Continuing Healthcare Policy

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2 DOCUMENT CONTROL DOCUMENT STATUS: DOCUMENT VERIFIED BY: FINAL Continuing Healthcare Management Team DATE ISSUED: February 2018 APPROVING BODY: Quality and Safety Committee DATE APPROVED: 19/02/2018 DATE TO BE REVIEWED: January 2020 INTENDED RECEIPENTS: CHC Team Adults Social Care Local Authority Public AMENDMENT HISTORY VERSION DATE AMENDMENT HISTORY 1 November November December 2017 New Revised Revised wording for Dispute Resolution REVIEWERS This document has been reviewed by: NAME TITLE/RESPONSIBILITY DATE VERSION Michelle Carolan Deputy Chief Officer Quality November 2017 Richard Thompson Head of Continuing Healthcare December 2017 Bev Morris Acting Head of Continuing Healthcare December 2017 Kay McEvilly CHC Business Operational Lead December 2017 Marc Duckett Appeals Lead December

3 NB: The version of this policy posted on the intranet must be a PDF copy of the signed, approved version. DOCUMENT STATUS This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled. 3

4 . Summary This Policy describes the overarching principles relating to the delivery of NHS Continuing Healthcare services by Sandwell and West Birmingham CCG (the CCG ). Specific operational processes that underpin the application of this Policy have been developed to support delivery and are subject to local update and review. The context for this Policy is provided in the form of The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (Department of Health, 2012 revised). It incorporates the best practice guidance for delivering the service and clarifies the role and functions of Clinical Commissioning Groups in meeting their statutory obligations. This policy should be read in conjunction with relevant legal acts and guidance/policies relating to: Mental Health Paediatrics Learning Disability 4

5 Contents Page 1. Introduction 6 2. Purpose 6 3. Roles & Responsibilities Delegation of roles Continuing Healthcare Team Multi-Disciplinary Team (MDT) Commissioner Review 9 4. Definitions 9 5. Procedure Eligibility for NHS Continuing Healthcare Application for eligibility process Dispute Resolution Fast Track Applications Commissioning of Care Packages Decision Making Principles Domiciliary Care Jointly Funded Packages of Care Changes of Circumstances Personal Health Budgets Appeals Funded Nursing Care Transition from Children s Services to 20 Adults Continuing Healthcare Section 117 Aftercare Complaints Training Monitoring the Compliance and Effectiveness of 22 this Policy 5

6 1. Introduction The context for this Policy is provided in the form of The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (Department of Health, 2012 revised). Sandwell and West Birmingham Clinical Commissioning Group (the CCG ) will continue to apply the principles and practice guidance within The National Framework in its assessment and decision making processes to determine the eligibility of individuals to have their care needs met through the use of NHS funding. This Policy recognises that the CCG has an obligation to commission care for adults eligible to have such care fully funded by the NHS under the Continuing Healthcare (Responsibilities) Directions This Policy sets out how the CCG will meet this obligation in a manner which appropriately balances the choices that may be offered to eligible individuals, and the preferences expressed by such individuals, with the duties of the CCG to make best use of NHS resources. This Policy provides the basis on which the CCG will commission NHS Continuing Healthcare in a manner to ensure equity of access to care services that are appropriate, safe and compliant with relevant quality standards. This Policy promotes consistency of decision making and transparency in how the CCG will comply with its obligations as a commissioner of NHS funded services. 2. Purpose Continuing Care means care provided over an extended period of time to a person aged 18 or over to meet physical or mental health needs which have arisen as a result of disability, accident or illness. NHS Continuing Healthcare means a package of continuing care arranged and funded solely by the NHS (National Framework for NHS Continuing Healthcare & NHS Funded Nursing Care (2012 revised)). An individual who requires continuing care may require services from NHS bodies and/or Local Authorities. CCGs have the responsibility to ensure that the assessment of eligibility for NHS Continuing Healthcare takes place within 28 days from the receipt of the Continuing Healthcare Checklist. Sandwell & West Birmingham CCG are committed to working in partnership with the coterminous local authorities of Sandwell Metropolitan Borough Council and Birmingham City Council to achieve these timescales. This policy sets out the roles and responsibilities of the CCG and its staff involved in the delivery of the National Framework for NHS Continuing Healthcare & NHS Funded Nursing Care for patients of Sandwell and West Birmingham CCG. 6

