and care. While this includes an obligation to consult with relatives and carers, the CCG will make the final decision. If there is a dispute as to best interests, the CCG will consider a formal best interests meeting, the advice of an independent individual or an application to the Court of Protection. 3.7 Where a person lacks capacity in relation to the relevant decision and has no family or friends that are available (or appropriate) for consultation on their behalf, the CCG will ensure that the Independent Mental Capacity Advocate service is involved. 4 Care Planning 4.1 The individual s Care Coordinator will discuss care provision with the individual (and/or his/her representative/s - where the individual gives consent for such a discussion or where the individual lacks capacity), including the question of where the care may be provided. 4.2 In many cases there will be a range of options for packages of support in different settings which are appropriate to meet the individual s needs. 4.3 Subject to the factors set out in paragraph 2.4, in making a decision about care provision, the relevant CCG will take into account any reasonable request/s from the individual (and/or his/her representative/s). 4.4 Care provision is likely to take two main forms: Care provided in a registered care setting (such as a nursing home or an independent hospital); Care within the individual s own home (this includes a supported living placement). 4.5 The CCG will only fund a care package which is deemed to be: Safe; Sustainable; An effective use of public funds. Page 8

9 4.6 The CCG will determine if a care package is safe and sustainable by considering an individual s needs and the proposed environment and care package. In most cases, the CCG will be assured of the safety and sustainability by using an Accredited Provider. 4.7 The CCG has a duty to make the best use of limited public funds and to treat individuals equitably. As a starting point, the CCG will achieve this by offering a package of care from an Accredited Provider. If an individual requests a particular package of care, the CCG will not fund any such care package which is more than 10% more expensive than the most cost effective option the CCG has offered, unless there are exceptional circumstances (see paragraph 11). CHC Fast Track 4.8 Where an individual has been deemed appropriate for Fast Track NHS Continuing Healthcare Funding the CCG will commission a package of care in line with the individual s assessed care needs which will reflect the approaches set out in the National End of Life Care Strategy. 4.9 Such packages of care will be reviewed and adjusted to reflect the individual s needs in line with this Policy. The CCG will not fund a care package which costs more than 10% more than the most cost effective of the Accredited Care Home Providers offered by the CCG, except in exceptional circumstances. 5 Provision of Care in a Registered Care Setting 5.1 If the CCG commissions a package of care for an individual that is more expensive than the standard cost due to either lack of availability in the market or the inability of the CCG to commission at the standard cost, the additional cost will be funded by the CCG on an interim basis. Where such an arrangement has been agreed, the CCG reserves the right to move the individual to a suitable preferred provider (when available) where this will provide a financial saving to the CCG. The CCG will notify the individual and/or their representative(s) that their location may be changed, should a preferred provider subsequently have capacity. In such circumstances, the CCG will give a minimum of 7 days notice to the individual. In making a decision as to whether or not to move an individual, the CCG will take into consideration the risks of a move, given the individual s clinical condition. Choice of Accredited Provider 5.2 In the interests of consistency and equity of provision, the CCG will, wherever possible, place individuals with Accredited Providers (see Definitions). 5.3 The CCG will consult with the individual (and/or his/her representative/s) when arranging the location of care, and will, wherever possible, seek to: (a) offer choice; (b) accommodate reasonable requests; and (c) take into account personal preferences. 5.4 The CCG will, where possible, offer the individual (and/or his/her representative/s) a choice of up to three Accredited Providers who have a current vacancy and are able to provide the care required. In this regard the CCG reserves the right not to offer the individual the choice of any Accredited Provider whose quote is significantly higher than other quote/s received. The CCG will commission a package which costs no more than 10% more than the most competitive quote, to support patient choice, but will not consider packages which are more than 10% of the cost of the most competitive quote, except in exceptional circumstances. Page 9

