ALLOCATION OF RESOURCES POLICY FOR CONTINUING HEALTHCARE FUNDED INDIVIDUALS

Transcription

1 ALLOCATION OF RESOURCES POLICY FOR CONTINUING HEALTHCARE FUNDED INDIVIDUALS APPROVED BY: South Gloucestershire Clinical Commissioning Group Quality and Governance Committee DATE Date of Issue:- Version No: 1 Date of Review:- Author:- 1

2 Document status: Current Version Date Comments Draft 1.0 Discussed at Policy Review Group Draft Version 1 2

3 CONTENTS Section Summary of Section Page Cont Contents 3 1 Introduction 2 Purpose and Scope 3 Responsibilities under the Care Act Fully Funded NHS Continuing Healthcare in a Care Home Placement 5 Fully Funded NHS Continuing Healthcare at Home 6 Top Up 7 Disputes regarding Continuing Healthcare Placement Decision 8 Training Requirements 9 Equality Impact Assessment 10 Review Date 11 Monitoring Compliance and Effectiveness 12 Counter Fraud Appendix Appendix 1 High Cost Placement Panel 3

4 1. BACKGROUND 1.1. This policy describes the way in which South Gloucestershire Clinical Commissioning Group (CCG) will make provision for the care of people who have been assessed as eligible for fully funded NHS Continuing Healthcare (CHC). The policy describes the ways in which the CCG will commission and provide healthcare in a manner that reflects the choice and preferences of individuals and balances the need for the CCG to commission care that is equitable, safe and effective and makes best use of the resources available to the CCG. This policy has been adapted from Bristol CCG s commissioning policy to offer consistency of allocation of resources within the region. 1.2 This policy should be read in conjunction with: National Framework on NHS Continuing Healthcare and NHS-funded nursing care CCG Policy and Procedure for Safeguarding Adults The Care Act 2014 (Mental Capacity Act and Deprivation of Liberty) South Gloucestershire CCG Continuing Healthcare Operational Guide South Gloucestershire CCG Personal Health Budget Operational Guide for Continuing Healthcare (CHC) eligible service users South Gloucestershire Safeguarding Policy 1.3 Where the CCG or organisation with delegated authority has assessed an individual and found that the person's primary need is a health need then that individual is eligible to receive fully funded NHS Continuing Healthcare. Fully funded NHS Continuing Healthcare describes a package of on-going care arranged and funded solely by the NHS, for the period the individual is found eligible. 1.4 As part of a fully funded NHS Continuing Healthcare package, the CCG is required to secure and fund, services necessary to meet the assessed health and personal care needs. Such needs are identified through a multidisciplinary assessment. 1.5 The CCG has a responsibility to make best use of the resources available and will take choice into account when arranging a suitable package of care as set out in the Care Act However there is no legal obligation for the CCG to provide a care package greater than the assessed need. 1.6 When deemed eligible for Continuing Healthcare, to access CCG funding a recognised formal assessment of care needs will need to be completed by a registered professional on behalf of the CCG and will be subject to CCG approval. 2 PURPOSE & SCOPE 2.1 The purpose of the policy is to provide clarity regarding the commissioning processes undertaken in relation to Continuing Healthcare service provision, ensuring that equality, equity and risk is managed and the most effective use of resources. 4

5 2.2 The policy is applicable to individuals deemed to be eligible for Continuing Healthcare funding including where a Personal Health Budget has been requested. 2.3 The CCG has developed this policy to support consistent equitable decision making taking into account: clinical safety and quality the obligation on the CCG to commission and fully fund packages of care for the assessed needs of CHC eligible individuals individual choice and preference the duty of the CCG to effectively commission and ensure value for money Application of this policy will aim to ensure that decisions will: be robust, fair, consistent and transparent be based on the objective assessment of the individual s clinical need, safety and best interests have regard for the safety and appropriateness of care packages to those involved in care delivery involve the individual and their family wherever this is possible take into account the need for the CCG to allocate its financial resources in the most cost effective way support choice to the extent possible in the light of the above factors 3. RESPONSIBILITIES UNDER THE CARE ACT The CCG has a duty to provide a care package to meet the reasonable needs of individuals as assessed by the relevant professionals. 3.2 The CCG aims to offer individuals a choice of care packages which meet their assessed needs. Where there is a request for a care package by the CHC eligible individual or their representative which is not usually commissioned by the CCG the expectation is that the most cost effective package that meets the assessed needs will be commissioned. 3.3 Where a care package requested by an individual is more expensive than the options offered by the CCG, then the CCG, taking into account the considerations set out below, may agree to fund such a package of care in exceptional circumstances approved and discussed at the CCG High Cost Panel. While there is no set upper limit on expenditure, the principle is that care provision will not be agreed where costs exceed 20% over the most cost effective package that has been assessed as able to meet an individual s needs. Funding decisions relating to such circumstances will be clearly documented and discussed with the individual eligible for CHC or their representative. 3.4 The CCG will support an individual in making the decision as to where they wish to receive their package of care. However, if there are concerns that an individual does not have the mental capacity to make the decision as to where 5