7 3. Roles & responsibilities The CCG has an obligation to meet the assessed care needs of eligible individuals in a way that is considered to be reasonable and affordable, whilst also in accordance with the CCG s relevant legal obligations. The CCG will maintain transparent and robust processes to ensure that the assessment of an eligible individual s care needs complies with the National Framework. When considering how and what care services can be commissioned, the CCG has a responsibility toward taxpayers to comply with its own Standing Financial Instructions to ensure that commissioning decisions take full account of the most cost effective options available, whilst also ensuring the assessed care needs of eligible individuals are met. The CCG will consider the appropriateness of funding care services from a variety of care settings, which may include an individual s own home or a residential setting. In the case of a residential setting, such as for example a Care Home, the CCG will also fund reasonable accommodation costs. The CCG will make a reasonable offer of care to eligible individuals. This offer will meet any identified care needs assessed under The National Framework, be compliant with the CCG s Standing Financial Instructions, and take account of the rights and preferences of the individual as far as is practicable. The CCG will undertake audits of this Policy to determine the extent to which it is delivering choice, equity and value for money in the delivery of NHS Continuing Healthcare to eligible individuals. Where all reasonable offers of care are declined, either by an individual with the mental capacity to make the decision, or by a representative legally authorised to make such decisions on their behalf, it shall be considered that the CCG has fulfilled its obligations to commission NHS Continuing Healthcare for the individual for the assessed episode of care, and the individual will be considered to have refused such provision. 3.1 Delegation of Roles Continuing Healthcare Care Team The CCG delegates responsibility to a Senior Clinician with a responsibility for CHC to head a Continuing Healthcare Team. The Senior Clinician ensures that with regard to the commissioning of CHC: 7

8 The CCG complies with The NHS Continuing Healthcare (Responsibilities) Directions 2009, and specifically The National Framework, relevant decision support tool and any applicable updates; There is adherence to this Policy and other policies of the CCG; Where there is a need to assess an individual s eligibility to have their needs fully funded by the NHS, that arrangements are made for a multidisciplinary team (the MDT ) to undertake such assessment, ensuring that such assessments are: Coordinated by the Continuing Healthcare Team; Undertaken by an MDT having the appropriate mix of clinicians and practitioners from health and social care, with knowledge and experience relevant to the individual s circumstances; Undertaken in line with The National Framework and using associated statutory documentation; and Are referred in good time to the CCG Multi-disciplinary Team (MDT) The MDT undertaking an assessment of an individual s eligibility to have their care needs met fully through NHS funding will: Ensure that the assessment is conducted thoroughly, considering all available and relevant evidence, in line with the National Framework and relevant legislation (such as Mental Capacity Act 2005); Include an appropriate mix of clinicians and practitioners representing health and social care interests relevant to the individual s circumstances, notifying the Senior Clinician responsible for CHC or a nominated deputy where further input is identified as necessary in order to comprehensively complete the assessment; Use statutory documentation to formally record each assessment; Take account of all relevant factors to identify and assess clinical need, and any risks associated with these needs; Provide full documentary evidence of the assessment and a clear MDT recommendation as to whether, following the application of the four key indicators (nature, intensity, complexity, and unpredictability), an individual should have their care needs met through NHS funding Commissioner Review 8