10 5.5 To support the individual to make an informed choice of Accredited Provider, the CCG will, in a timely fashion, provide the individual (and/or his/her representative/s) with relevant information regarding each Accredited Provider. 5.6 It may not always be possible for the CCG to offer to accommodate an individual in their preferred care setting. This may be because that care setting it is not an Accredited Provider or may be because, although it is an Accredited Provider, there is currently no vacancy at that care setting. In all cases, the CCG will offer to accommodate the individual in a care setting which is appropriate to meet his/her reasonable assessed health and associated social care needs. 5.7 Though all reasonable requests from individuals and their families will be considered, the CCG is not obliged to accept requests from individuals for specific care providers which have not been classified as preferred or Accredited Providers. 5.8 Where the CCG deems that a provider is not providing care of an acceptable quality and standard, the CCG reserves the right to move the individual to an alternative provider. 5.9 The CCG contracts with different providers to meet the needs of different service users. Where an individual s needs change, the CCG may offer a package of care with an alternative provider in order to discharge its statutory duties Where an individual expresses a preference to receive care at home, the CCG will benchmark the cost of such a package against the cost of a suitable package of care in an alternative care setting As noted above, if the cost of the requested provision (in this case, home care provision) is more than 10% above the cost of the most cost effective quote, the CCG will not fund the requested placement unless there are exceptional circumstances. Avoiding delayed discharge from hospital 5.12 Where an individual is currently in a hospital setting and is medically fit to be discharged, in order to avoid delays to discharge, the individual (and/or his/her representative/s) will be given 48 hours to make their first choice from among the Accredited Providers offered. Where no decision is communicated within this timescale, the relevant CCG, in conjunction with the hospital, will, in order to prevent an unnecessary further stay in hospital, arrange to move the individual to an appropriate care setting. This may be a temporary measure until such time as the relevant CCG receives communication from the individual (and/or his/her representative/s) regarding his/her preferred choice from among the Accredited Providers offered. Refusal to accept the CCG s offer of accommodation at an Accredited Provider 5.13 Where an individual declines all of the Accredited Providers offered by the CCG, the individual can propose an alternative care setting, provided that it satisfies the following criteria: The individual s proposed care setting is available; The individual s proposed care setting is assessed by the CCG as appropriate and it is capable of meeting the individual s reasonable assessed health and associated social care needs; Page 10

11 The individual s proposed care setting is able to provide the required care to the individual subject to the CCG s usual contract terms and conditions as appropriate to the nature of the care setting; and The cost of making arrangements for the individual at his/her proposed care setting does not require the CCG to pay more than it would usually expect to pay having regard to the individual s assessed health and associated social care needs. The CCG will compare the cost of the proposed care setting to the cost of the Accredited Providers offered by the CCG and rejected by the individual. The CCG will not fund any placement which exceeds 10% more than the most cost effective placement offered by Accredited Providers, except in exceptional circumstances The CCG will not accept an alternative care setting proposed by the individual (and/or his/her representative/s) which is embargoed by the CCGs or the Local Authority or where the CQC has raised concerns as to the provision of services If the alternative care setting proposed does not satisfy the criteria set out in 5.13 above, the CCG may offer: A temporary placement for the individual with another Accredited Provider; or A care package to be provided at the individual s own or a family member s home, provided that it is safe to do so and the cost implications to the CCG are within 10% of the most cost effective placement, except in exceptional circumstances If the individual does not have the mental capacity to make decisions him/herself, unless there is a health and welfare attorney or deputy, the CCG will take the lead on making a best interest s decision in respect of residence and care. While this includes an obligation to consult with relatives and carers, the CCG will make the final decision. If there is a dispute as to best interests, the CCG will consider a formal best interests meeting, the advice of an independent individual or an application to the Court of Protection. Temporary placements 5.17 Where no Accredited Providers are available to meet the individual s reasonable assessed health and associated social care needs, the CCG may make a specific purchase and place the individual with an alternative provider identified by the CCG who fulfils the criteria. In this case, the CCG may subsequently make arrangements to relocate the individual should a placement at an Accredited Provider become available. In such cases, and prior to re-locating the individual, the CCG will give consideration to a range of factors, including the possible impact of the re-location on the individual s health and well-being, and will take into account whether re-locating the individual will provide a significant financial advantage (a reduction in excess of 10% of the placement cost) to the CCG. The CCG will only take a decision to re-locate an individual if it is safe to do so. 6 Provision of Care in an Individual s Own Home (Home Care) 6.1 The CCGs acknowledge that many individuals will wish to remain in their own homes with a package of care in place to meet their reasonable assessed health and associated social care needs. 6.2 Where an individual (and/or his/her representative/s) expresses such a desire, the relevant CCG will consider whether it would be feasible and within the powers of the CCG to commission a clinically safe and sustainable package of NHS Continuing Healthcare services within the individual s home or the home of a family member. Prior to making any adaptations or securing an alternative address, individuals/representatives should seek clarification from the CCG regarding CHC funding. The CCG will need to consider whether a package of care at home meets the requirements of this policy. Page 11

