NHS Continuing Healthcare - Choice and Equity Policy NHS Swindon Clinical Commissioning Group Page 1 of 13
Policy: NHS Swindon Clinical Commissioning Group (CCG) NHS Continuing Healthcare Choice and Equity Policy Policy Reference: CG23 Policy Statement: This policy describes the way in which the CHS Healthcare Continuing Healthcare Team (CHC) on behalf of Swindon CCG will provide care for people who have been assessed as eligible for fully funded NHS Continuing Healthcare. The policy describes the way in which the CHC Service will commission care in a manner which reflects the choice and preferences of individuals but balances the need for Swindon Clinical Commissioning Group (CCG) to commission care that is safe and effective and makes the best use of available resources. Version Number: 1.0 Version Date: 23.02.2018 Review Date: 23.02.2019 Author: Jacqui Connelly, CHC Lead Responsible Owner: Gill May, Executive Nurse Approving Body: Document Control CHC Programme Board EMT Integrated Governance Committee Governing Body Reviewers & Approvals This document requires the following reviews and approvals. Name Position Version Approved Date Approved Dr Peter Mack Clinical Chair Governing Body 0.3 28/06/18 Revision History Version Revision Details of Changes Author Date 0.1 19.10.16 Comments received from CHC Programme Amanda du Cros Board membership and changes in formatting to comply with Corporate Governance Guidelines 0.2 20.10.16 Updated as above. Amanda du Cros 0.3 23.2.18 Updated following comments from Equality and Human Rights Commission. Jacqui Connelly Page 2 of 13
Acknowledgement of External Sources: List any policies or from external institutions that have been used to inform the writing of this policy. Title/Author Institution Comment / Link Links or overlaps with other key documents & policies: Document Title Version and Issue Date Link/Document Continuing Healthcare Policy V4 19.10.16 Distribution and Consultation: This document has been distributed to the following people for consultation Name Date of Issue Version Art Calder, Lead Manager, CHS 4.7.16 0.1 Amanda du Cros, Head of PMO, NHS Swindon CCG 4.7.16 Jacqui Connelly, CHC Clinical Lead 12.10.16 and 17.1.18 for version 3 Graeme O Malley, Project Manager, NHS Swindon CCG Sharren Pells, Associate Director for Quality, NHS Swindon CCG Rachel Cooke, Corporate & Information Governance Coordinator, NHS Swindon CCG Gill May, Executive Nurse, NHS Swindon CCG Matthew Hawkins, Deputy Director of Finance, NHS Swindon CCG Angela Plummer, Head of Adult Services, Swindon Borough Council Jackie Walker, Head of Finance and Change, Swindon Borough Council Joy Kennard, Head of Commissioning, Swindon Borough Council Alison Forster, Service Operational Manager, Swindon Borough Council and LA representative on CHC Panel Brian O Shea, Service Operational Manager, Swindon Borough Council and LA representative on CHC Panel Kay Reeve, Head of Learning Disability Social Care and Adult Commissioning 0.1 and 03 Jacqui Connelly, CHC Clinical Lead ( as above) 23.2.18 0.3 Page 3 of 13
Kirstie Jackman, Team Leader, Swindon CHC Team 23.2.18 0.3 Gill May, Executive Nurse, Swindon CCG 23.2.18 0.3 Sharren Pells, Associate Director for Quality, Swindon CCG 23.2.18 0.3 Lynnette Glass, Quality Lead for Projects 23.2.18 0.3 Sarah Corkery-Lloyd, Finance Manager, Swindon CCG 23.2.18 0.3 Rachel Cooke, Corporate & Information Governance Coordinator, NHS Swindon CCG 23.2.18 0.3 Sharon Gerry, Urgent Care Commissioning Manager 23.2.18 0.3 Tracy Wray, Commissioning Manager, Planned Care 23.2.18 0.3 Angela Plummer, Director of Adults, Swindon Borough Council Joy Kennard, Head of Commissioning, Swindon Borough Council Jackie Walker, Head of Finance and Change, Swindon Borough Council 23.2.18 0.3 23.2.18 0.3 23.2.18 0.3 Governing Body Members 28.06.18 0.3 Document Version Numbering: Document versions numbered 0.1, 0.2, 2.4, are draft status and therefore can be changed without formal change control. Once a document has been formally approved and issued it is version numbered Issue 1.0 and subsequent releases will be consecutively numbered 2.0, 3.0, etc., following formal change control. Freedom of Information If requested, this Document may be made available to the public and persons outside the healthcare community as part of NHS Swindon Clinical Commissioning Group s commitment to transparency and compliance with the Freedom of Information Act. Accessibility This document is available in other styles, formats, sizes, languages and media in order to enable anyone who is interested in its content to have the opportunity to read and understand it. These alternatives include but are not limited to: Alternative languages and dialects Larger and smaller print options (font 8 to 18) Simplified versions including summaries and translation into symbols Audio or read versions Web based versions that can be zoomed into or shrunk on screen Braille Page 4 of 13