6 they live, a mental capacity assessment will be undertaken. 3.5 Where the individual lacks capacity to make the decision on where to live and there is no Lasting Power of Attorney which extends to healthcare decisions then the CCG has a duty to act in accordance with the individual's best interests and in accordance with the Mental Capacity Act. The CCG will make the decision on the basis of consideration of the best interests of the individual taking into consideration the views of the family/carers. The CCG will need to consider whether there is a requirement for a deprivation of liberty authorisation. 3.6 Where the individual does not have the capacity to understand the particular decision then the CCG will consider whether it is appropriate to involve an independent advocate if the CCG considers that there is no one else willing and able to be consulted or that appointing an independent advocate will benefit the individual. 3.7 Where a personal welfare deputy has been appointed by the Court of Protection under the Care Act or a Lasting Power of Attorney with powers extending to healthcare decisions then the CCG will consult with that person. 3.8 All individuals will have their care reviewed after 28 days and thereafter in line with CHC eligibility or sooner if their care needs indicate that this is necessary. Individuals with palliative care needs will have their care reviewed more frequently in response to their medical condition. 3.9 The review may result in either an increase or a decrease in support offered and will be based on the assessed need of the individual at that time The individual s condition may have improved or stabilized to such an extent that they no longer meet the criteria for NHS continuing healthcare (CHC). Consequently, the individual will be referred to the Local Authority who will assess their needs. This may mean that the individual will be charged for aspects of their ongoing care or may need to fully fund their ongoing care. Where possible, transition to Local Authority care will be managed by agreement between the respective authorities within 28 days of the individual being found no longer eligible for CHC Where an individual is no longer eligible for CHC funding, in line with the National Framework, a 28 day notice period will be given. The individual is able to appeal the eligibility decision locally as outlined in the CCG CHC operational policy. During the local appeal period the CCG may continue to fund the CHC eligible individual following negotiation with the care provider and Local Authority. Funding responsibility will transfer to either the individual or the Local Authority following 28 days notice. 4 FULLY FUNDED NHS CONTINUING HEALTHCARE IN A CARE HOME PLACEMENT 4.1 Where an individual s choice or the complexity of need is to receive care in a care home the CCG aims to offer individuals a reasonable choice of care homes and care providers. To ensure consistent high quality care and equity 6

7 in provision the CCG has collated a list of preferred care home providers (the "Care Home List") with which it holds a Memorandum of Agreement. The CCG will provide information to individuals/representatives about the available choice of care homes so that they are able to make an informed choice. 4.2 An individual has the right to decline CHC NHS funding for their care and make private arrangements. For the avoidance of doubt, in the event that an individual has been assessed and found to be eligible for CHC they will no longer be able to receive funding from the Local Authority towards their care even if they decline CHC NHS funded care. 4.3 Where an individual is found eligible for NHS Continuing Healthcare they will be able to choose where they wish to be placed from the care home list. However there may be circumstances where the preferred provider is unable to meet their care needs and an alternative provider(s) will be offered. 4.4 Where, immediately prior to being found eligible for CHC, an individual is residing in a care home which is not on the CCG's Care Home List and that individual does not wish to move, the CCG will undertake a clinical risk assessment of the individual to consider the clinical or psychological risk impact of a move to an alternative placement. 4.5 The CCG will consider whether it is appropriate to commission a package outside of the Care Home List taking into account the following: the cost of the package; the Care Quality Commission's assessed standard; the appropriateness of the package; the clinical assessment of the individual's needs and the risk of any change to the individual's health; the likely length of the proposed package; In the event that the CCG commissions care in a home that is not on the Care Home List, the appropriateness of the placement will be reviewed at the initial and any subsequent reviews. 4.6 The CCG will not normally fund a placement where the requested care home is not the most suitable place for the provision of care and the care package can only be provided safely or resiliently at the current home with additional staffing at significant extra cost to the CCG. 4.7 If the individual or their family/representative indicates that they are unwilling to accept any of the placements offered by the CCG then the CCG shall issue a final offer letter setting out the options available. If the CCG does not receive confirmation that the individual has accepted one of the placements within 14 days then the CCG will issue a Notice of Care being declined by a service user confirming that the NHS funding has been turned down and NHS funding will cease from 28 days after the date of the Notice of Care being declined by a service user. If during the period of the notice the individual or individual s representative chooses to accept the offered care, this offer will be reinstated. 7