12 6.3 In considering any request for a package of home care, the CCG will take account of the following nonexhaustive list of factors: The extent of the individual s needs; Whether care can be delivered safely to the individual without undue risk to him/her, any family member/s and the staff engaged to provide the care. Safety will be determined via a formal risk assessment undertaken by an identified professional. The risk assessment will consider the availability of suitably skilled carers and/or equipment and the appropriateness of the environment The acceptance by the individual of any identified risk/s and whether plans to minimise such risk/s can be put in place, which are agreed by the individual (where the individual has capacity), the care provider/s and the relevant CCG (see section 3.3 of this policy for adults who lack capacity); Whether the individual s GP has agreed to provide primary medical support; The individual s preferences; The suitability of alternative arrangements; The willingness and ability of family members/informal carers to provide elements of care and the agreement of those persons that the provision of such care will form an integral part of the Care Plan; Provision of contingency arrangements if any care provider fails or is unable to deliver care to the individual; The capacity of the individual (and their best interests if they are found to lack capacity to decide on their residence and care); The individual s right to respect for their family life under Article 8 of the ECHR. 6.4 Where the relevant CCG decides to offer a package of home care, the individual s home becomes the place of work of any staff member/s engaged to provide care. Therefore, employee safety is a key consideration and the individual s or family member s home must be a reasonably safe environment in which to work and deliver care. 6.5 The CCGs recognise that the affordability of a home care package may be dependent upon family members being willing and able to provide elements of care to the individual without charge. Whilst family members are under no legal obligation to offer such care and no pressure will be placed upon them to do so, the relevant CCG will ask family members if they are prepared to do so. If they agree, in designing any home care package, the CCG will be entitled to assume that family members will provide the agreed level of support. In these circumstances, the CCG will ensure that there is a programme of on-going assessments of the individual s needs to ensure that he/she is receiving the appropriate level of care to meet his/her assessed needs. In addition, in line with paragraph 89.1 of the Practice Guidance incorporated within the Framework, the CCG will consider whether there is a need to make a referral for a separate carer s assessment by the relevant Local Authority and/or to meet any training needs that the carer may have to carry out his/her role (this will only be relevant where the involvement of a family member in the provision of care is an integral part of the care plan). 6.6 The relevant CCG may be prepared to support a package of home care but only where the anticipated cost to the CCG is no more than 10% more than the most cost effective placement assessed by the CCG as capable of meeting the reasonable assessed needs of the individual. This applies unless there are exceptional circumstances. The cost will be compared by the CCG with the cost of up to three Accredited Providers. In line with the Framework, the cost comparison will be based on the actual cost that would be incurred in supporting a person with the specific needs of the individual in a registered care setting. Page 12