Table of Contents Contents 1. Introduction... 6 2. The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care November 2012 (Revised)... 6 3. Context... 7 4. The Provision of Services for People Who are Eligible for NHS Continuing Healthcare... 7 5. Continuing Healthcare Funded Care Home Placements... 9 6. Continuing Healthcare Funded Packages of Care At Home... 10 7. Circumstances to be Taken into Consideration... 11 8. Appeal Regarding Care Provision... 12 9. Capacity... 12 10. Agreement to Fund... 13 11. Review... 13 Page 5 of 13
Foreword NHS Continuing Healthcare Choice and Equity Policy It is the statutory responsibility of Swindon Clinical Commissioning Group (CCG) to provide and fund a package of care that meets all assessed health, personal care and associated social care needs for those individuals found eligible for 100% NHS Continuing Healthcare funding. CHS Healthcare are responsible for providing the Continuing Healthcare Team from 1 April 2016. The principles of personal health budgets have now been implemented and individuals are offered a Personal Health Budget and a support plan approach is used to determine health outcomes and provision of care. 1. Introduction 1.1 This policy describes the way in which the CHS Healthcare Continuing Healthcare Team (CHC) on behalf of Swindon CCG will provide care for people who have been assessed as eligible for fully funded NHS Continuing Healthcare. The policy describes the way in which the CHC Service will commission care in a manner which reflects the choice and preferences of individuals but balances the need for Swindon Clinical Commissioning Group (CCG) to commission care that is safe and effective and makes the best use of available resources. 2. The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care November 2012 (Revised) 2.1 The National Framework says: Where an individual is eligible for NHS continuing healthcare, the CCG is responsible for care planning, commissioning services and for case management. It is the responsibility of the CCG to plan strategically, specify outcomes and procure services, to manage demand and provider performance for all services that are required to meet the needs of all individuals who qualify for NHS continuing healthcare, and for the healthcare part of a joint care package. The services commissioned must include ongoing case management for all those entitled to NHS continuing healthcare, as well as for the NHS elements of joint packages, including review and/or reassessment of the individual s needs. (paragraph 108) Where a person qualifies for NHS Continuing Healthcare, the package to be provided is that which the CCG assesses is appropriate for the individual s needs. Although the CCG is not bound by the views of the LA on what services the individual needs, the Local Authority s (LA) assessment under Section 47 Page 6 of 13
of the National Health Service and Community Care Act 1990, or its contribution to a joint assessment, will be important in identifying the individual s needs and, in some cases, the options available for meeting them (paragraph 167). 3. Context 3.1 NHS Continuing Healthcare means a package of continuing care arranged and funded solely by the NHS where the individual has been found to have a primary health need as set out in the National Framework. The actual services provided as part of that package should be seen in the wider context of best practice and service development for each client group. In many circumstances there is likely to be a range of options and settings appropriate for the needs of individual s found eligible for NHS Continuing healthcare Funding (paragraph 83.2). 4. The Provision of Services for People Who are Eligible for NHS Continuing Healthcare 4.1 The Swindon CCG and the CHS Healthcare Continuing Healthcare Service has developed this policy in light of the need to balance personal choice alongside safety and effective use of finite resources. It is also necessary to have a policy which supports consistent and equitable decisions about the provision of care regardless of the person s age, condition or disability. These decisions need to provide transparency and fairness in the allocation of resources. 