8 4.8 Where the individual or their family/representative decline CHC funding they will not be able to access local authority funding for the care and will need to make private arrangements. 4.9 If after a Notice of Care being declined is issued the individual or their representatives want to access NHS services they remain entitled to do so and can re-enter the CHC process at any time. 5 FULLY FUNDED NHS CONTINUING HEALTHCARE AT HOME 5.1 The CCG supports the use of care at home packages where they are appropriate and recognises the importance of individual choice. However, there may be situations where the CCG cannot provide the individual's choice of having a care at home package either because the risk assessment identifies or results in inequality of inappropriate use of CCG funds due to the increase associated with the package or the care cannot be safely provided at home. The CCG considers that packages which require a high level of input may be more appropriately and safely met in another care setting The CCG's duty to fund CHC care does not extend to funding for the wide variety of different, non-health and non-personal care related services that may be necessary to maintain the individual in their home environment. Should the CCG identify that such basic needs are unable to be (or have not been) properly met, the CCG may find that a care at home package is not or no longer appropriate. Whether a particular service should be provided by the CCG will depend on the review by the CCG of whether that particular service is required in order to meet that individual's personal or healthcare needs The CCG will take account of the following considerations when considering a request to deliver a care at home package: Care will be delivered safely to the individual and without undue risk to the individual, the staff or other resident members of the household The acceptance by the individual, the CCG High Cost Panel and each person involved in the individual's care of any risks relating to the care package The General Practitioner's opinion on the suitability of the package and confirmation that he/she agrees to provide primary medical support It is the individuals preferred choice The suitability, accessibility and availability of alternative arrangements The extent of a individual s needs (e.g. frequency of qualified nurse intervention required) The cost of providing the individual s package of choice The cost (or range of costs) of the care package(s) identified by the CCG as suitable to meet the individual's assessed care needs The psychological, social and physical needs impact on the individual The individual's human rights and the rights of their family and/or carers including the right of respect for home and family life 8

9 The ability of family members or friends to provide elements of care where this is a necessary/desirable part of the care plan and the agreement of those persons to the care plan. 5.4 Assessments for Fully Funded NHS Continuing Healthcare at Home The CCG will undertake a number of assessments prior to agreeing to any care at home package in order to establish whether it is appropriate to fund the package. Safety will be determined by a formal assessment of risk, undertaken by appropriately qualified professionals. The overarching assessment of risk will include: Environmental Risk assessment (including the availability of equipment, the appropriateness of the physical environment) Clinical Risk assessment Staffing Assessment (availability of appropriately trained carers and/or staff to deliver care whenever it is required and the resilience of the package will be assessed and contingency arrangements will need to be put in place for each component of the package in case any component of the package fails) If a package of care at home is agreed the individual or their representative will be expected to sign a Memorandum of Understanding (detailed below). 5.5 Environmental Risk Assessment The risk assessment must consider all risks that could potentially cause harm to the individual, any family and the staff. Where an identified risk to the care providers or the individual can be minimised through actions by the individual or his/her family and/or carers, those individuals must agree to comply with the steps required to minimise such identified risk Where the individual requires particular equipment then this must be able to be suitably accommodated within the home The CCG is not responsible for any alterations required to a property to enable a care at home package to be provided. For the avoidance of doubt, where an individual or representative has made alterations to the home but the CCG has declined to fund the package, the CCG will not provide any compensation for those alterations As part of the risk assessment a Safeguarding Adult assessment will be undertaken by the Local Authority in order to assess whether there may be any actual or potential risks to the individual. 5.6 Clinical Risk Assessment When considering whether a package of care is suitable, the CCG will undertake a clinical assessment of the individual's needs and the extent to which that clinician considers that the proposed care at home package meets those needs. The clinical assessment will consider the benefits of a care at home package against the benefits of a care home placement. 9