13 6.7 Where a package of home care is agreed to be provided, the CCG will commission such care from domiciliary care agencies suitably qualified to deliver the care that meets the individual s reasonable assessed health and associated social care needs. 6.8 The relevant CCG will not fund a package of home care where the CCG determines that it is unable to put in place a package of home care which is safe, sustainable and capable of meeting the individual s reasonable assessed health and associated social care needs. 6.9 Night sits The CCG aims to ensure fair and consistent decision making when designing packages of care, in respect of night time care and to manage expectations of individuals, clinicians and their families The starting point for designing any package of care will be the individual s care needs and preferences; however, the CCG also needs to take comparative costs and value for money into account when determining the model of support to be provided. Such comparisons should be based on the actual costs of providing care for the individual and considering different approaches to meeting the individual s needs. Where care at night is required, the CCG s provision of care at night will aim to provide the least intrusive care to individuals. The options for providing care at night will be considered in the order they are set out below. An option later in the list will only be provided if earlier options cannot meet the individual s needs There are a range of different methods by which an individual s care needs can be met during the night. These include: Self-care. Informal care by unpaid carers. Aids and adaptations. Assistive technology. Shared care with other patients Roaming Night. Sleeping Night. Waking Night The CCG will determine whether an individual needs care during the night, when assessing, reviewing or reassessing their needs. Assessments and reviews should not state that an individual needs a particular service. Rather, they should detail the clinical or social function with which the individual requires care. The proposals as to how to meet the individual s needs should then be made via a care requirement document The CCGs will support night sits for carer support and the level of need will be determined on an individual case basis. The CCGs will make a decision regarding the most appropriate care for the patient and will consider a nursing home if it is an option that will better meet the patient s needs In order to commission the most appropriate provision, night sits will be commissioned after a clinical recommendation has been made along with clinical evidence. If a request for night sits is made, the CCGs are responsible for looking at the care provision in its entirety to ensure a patient centred review and that the patient is receiving the best care possible for their individual needs. 7 Funding of Holidays Page 13

14 7.1 In the event that any of the CCGs receives a request from an individual (and/or his/her representative/s) to fund a period of respite/holiday, the CCG will review the individual case with the aim of determining whether there are any circumstances which would warrant the approval of additional funding over and above the agreed package of care. The CCG will not in any circumstances fund any direct holiday costs, such as travel or accommodation costs, for the individual or any family member accompanying him/her. 8 Additional Services 8.1 The relevant CCG will only commission those services that are identified in an individual s care plan and for which it has statutory responsibility. Privately funded services 8.2 The individual (and/or his/her representative/s) has the right to enter into discussions with any care provider to supplement the care package (whether provided in a registered care setting or at home), over and above the package of care that the CCG has agreed to commission. Any costs arising out of any such agreement must be funded by the individual or through third party funding. These costs may, for example, relate to: Additional non-healthcare services provided to the individual. For example, hairdressing, provision of a larger room, provision of an en-suite room or enhanced TV packages; Healthcare services not included in the NHS Continuing Healthcare package such as chiropractor appointments or physiotherapy above the sessions that the individual is assessed as reasonably requiring. 8.3 Any decision to fund additional non-healthcare or healthcare services must be made on an entirely voluntary basis. The provision of the NHS Continuing Healthcare package by any care provider must not be contingent on the individual (and/or his/her representative/s) agreeing to fund any additional services. This means that the registered care setting or home care provider must be able to meet the assessed needs of the individual, without the package being supplemented by other services. 8.4 Equally, NHS Continuing Healthcare funding should not in any way be used to subsidise any additional nonhealthcare or healthcare services that an individual chooses to purchase outside of his/her care plan. 8.5 Where an individual is funding additional non-healthcare or healthcare services, the associated costs to the individual must be explicitly stated and set out in a separate agreement. If the individual chooses to hold a contract for the provision of additional non-healthcare or healthcare services, it should be clear that the additional payments are not made in respect of any care provision (relating to the individual s assessed needs) which is funded by the relevant CCG. 8.6 In order to ensure that there is no confusion between the NHS and the privately funded services, the relevant CCG will enter into a legally binding service agreement with the selected care provider which details the provision by that care provider of a defined level of health and social care to the individual. This will expressly be independent of any arrangement between the selected care provider and the individual (and/or his/her representative/s) and will be expressed to continue notwithstanding the termination of any separate arrangements made between the individual (and/or his/her representative/s) and the care provider. 8.7 Any payments made by the individual (and/or his/her representative/s) under any such separate contract with a care provider for additional services cannot be made under the CCG's contract. Page 14