9 The CCG will consider the evidence for, and appropriateness of, MDT recommendations for individuals eligibility to have their assessed care needs met through NHS funding. The CCG will scrutinise the evidence gathered and reported by the MDT following their assessment process and give careful consideration to the recommendation made by the MDT. Where considered necessary, the CCG may request the MDT to provide additional evidence or undertake further assessment to support recommendations in regard to individuals assessed needs and eligibility. The CCG carries the legal responsibility to make a decision regarding individuals eligibility and will provide a reasoned decision in writing to the individual and/or nominated representative. Where, in exceptional circumstances, the recommendation of the MDT is not followed, the CCG will provide reasons as to why that is the case. Where the decision is made that the individual does not meet the criteria for Continuing Healthcare funding, full details of the appeals process will be provided. 4. Definitions Continuing Healthcare NHS Continuing Healthcare Care packages Care Plan Decision Support Tool (DST) CHC Ratification Process Care provided outside of a hospital to patients with long-term healthcare needs. This may include jointly commissioned and funded health and social care provision. Care arranged and solely funded by the NHS. Patient centred services (nursing, therapist, home care, etc.) that are designed to meet the assessed needs of the patient. Individualised, person-centred plan drawn up by a clinician or clinical team to meet the identified care needs of the patient The standardised needs assessment tool used by clinicians to assess the needs of the patient. The outcome of the DST is to make a recommendation regarding the eligibility of the patient to a NHS funded package. Joint process involving NHS and Social Care professionals to verify the eligibility of patients, based on the recommendation of the MDT and presented DST. 9

10 Case Manager Named professional responsible for devising an individual care plan, maintaining contact with the patient, their representatives and relevant professionals, monitoring and reviewing the needs of the patient receiving a care package, and assessing the ongoing suitability of the package. 5. Procedure 5.1 Eligibility for NHS Continuing Healthcare The National Framework for NHS Continuing Healthcare & NHS Funded Nursing care (2012, revised) provides a consistent approach to establishing eligibility for NHS continuing healthcare. This is achieved through the use of the revised National Tools and Practice Guidance developed to assist in making decisions about eligibility for NHS Continuing Healthcare. As a result of the Coughlan Judgement (1999) and the Grogan judgement (2006), under the National Health Service Act 2006, the Secretary of State developed the concept of a primary health need to assist in deciding what treatments and other health services it is appropriate for the NHS to provide under NHS Continuing Healthcare. Where a person s primary need is a health need, they are eligible for NHS Continuing Healthcare. Deciding whether this is the case involves looking at the totality of the relevant needs from the assessment process. Where an individual has a primary health need, the NHS is responsible for providing all of the health and social care to meet the individual s needs, including accommodation, if that is part of that need. Consideration of primary health need includes consideration of the characteristics of need and their impact on the care required to manage the needs, in particular to determine whether the quantity or quality of care is more than the limits of responsibility of Local Authorities (as in the Coughlan judgement). Consideration is given to the following areas, referred to as the four key indicators: Nature and type of need: the particular characteristics of an individual s needs and the overall effect of those needs on the individual, including the type of interventions required to manage them; Intensity of need: both extent (quantity) and severity (degree) of the needs, including the need for sustained care (continuity); 10

11 Complexity of need: how the needs present and interact to increase the skill required to deliver, monitor and manage the care. This may arise with a single condition, or the interaction between a number of conditions. It may also include situations where an individual s response to their own condition has an impact on their overall needs; Unpredictability of need: the degree to which needs fluctuate, creating difficulty/challenges in managing the need. It also relates to the level of risk to the person s health if adequate and timely interventions are not provided. To minimise variation in interpretation of the principles, and to inform consistent decision making, the NHS Continuing Healthcare Decision Support Tool has been developed for use by practitioners to obtain a full picture of needs and to inform the decision regarding the level of need that could constitute a primary health need. Application of the DST, combined with the practitioners own expertise and professional judgement, should enable them to apply the primary health needs test in practice in a way which is consistent with the limits on what can be legally provided by a Local Authority. Eligibility for NHS Continuing Healthcare is based on an individual s assessed health and social care needs. The DST provides the basis for decisions on eligibility for NHS funded continuing healthcare. The DST must be completed by the multidisciplinary team, which must include as a minimum, two professionals from different health professions, or one professional from a healthcare profession and one who is responsible for undertaking community care assessment (a social care professional). Specialist staff and mental health staff should be involved to inform the assessment process dependent on the individual s needs. The multi-disciplinary team will make a recommendation on eligibility of the individual for NHS funded continuing healthcare; the final ratification of this decision is the responsibility of the CCG. Further details on the decision making process are outlined in the following sections. 5.2 Application for eligibility process In the majority of cases, the first stage of the eligibility process is screening using the NHS Continuing Healthcare Checklist. The Checklist identifies those individuals requiring a full assessment of their care needs. Prior to completion of the Checklist, it is paramount that the individual and their representatives understand the Checklist does not indicate the likelihood that the individual will be found eligible for NHS funded continuing healthcare; the purpose is to identify those individuals requiring further consideration and multi-disciplinary assessment only. The positive threshold for the Checklist has been set at a level to ensure all those who require full consideration of their needs get the opportunity. 11