10 5.6.2 A nurse and the multi-disciplinary panel will be asked to consider the proposed arrangements in order to determine whether it is the most appropriate care package. This will include current and likely future clinical needs and psychological needs. Where part of the package is based on care being provided by a family carer(s) it will also include consideration of how needs will be met in the event that the carer is unable to provide the care either temporarily or permanently. 5.7 Staffing Assessment The CCG will assess the care need and the input required by the individual to meet those needs. The CCG shall consider the qualification of any required staff and the sustainable availability of appropriately qualified staff including appropriate contingency arrangements The CCG is committed to ensuring that professionals are able to provide care in a safe environment and when required will assess any potential harm and take steps to prevent it. This covers both physical risks and any potential psychological risks that may arise. The CCG's Health and Safety policy will apply The individual (or representatives) are responsible for ensuring that the environment is safe for the ongoing provision of the care package. Where the safety assessment identifies a potential risk associated with the home, the individual is responsible for remedying that The individual (or representatives) are also responsible for ensuring that the environment is appropriate for the ongoing provision of the care package by staff. This includes ensuring staff are treated with dignity and respect and have access to toilet, bathroom and kitchen areas and such areas are kept in a clean state. 5.8 Memorandum of Understanding for Care at Home Package Where the CCG agrees to fund a care at home package the individual (if appropriate) and/or representatives will be required to enter into a Memorandum of Understanding ("Memorandum") confirming that they accept the terms on which any care is provided This Memorandum will set out what the CCG will provide and what the individual and representatives have agreed to provide This Memorandum will also confirm that the individual and representatives understand that the care package is agreed on the basis of the assessed health and personal care needs and the required input at the date of the Memorandum. Where the cost of meeting the assessed care needs increases for any reason, the individual and representatives acknowledge that it may no longer be appropriate for the CCG to provide and they will work with the CCG to agree an alternative care package. 10

11 5.8.4 The Memorandum will set out the agreed alternative arrangements should the care package break down. 5.9 Termination of a Care at Home Package In any circumstance where the CCG considers that the safety of its staff or its agents/contractors are at risk it shall take such action as it considers appropriate in order to remove that risk. Where this relates to the conduct of the individual or the home environment it shall request that the individual/representatives take the necessary action to remove the risk Where a review identifies, or the CCG otherwise becomes aware that an action to reduce an identified risk to either the people involved providing care or to the individual has not been taken and such failure may put those individuals at risk or may significantly increase the cost of the package, the CCG will take the necessary steps to protect the individual and staff involved with a view to ensuring the safety of all concerned Harassment or bullying of care workers by the individual, carers or family members is unacceptable and the CCG will take any action considered necessary to protect their staff and contractors Where safety of the individual and/or those people involved in providing care is likely to be compromised without such action and the individual or representative does not take the required action then this may result in the CCG issuing a Withdrawal of Care Notice. Where there is a threat to the safety of CCG staff or agents then the CCG retains the right to take any action it considers necessary to remove the threat including the immediate withdrawal of the care provision Where the individual is in receipt of a care at home package and an assessment determines that this is no longer appropriate for any reason (including increase in care needs, inability for family to provide agreed care or identified risk) then an alternative package will be discussed and agreed. If the individual declines to accept alternative suitable provision this may result in the CCG issuing a Withdrawal of Care Notice giving no less than 28 days notice for alternative arrangements to be put in place by the individual. 6 TOP UP 6.1 The CCG is only obliged to provide services that meet the assessed needs and reasonable requirements of an individual. An individual has the right to decline NHS services and make their own private arrangements. 6.2 Where an individual is found eligible for Continuing Healthcare, the CCG must provide any services that it is required to provide, free of charge. In the context of care home placements this will be limited to the cost of providing accommodation, care and support necessary to meet the assessed needs of the individual. For care at home packages this will be the cost of providing the services to meet the assessed needs of the individual. The package of care which the CCG has assessed as being reasonably required to meet the individual's needs is known as the core package. 11