15 8.8 If the individual (and/or his/her representative/s) decides for any reason that the funding of the additional services is to be terminated, the relevant CCG will not assume responsibility for funding those additional services. 8.9 Where additional services are being provided to the individual under a separate arrangement with the care provider, the CCG will review the situation periodically, in order to satisfy itself as to whether those services should or should not constitute part of the agreed NHS care package. 9 Acceptance of an Offer of Services/Withdrawal of Services Acceptance of an offer of services 9.1 The NHS discharges its duty to an individual by making an offer of an appropriate package of care to the individual, whether or not s/he subsequently chooses to accept the offer. The following are examples of how this can work in practice: The relevant CCG discharges its duty by offering to provide a package of services for an individual in one or more appropriate registered care settings, which may not be situated in the individual s preferred location; The relevant CCG discharges its duty to an individual who, to date, has had a package of home care by moving the individual to an appropriate registered care setting; The CCG offers a home care package in accordance with section 6 above. 9.2 An individual is not obliged to accept an offer of an NHS Continuing Healthcare package. Offers of a package of care cannot be held indefinitely. If an offer of a package of care is rejected, the CCG has fulfilled its duty. If an individual rejects the CCG s offer but subsequently decides to accept the offer, depending on the passage of time, the CCG may need to re-assess the individual and re-consider the options available. 9.3 Individuals and their representatives should note that if they choose not to accept an NHS package, the Local Authority will not assume responsibility to provide care to the individual. The CCG will work with the individual to help him/her understand his/her available options. 9.4 If an individual is not satisfied with a commissioned package of care, they should bring this to the CCG s immediate attention. The CCG will work with the individual/representative and the commissioned care provider to resolve the issues wherever possible. Should this not be possible, and the complaints are considered reasonable, the CCG will commission an alternative package of care, which could include the option of a personal health budget. The notice given to providers will need to be in line with the NHS standard contract terms and conditions. Individuals and representatives will need to be aware that, except in exceptional circumstances, the CCG will not support the overlapping of two commissioned providers during the notice period. Withdrawal of services 9.5 On the basis of a review, as described in section 10 below, it may be determined that the individual s needs have changed to the extent that s/he is no longer eligible for NHS Continuing Healthcare. In these circumstances, subject to the time limits set out below, the relevant CCG will no longer have a statutory duty to Page 15

16 fund the care package. However, in all such cases, the relevant CCG will work within the Framework and carry out a joint review with the Local Authority as follows: The individual will be notified that s/he is no longer eligible for NHS Continuing Healthcare. At this point the Local Authority will have 28 days to review the individual s needs and financial circumstances, which will identify the funding arrangements for their on-going care; The CCG and the Local Authority will work together to ensure a smooth transition to ensure minimal disruption for the patient; Where there is a dispute between the relevant CCG and the Local Authority as to the funding and/or care management responsibilities, the CCG will follow any Dispute Resolution Protocol agreed with the Local Authority; Where an individual appeals a decision as to eligibility for NHS Continuing Healthcare, the CCG will not continue funding pending the outcome of the appeal. If the decision is subsequently overturned, the CCG will consider financial redress in accordance with the relevant guidance. 9.6 It may be appropriate for the relevant CCG to withdraw NHS Continuing Healthcare services: Where the situation presents a risk of danger or violence to, or harassment of, staff who are delivering the care package; or Where the CCG considers that the level of clinical risk to the individual has become unacceptable and cannot be safely managed. 9.7 The CCG will not make any decision to withdraw NHS Continuing Healthcare from an individual without consulting with the individual and/or their representatives and the Local Authority. 9.8 In such circumstances the CCG will consider whether it is appropriate to offer an alternative care package to the individual. This might be by offering to accommodate him/her in an alternative registered care setting in accordance with section 5 of this Policy (that is by making an offer of up to three suitable Accredited Providers to the individual) or, where the individual is already receiving care in a registered care setting, by offering to put in place a package of home care in accordance with section 6 of this Policy. 10 NHS Continuing Healthcare Review 10.1 A case review should be undertaken no later than three months after the initial eligibility decision, in order to reassess the individual s care needs and eligibility for NHS Continuing Healthcare, and to ensure that the individual s reasonable assessed needs are being met. Reviews should thereafter take place annually, as a minimum The CCGs will invite the Local Authority to contribute to the review process. If the review demonstrates that the individual s condition has improved to an extent that they no longer meet the eligibility criteria for NHS Continuing Healthcare, the CCG is no longer under a duty to continue funding the care package and the individual will be informed accordingly At this point the Local Authority has 28 days to review the individual s requirements. CCG funding for an individual s care will continue for 28 days in order for the Local Authority to identify the appropriate funding stream to meet the individuals on-going care needs. Page 16