12 A nurse, doctor or other qualified healthcare professional or social care practitioner can apply the Checklist to refer individuals for a full consideration of eligibility from community or hospital settings. Whoever applies the Checklist will have to be familiar with, and have regard to, the National Framework for NHS Continuing Healthcare & NHS funded-care (Department of Health 2012, revised) and the DST. All completed NHS Continuing Healthcare Checklists should be sent to the Continuing Healthcare team at: SWBCCG NHS Continuing Healthcare 4 th Floor Rear Kingston House 438 High Street West Bromwich West Midlands B70 9LD Secure continuinghealthcare@nhs.net Receipt of the completed positive Checklist commences the 28 day period for eligibility decisions and will ensure that the monitoring of timelines and activity take place. Following receipt and clinical verification of a positive Checklist, the Continuing Healthcare team will coordinate the multi-disciplinary assessment and completion of the DST. The DST must be completed to support all initial determinations of eligibility for NHS continuing care and provides practitioners with a framework to bring together and record the various needs in the domains specified within the Tool. The multi-disciplinary team use the DST to apply the primary health needs test, ensuring that the full range of factors that may influence an individual s eligibility are taken into account in making their recommendation. The DST cannot directly determine eligibility, but it provides the basis from which decisions are made, through the exercising of professional judgement and in consideration of the primary health need criteria (the four key indicators). Once the multi-disciplinary team has completed the DST, they will make their recommendation on eligibility, recorded on the DST and pass to the CCG for final ratification. Ratification of eligibility recommendations may be completed by Continuing Healthcare clinicians (in the absence of recorded disagreements within the multidisciplinary team) or by the multi-disciplinary CHC Ratification process. The purpose of ratification is to review received applications to ensure consistency and quality of decision making processes, and to ensure governance of the decision making on 12

13 eligibility. This process ensures equity of access to NHS funded continuing healthcare and consistent decision making for all applications. With regard to MDT recommendations about eligibility for NHS continuing healthcare, the ratification process (via either mechanism) can make the following decisions: Verify the recommendations of the multi-disciplinary team Not verify the recommendation, defer the decision and request further evidence to support the recommendation In exceptional circumstances, where the evidence provided by the multi-disciplinary team does not support the assessed level of need recorded in the DST and any subsequent recommendation for eligibility, and where requests for additional information have not provided substantive clarification, the CCG may reject a recommendation for eligibility. In these circumstances, a detailed written explanation of the decision will be provided to the applicant and/or their representative (where applicable), and to the multi-disciplinary team undertaking the original assessment. A person only becomes eligible for NHS Continuing Healthcare once a recommendation regarding eligibility has been ratified by the CCG. Prior to that decision being made, any existing arrangements for the provision and funding of care should continue, unless there is an urgent need for adjustment. Where individuals are found to be eligible for NHS funded continuing healthcare, funding will be agreed from the date of the ratified decision on eligibility or from day 29 from the date of the Checklist, if there has been an unreasonable delay in verification of eligibility, whichever is the earlier. Fast Track applications (detailed below) will be funded from the introduction of the agreed package of care Dispute Resolution All disputes in respect of CHC eligibility decisions between the CCG and Local Authorities (Sandwell Metropolitan Borough Council & Birmingham City Council) will be resolved in accordance with the Dispute Policy. Local Authorities Adult Social Care representatives are invited to participate in the Sandwell & West Birmingham CCG ratification process. Local Authorities may dispute an eligibility decision that is made by Sandwell & West Birmingham CCG in respect of an application for NHS continuing healthcare. Sandwell & West Birmingham CCG subscribe to the principle that there should be no delay in the provision of services due to disagreements or disputes on the assessment recommendation or outcome of eligibility. Should such situations arise, the National Framework for NHS Continuing Healthcare & NHS funded-nursing care 13