12 6.3 Where an individual wishes to augment any NHS funded care package to meet their personal preferences they are at liberty to do so. However, this is provided that it does not constitute a subsidy to the core package of care identified by the CCG. Joint funding arrangements are not lawful under the National Framework for NHS Continuing Healthcare. 6.4 As a general rule individuals can make a contribution to their care package where the additional services are optional, non-essential services which an individual has chosen (but was not obliged) to include in their care package. 7 DISPUTES REGARDING CONTINUING HEALTHCARE PACKAGE OR PLACEMENT DECISION 7.1 Should an individual or representative wish to dispute the decision of the CCG in the provision a care at home package or home care placement for a person eligible for continuing healthcare, the High Cost Panel will consider the decision. 7.2 Any dispute in care provision should not lead to a delay in discharge from an Acute (Hospital) care and while the dispute is resolved the individual will receive their care in an appropriate environment outside of acute hospital. The CCG will fund the cost of the placement during the dispute period for CHC eligible individuals. 8. EQUAL OPPORTUNITIES/EQUALITIES IMPACT ASSESSMENT 8.1 An Equality Impact Assessment is being completed together with PPI engagement. 9. REVIEW DATE 9.1 This policy and procedure will be reviewed after 2 years, or earlier at the request of either staff or management, or in light of any changes to legislation or National Guidance. 10. MONITORING COMPLIANCE AND EFFECTIVENESS 10.1 A model for monitoring compliance and effectiveness will be developed in conjunction with finance and the lead for CHC. 11. COUNTER FRAUD 11.1 This policy will be shared with NHS Counter fraud for their contribution Any service user found to be mis-representing their clinical needs will be referred by the CHC commissioning team to Counter fraud for investigation. 12

13 APPENDIX 1 High Cost Placement Panel 1 PURPOSE 1.1 To provide a process to ensure South Gloucestershire Clinical Commissioning Group exercises firm financial and risk control and accountability in respect of high cost packages of care for Continuing Healthcare, Mental Health, Learning Disabilities, complex cases for children or any other individual care packages. The risks include clinical risk, environmental risk and financial risk. 1.2 To ensure that all care packages with a cost of 2,500 or more per week are appropriately authorised and that a timeframe for review has been agreed. Any packages agreed outside of panel to be reviewed and approved by panel at the next meeting. 1.3 Cases which will be presented to the panel will be those where the cost of care exceeds 20% additional to the most cost effective care provision, or where a service user or representative (where the service user does not have capacity) disputes the care provision proposed the CCG. 2 RESPONSIBILITIES 2.1 To consider each case on its own merits and assess against the following criteria: The suitability of the care package to meet the individual s clinical needs The quality of care being sought The availability of at least two proposed care options The risk to individual s care needs The cost effectiveness of the proposed care option relative to all options available Any statutory or legal responsibilities. 2.2 To agree an appropriate review timetable for each care package approved. 2.3 To refer cases to the Joint Funding Panel, where appropriate. 2.4 To provide assurance to the Quality and Governance Committee that a robust system is in place to maintain financial control. 3 PANEL MEMBERSHIP AND MEETING ARRANGEMENTS 3.1 Membership will be constituted of: 13