17 Where it is identified that an individual remains eligible for NHS Continuing Healthcare, the review may nevertheless identify that the individual s needs have changed to an extent that his/her care package requires adjusting. In this case: Where an individual is receiving a package of home care, the relevant CCG will consider whether it is possible and cost effective for the revised care package to continue to be delivered in the individual s home environment in accordance with section 6 of this Policy; Where an individual is accommodated in a registered care setting, the relevant CCG will ensure that the care setting is able to deliver the revised package of care. Where the care setting is unable to deliver the revised package of care, the CCG will offer to accommodate the individual in an alternative registered care setting (that is able to deliver the revised package of care) in accordance with section 5 of this Policy (that is by making an offer of up to three suitable Accredited Providers to the individual); Where an individual is accommodated in a registered care setting and the case review has identified a decreased need for services, the relevant CCG will consider whether it is cost effective for the revised package of care to be delivered in the current care setting. The CCG may re-locate the individual to an alternative care setting (that is able to deliver the revised package of care) in accordance with section 5 of this Policy (that is by making an offer of up to 3 suitable Accredited Providers to the individual). 11 Exceptional Circumstances 11.1 In exceptional cases, the relevant CCG may be prepared to consider funding a package of care where the anticipated cost to the CCG is more than it would usually expect to pay having regard to the individual s assessed health and associated social care needs Exceptionality will be determined by the CCG on a case by case basis Exceptionality may include: the provision of a package of home care to an individual who has an advanced, progressive, incurable illness; those cases in which consideration must be given to address the particular cultural and/or linguistic needs of the individual; those cases in which an individual in an existing out of area placement becomes eligible for NHS Continuing Healthcare and wishes to continue to be accommodated out of area. In such cases the CCG will take into account a range of factors including the market rates in the locality of the existing care setting and whether there are particular circumstances (for example, the fact that the individual has resided in the placement for many years) which make it reasonable to fund the placement out of area. If the CCG places the patient out of area, the responsibility for commissioning between different CCGs will be decided in accordance with Department of Health guidance In addition the CCGs recognise that there will be cases in which, as a consequence of the nature of the needs of the individual in that particular case, it may be necessary to fund a higher cost package of care for a limited period of time (for example, in cases where a high/intense level of staffing needs to be put in place to set up the care package). In such cases the CCG may be prepared to consider funding the higher cost package of care for a strictly limited period of time. 12 Complaints Page 17

18 12.1 In compliance with paragraph 99.9 of the Practice Guidance incorporated within the Framework, an individual (and/or his/her representative/s) who wishes to dispute a decision by a CCG as to the package of care to be provided to him/her may make a complaint to the relevant CCG in accordance with the NHS complaints process. 13 Personal Health Budgets 13.1 The CCGs are committed to using personal health budgets where appropriate and recognise that the use of a personal health budget can enable an individual to have greater choice, flexibility and control over the care and support s/he receives Personal Health Budgets are delivered in line with the CCG Commissioning Policy for Personal Health Budgets. The principles of this Policy (in relation to the allocation of resources) will be applicable to personal health budgets. 14 Transition from Child to Adult services 14.1 In relation to transition planning, the CCG will have regard to the various requirements outlined in paragraphs of the Framework. In line with paragraph 131, at the age of 17 any relevant young person s eligibility for adult NHS Continuing Healthcare will be determined in principle by the relevant CCG so that, wherever applicable, effective packages of care can be commissioned in time for the individual s 18th birthday. In commissioning care packages under such circumstances, the principles of this Policy (in relation to the allocation of resources) will be applicable. 15 Compensation Awards 15.1 The CCG recognises that there are cases in which an individual may previously have received an award of damages for future care as part of a claim for compensation. Where the CCG becomes aware that such circumstances exist, it will request full details of the award and may seek its own legal advice regarding the nature of the award and its impact in relation to the consideration of eligibility for NHS Continuing Healthcare or the package of care to be commissioned. Page 18

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