14 (DH, revised 2012) states that any existing funding arrangements cannot be unilaterally withdrawn without a joint assessment being carried out and alternative funding arrangements put in place. Therefore anyone in their own home, or care home funded by the Local Authority must continue to be financially assisted by the Local Authority until the dispute is resolved. Similarly, anyone in hospital, or funded by the NHS must remain funded by the NHS until the dispute is resolved. In such a circumstance, a without prejudice approach will be adopted. The final outcome of the dispute will be backdated to day 29 following the checklist date. 5.3 Fast Track Applications A Fast Track referral provides individuals with a rapidly deteriorating condition, which may be entering a terminal phase get the care required to manage these needs as quickly as possible. The National Framework for NHS Continuing Healthcare & NHS funded-nursing care (2012, revised) provides the Fast Track Tool for use in these circumstances. The Fast Track Tool needs to be completed by an appropriate clinician, described in the National Framework as: someone responsible for an individual s diagnosis, treatment or case as a registered medical practitioner or registered nurse. These can include senior clinicians employed in the voluntary and independent sectors that have a specialist role in end of life needs and the organisations services are commissioned by the NHS. Use of Fast Track applications will be monitored by Sandwell & West Birmingham CCG to ensure appropriate use of the tool. Where it is suspected that improper use of the process has occurred, a duty clinician will support the referrer to apply the most suitable entry route to Continuing Healthcare assessments, where applicable. Where persistent inappropriate referrals are received, these will be addressed with the referral source by the Senior Clinician or a nominated deputy. 5.4 Commissioning of Care Packages It is the responsibility of Sandwell & West Birmingham CCG to: Plan strategically to meet anticipated service demand; Develop care plans and specify outcomes from commissioned services; Procure services to meet assessed needs; Manage demand and service capacity; Manage provider performance for all services that are required to meet the needs of all individuals who qualify for NHS continuing healthcare; 14

15 Manage provider performance for the healthcare component of joint packages of care Decision Making Principles The CCG is committed to commissioning care services that meet clinically acceptable quality of care standards, and that evidence value for money. The CCG intends to make decisions with regard to eligible individuals that: Are robust, fair, consistent and transparent; Are based on objective assessments of individuals clinical needs and safety; Have regard for the safety and appropriateness of care services to those involved in delivery of such care; Take into account all relevant factors Involve the individual and family or appointed representatives wherever this is appropriate and possible; Take account of the need to utilise NHS resources in the most cost effective manner; Strive to support the offering of choices to individuals where it is reasonable and affordable to do so having regard to the above factors; Comply with relevant and applicable legislation (such as Mental Capacity Act and the Disability Discrimination Act). The services commissioned will include on-going case management for all those entitled to NHS Continuing Healthcare, as well as for the NHS elements of joint packages of care, including the assessment and review of individual patient needs. Care packages will ordinarily only be commissioned from care homes, domiciliary care providers and from nursing agencies registered with the Care Quality Commission, where a NHS contract is in place for continuing healthcare provision. When a care package is commissioned by the Continuing Healthcare service where there is no existing agreement in place, a spot contract purchasing arrangement will be agreed in order to ensure that there are quality standards in place to meet the requirements of the provision of NHS services. Care will not be commissioned from those care providers where there are significant concerns raised about the quality of the care provided, or where they are known not to meet the Care Quality Commission minimum standards for the applicable setting. The CCG will work in partnership with Sandwell MBC, Birmingham City Council, and neighbouring CCGs, where appropriate, to ensure the quality of care in care homes continue to meet the required standards. Where substantiated concerns about standards are raised, the owners of the care home provider will be informed that commissioning arrangements for NHS funded 15