14 Director of Nursing and Quality or Deputy Director of Nursing and Quality (Chair) Deputy Chief Financial Officer Director of Partnerships or Deputy Director of Community Commissioning and Mental Health Head of Medicine Management, Long Term Conditions and Primary Care CHC administrator (minute taker). 3.2 The appropriate commissioning manager will provide details of case and rationale for each care package. 3.3 The Scheme of Delegation, as referenced in the CCG Detailed Financial Policies, permits the approval of expenditure of up to 199,999 to officer members of the panel. Approval for expenditure of 200,000 or above will be sought from the Chief Officer or Chief Finance Officer, approval for expenditure above 1m will be sought from the Governing Body. 3.4 Where a decision by the CCG is being contested the individual and / or their representative will be invited to the panel. 4 QUORUM 4.1 The meeting will be quorate when there are at least three members present to include the Director of Nursing and Quality or Deputy Director of Nursing and Quality, the Chief Financial Officer or the Deputy Chief Financial Officer and another Director either the Director of Partnerships and Joint Commissioning or the Deputy Director of Community Commissioning and Mental Health Head of Medicine Management, Long Term Conditions and Primary Care. 5 DEPUTIES 5.1 Deputies will be accepted at the discretion of the Chair. Any deputies agreed by the Chair will have fully delegated decision making. 6 FREQUENCY OF MEETINGS 6.1 Meetings will be held on a monthly basis. 7 EMERGENCY DECISIONS 7.1 It is acknowledged that there will be occasions where a high cost package needs to be agreed at short notice and where waiting for decision until a panel could be convened would be inappropriate or fail to meet statutory requirements. 7.2 In such circumstances the following process will apply: The package will be reviewed and provisionally agreed by telephone/ as appropriate by: 1. Director of Nursing and Quality or Deputy Director of Nursing and Quality; 14

15 2. Chief Financial Officer or Deputy Chief Financial Officer and Director of Partnerships and Integration Deputy Director or Deputy Director of Community and Mental Health Commissioning. If the package is a long term package it will be reviewed and formally agreed at the next panel meeting. Short term packages which have been agreed by this method will be reviewed and formally agreed at the next panel meeting and any learning points discussed. 8 REFERRALS TO PANEL 8.1 Referrals and presentation of cases to the panel can be made by members of the Commissioning Managers within the CCG. The panel referral template should be completed and returned to the CHC team administrator. 8.2 Panel papers these will be sent to panel members by 2pm on the day prior to the panel meeting. 9 DECISION MAKING PROCESS 9.1 Each case will be considered on its own merits and assessed against following criteria: Suitability of the care package to meet the individual s clinical needs; Quality of care being sought; Availability of at least two proposed care options; Risk to individual s care needs; Cost effectiveness of proposed care options relative to all options available; 9.2 It is not the role of the panel to assess a individual s entitlement to continuing healthcare. However, in considering individual cases, if there is a query as to a individual s entitlement then the case will be referred back to the Health Assessment and Review Team for an early continuing healthcare review. 9.3 The panel members will need to seek consensus based on the information supplied at the panel meeting. A majority decision is required; if this cannot be achieved, the Chair will have the casting vote. It is expected that the decision will be made during the panel meeting and therefore communicated to those present immediately. However, if a decision cannot be made based on a lack of information, then the case will need to be re-presented to the panel as quickly as possible with the additional information supplied by the case presenter. 9.4 Right of appeal presenting staff have no right of appeal against the panel s decision. Should an individual wish to appeal the decision of the panel the CCG complaints process will need to be used. 10 POST PANEL PROCESS 15

16 10.1 The decision needs to be communicated as relevant to the individual and/or their family/carer and the care provider; how this is done will need to be determined by the panel on a case-by-case basis. All cases will receive a written confirmation of the panel decision within 2 working days Where funding is approved the case presenter will advise the individual and/or their family/carer within 24 hours of the panel meeting. He/she will then need to liaise with the relevant commissioner to put in place the appropriate care package. South Gloucestershire CCG CHC team will coordinate the funding arrangements to support the package Where funding is not approved the case presenter or a nominated person will advise the individual and/or their family/carer within 24 hours of the panel meeting. South Gloucestershire CCG CHC team will then need to seek an alternative care package For care packages exceeding 20% additional to the most cost effective care provision. The panel chair will need to seek approval from the South Gloucestershire CCG Director of Finance, or his/her nominated deputy. This will need to take place within three working days of the panel s decision. Until this decision is made, no new care package can be procured. 11 REPORTING 11.1 The panel will produce a six monthly report to the Quality and Governance Committee. 12 REVIEW 12.1 The Terms of Reference will be reviewed at 6 months or as required This operational protocol will be reviewed within three months of implementation and amended as appropriate to reflect its operation in practice. Thereafter it will be reviewed annually The financial limits contained within this protocol will need to be reviewed ready for the start of each new financial year. 13 GLOSSARY OF TERMS 13.1 The term CHC is used in this policy as an abbreviation for fully funded NHS Continuing Healthcare as defined in the NHS National Framework for Continuing Healthcare (glossary of terms). 16