16 continuing healthcare will be suspended until improvements have been made to achieve the Care Quality Commission minimum standards of care. Where possible, decisions on suspension of commissioning will be taken with the involvement of Local Authority partners to ensure a consistent local response. Where care is already commissioned for patients in a care setting, a risk assessment will be undertaken in partnership with the individual patient and their family or representative to ensure appropriate controls are in place to assure the individual s safety and the quality of care provided Domiciliary Care Where consideration is being given to the commissioning of care to be delivered in a domiciliary care setting, such as an individual s own home, Sandwell & West Birmingham CCG will consider the following factors before making a reasonable offer of care: Whether it is possible to commission the necessary care interventions and services within the proposed domiciliary care setting, meeting the assessed needs of the individual while satisfactorily maintaining care standards and governance arrangements; Whether such care services can be delivered safely and without presenting an unacceptable level of risk to either the individual or to those involved in the delivery of such care, or to any other person, including reference to the: Availability and maintenance of necessary equipment; Environment and the impact upon and of the location where care is to be provided; Availability of appropriately trained carers to deliver the required care; The suitability and robustness of contingency arrangements. The extent to which such domiciliary care can reasonably be expected to benefit and enhance the quality of life of the individual; The extent to which the delivery of care services within the proposed domiciliary care setting may incur additional costs to the NHS, such costs being over and above those that would otherwise be incurred through the provision of alternative care services, such as residential care services and, whether such additional costs are considered to be reasonable and affordable. Where the above factors have been carefully considered by the CCG, and the case for care services being commissioned within a domiciliary care setting is not supported, the CCG will liaise with the individual and/or their representative to consider an appropriate placement within a residential care setting, such as a registered Care Home. 16

17 5.5 Jointly Funded Packages of Care The National Framework for NHS Continuing Healthcare & NHS funded-nursing care (2012, revised) states that if a person does not qualify for NHS continuing healthcare fully funded care, the NHS may still have a responsibility to effectively contribute to that person s health needs. This is known as a joint package of care. Joint packages of care may also be provided through the provision of NHS services such as district nursing and community physiotherapy. A joint package of care with the Local Authority will only involve joint funding where there is a particular identified health need requiring an identified care package to be commissioned. In these circumstances Sandwell & West Birmingham CCG will fund the care costs for the identified health element of the package. 5.6 Change of Circumstances The NHS has a responsibility to regularly review the care needs of funded patients to ensure that care services remain appropriate. An initial review should take place 3 months after the first assessment, thereafter continued eligibility and care plans should be reviewed, as a minimum, on an annual basis. Outcome decisions should be communicated to the individual and/or their representative. Eligibility for Continuing Healthcare is not a permanent arrangement and remains subject to regular reviews and confirmation of continuing eligibility. The health needs of individuals may improve or stabilise to the extent that they no longer meet the eligibility criteria for NHS Continuing Healthcare. For individuals with progressive conditions, dominant needs conferring eligibility may also diminish over time as their condition changes, leading to a change in status. Where evidence no longer supports an individual s eligibility for NHS Continuing Healthcare, leading to a revised MDT recommendation, the CCG will review the case before making a decision and communicating this to the individual and/or their representative. Details of individuals no longer eligible for NHS Continuing Healthcare will, with the consent of the individual, be forwarded to the Adult Social Services within the relevant Local Authority, so that an assessment can be arranged to determine the extent to which the individual may qualify for Social Services funded care. The CCG will liaise effectively and with sufficient notice with the Local Authority to ensure that any transition of responsibilities for commissioning care services are coordinated effectively by an appointed Case Manager, and that there are no gaps in care provision. Individuals no longer eligible for NHS Continuing Healthcare may be eligible for NHS Funded Nursing Care, which will be considered by the CCG in accordance with The Framework. 17

18 If the individual declines a community care assessment, or following a community care assessment is not eligible for local authority funding, for example because they are responsible for funding their own care, the CCG will continue to fund care costs for a maximum of 28 days from the individual receiving formal notification of the CCG decision. 5.7 Personal Health Budgets CCGs are required to be able to offer personal health budgets to people in receipt of NHS Continuing Healthcare funding, in order to give patients better flexibility, choice and control over their care. A personal health budget helps people to access services they need to achieve their agreed health and wellbeing outcomes (agreed between the patient and clinician). Financially, personal health budgets can be managed in a number of ways, including: A notional budget held by the CCG commissioner; A budget managed on the individual s behalf by a third party; and A cash payment directly to the individual (a healthcare direct payment ) For further details refer to Sandwell & West Birmingham CCG s Personal Health Budget policy. 5.8 Appeals The CCG will communicate ratified decisions of CHC eligibility in writing to the individual patients and/or their representatives within 5 working days of ratification. The original referrer and social care professional can be informed verbally or by secure following the ratification process. Where an individual has been found not eligible for NHS Continuing Healthcare or NHS Funded Nursing Care, they or their representative can appeal Sandwell & West Birmingham CCG s decision within 6 months of the notification of the eligibility decision. Upon receipt of a formal appeal, the appeal request is acknowledged in writing. The evidence is reviewed by a Lead Nurse not previously involved in the assessment of the individual, and an invitation to attend an informal resolution meeting is extended to the individual and their representative. This provides an opportunity for the Lead Nurse to guide the individual and their representative through the Appeals Process. Appeals should be sent to: SWBCCG Continuing Healthcare 4 th Floor Rear Kingston House 18

19 438 High Street West Bromwich West Midlands B70 9LD Secure If following the informal resolution meeting, the individual and their representative remains unsatisfied with the CCG s decision a Local Review Panel will be arranged. The members of the Appeal Panel are independent of the initial Continuing Healthcare Ratification Panel and Multi-Disciplinary Team who conducted the assessment. The individual and their representative will be asked to submit supporting evidence as to why they disagree with the CCG s decision. Individuals and their representatives are encouraged to attend the Local Review Panel to participate in the discussion and review of the case. Should the individual remain dis-satisfied with the Appeals Panel outcome they can write to NHS England requesting an independent review at the address below: NHS England St Chads Court 213 Hagley Road Edgbaston Birmingham West Midlands B16 9RG 5.9 Funded Nursing Care Sandwell & West Birmingham CCG, working in partnership with Local Authorities, is responsible for eligibility assessments and decisions for NHS-funded nursing care and the commissioning of care to meet the patient s identified needs. Funded Nursing Care contributions support the provision of nursing care by a registered nurse for those assessed as eligible. If an individual does not qualify for NHS Continuing Healthcare, the need for care from a registered nurse should be determined. If the individual has such a need and it is determined that the individual s overall needs would be most appropriately met in a care home providing nursing care, then this would consequently lead to eligibility for NHS-funded nursing care. Once the need for such care is agreed, the CCG s responsibility to pay a flat rate contribution to the care home towards registered nursing care costs arises. 19

20 5.10 Transition from Children s Services to Adults Continuing Healthcare The National Framework for NHS Continuing Healthcare & Funded Nursing care (2012, revised) and the supporting guidance and tools only applies to people aged 18 years or over. It is important that both the Adult and the Children s Frameworks consider transition. Sandwell & West Birmingham CCG ensures that it is actively involved in the development and oversight of the local transition planning processes with their partners, and that their representation includes those who understand and represent adult NHS Continuing Healthcare. Adult NHS Continuing Healthcare will be appropriately represented in all transition planning meetings regarding individual young people whenever the individual s need suggest that there may be potential eligibility. Any future entitlement to adult continuing healthcare should be clarified as soon as possible in the transition planning stage, especially when the young person s needs are likely to remain at a similar level until adulthood. Professionals responsible for children s transition into adult NHS continuing healthcare should identify those young people for whom it is likely that NHS continuing healthcare will be necessary, and should notify the Continuing Healthcare Team. This should occur when a young person reaches the age of 14. This should be followed up by a formal referral for screening at age 16 to the adult NHS Continuing Healthcare Team Section 117 Aftercare A patient liable to detention under Sections 3, 37, 45A, 47 or 48 of the Mental Health Act 1983 may be eligible for Section 117 aftercare; these arrangements are separate and different from NHS funded Continuing Healthcare. Only if an individual has additional health needs that are not covered under the provisions of Section 117 might it be necessary to carry out consideration for NHS-funded Continuing Healthcare. Under Section 117 of the Mental Health Act, CCGs and Local Authorities have a duty to provide after-care services to individuals detained under applicable sections of the Mental Health Act. Section 117 is a free-standing duty to provide after-care services for needs arising from the individual s mental disorder; CCGs and Local Authorities should have local policies in place detailing respective responsibilities, including funding arrangements. The provision of Section 117 services are the joint responsibility of Local Authorities and the NHS. Where an individual is eligible for Section 117 services, these should be provided under Section 117 and not under NHS Continuing Healthcare. 20

21 Therefore, it is not necessary to assess eligibility for Continuing Healthcare if all service provision is to be provided as after-care services under Section 117. However, an individual in receipt of after-care services under Section 117 may also have on-going care needs (for example, for a physical health condition) that are not related to their mental disorder, and as a result may not fall within the provision of Section 117. In addition, an individual receiving Section 117 services may develop a separate physical healthcare need which could trigger a NHS Continuing Healthcare assessment. This need would be considered separately, initially through completion of a CHC Checklist, but in all instances NHS Continuing Healthcare should not be utilised to meet Section 117 needs. Where an individual in receipt of Section 117 services develops physical care needs resulting in a rapidly deteriorating condition which may be entering a terminal phase, consideration should be given to the use of the Fast Track Pathway Tool. Arrangements under the Mental Health Act are separate and different from NHS Continuing Healthcare and the two should not be confused. The above guidance particularly deals with Section 117, however the same principle (regarding the need to determine whether the services are provided under the Mental Health Act or under NHS continuing healthcare) applies where an individual is subject to section 17 leave or to a section 17A supervised community treatment order Complaints If an individual or their representative is dis-satisfied with the CHC process (rather than the eligibility outcome), they may raise their complaints and concerns with Sandwell & West Birmingham CCG via Time2Talk, the CCG s customer care team: Time2Talk Sandwell & West Birmingham CCG 4 th Floor Front Kingston House 438 High Street West Bromwich West Midlands B70 9LD Swbccg.time2talk@nhs.net Tel: Training Training will be provided to all hospital staff, community staff and adult social care involved in the implementation and application of the National Framework of NHS 21

22 Continuing Healthcare & Funded Nursing Care. Training will be provided in the use of the national tools, the identification of primary heath need and the application process. All those applying the Checklist and DST must have been trained in the use of these documents. For greater understanding of the Continuing Healthcare process, e- learning is provided via Health Education England and is mandatory for all members of the CCG Continuing Healthcare team. 7. Monitoring the Compliance and Effectiveness of this Policy Quarterly report presented to the Quality & Safety Committee used to inform the Governing Body. Preliminary quality checks will be undertaken on all providers of care prior to commissioning any packages of care. The Continuing Healthcare Co-ordinator will liaise with the Care Quality Commission, Local Authority and care provider to establish any concerns with the care provider. Information collected on completion of these checks will be transferred to the Quality Assurance Check Form. The CCG is committed to enhancing the quality of care delivered across Sandwell and West Birmingham. Continuing Healthcare work closely with the Care Quality Team, any issues and concerns which arise are communicated to the Continuing Healthcare team to ensure patient safety is not compromised. Reviews of care quality are completed during individual patient reviews and the results of these are collated for on-going performance monitoring. In addition, the Care Quality team undertake reviews on care homes using an in-house monitoring tool, which identifies areas of good practice and where improvements can be made. Any concerns raised between annual reviews will instigate substantial performance and quality checks on the identified Nursing Home/Care Agency. Issues can be raised by healthcare professionals, family and members of the public. The NHS Continuing Healthcare team, supported by the Finance Department, are responsible for the recording and collating of required information including:. Continuing Healthcare activity regarding eligibility decisions, placements and packages of care; Financial expenditure and savings; Cost of packages and placements; Continuing Healthcare reviews, appeals and disputes outcomes. 22