4.2 Application of this policy will ensure that decisions about care provision will: be based on the objective assessment of the person s clinical need and potential health outcomes, safety and best interests taking into consideration individual preferences; be robust, fair, consistent and transparent; have regard for the safety and appropriateness of care to the individual and staff involved in the delivery; implement the principles and processes of Personal Health Budgets (PHBs) and ensure availability of information and support to allow take-up of all options related to PHBs. involve the person and their family/representative wherever possible; take into account the need for the CCGs to allocate its financial resources in the most cost effective way support choice to the greatest extent possible in view of the above factors. 4.3 The CCGs have a duty to provide care to a person with continuing healthcare needs in order to meet those assessed needs. It is important to be clear about the extent and nature of the need; for example Individuals can sometimes be Page 7 of 13
described as needing 24hrs care when what is meant is they need 24 hour access to support and/or supervision. 4.4 Where Individuals are described as requiring nursing care, the CHC Service should identify whether their needs require the actual presence of a nurse at all times or whether the needs are for qualified nursing staff for specific tasks or to provide overall supervision. 4.5 An individual or their family/representative cannot make a financial contribution to the cost of the care identified by the CHC Service as required to meet the individual s assessed needs. An individual however, has the right to decline NHS services and make their own private arrangements. 4.6 Access to NHS services depends upon clinical need, not ability to pay. The CCGs will not charge a fee or require a co-payment from any NHS patient in relation to the assessed health needs. The principle that NHS services remain free at the point of delivery has not changed and remains the statutory position under the NHS Act 2006. The CCGs are not currently able to allow personal top up payments into the package of healthcare services under NHS CHC, where the additional payment relates to core services assessed as meeting the needs of the individual and covered by the fee negotiated with the service provider (e.g. the care home) as part of the contract. 4.7 However, where service providers offer additional services which are outside the person s needs as assessed under the NHS CHC framework, the person or family member may choose to use personal funds to take advantage of these services. 4.8 Examples of such services falling outside NHS provision include hairdressing, a bigger room or a nicer view. Any additional services which are unrelated to the person's primary healthcare needs will not be funded by the CCGs as these are services over and above those which the service user has been assessed as requiring, and the NHS could not therefore reasonably be expected to fund those elements. 4.9 In instances where more than one suitable care option is available (i.e. a nursing home placement and a domiciliary care package) the total cost of each package will be identified and assessed for the overall cost effectiveness. While there is no set upper limit on the cost of care, the expectation is that the most cost-effective option will be commissioned that meets the individual s assessed health needs and circumstances. 4.10 The cost comparison must be based on the genuine costs of alternative models. A comparison with the cost of supporting a person in a care home should be based on the actual costs that would be incurred in supporting a person with specific needs in the case and not on an assumed standard care home cost. Page 8 of 13
4.11 Any assessment of care options will include the psychological and social care needs of the individual. The impact on the home and family life as well as the individual s care needs. The outcome of this assessment will be taken into account in arriving at a decision. 4.12 When determining the Service provision for an individual the primary consideration is to ensure the individual s safety and it is essential that all risks are identified and managed. Risk management must be proportionate. Individuals with capacity have the right to manage their own risk and make unwise choices. 4.13 The setting in which CHC is provided is ultimately a matter for a decision by the CCGs and not the individual or their family. However the CCGs will take into account all reasonable requests. Where such a request involves additional costs to the CCG in accordance with the paragraphs below. 5. Continuing Healthcare Funded Care Home Placements 5.1 Where a person has been assessed as needing placement within a care home, and the CHC Service operates an accredited provider list for the type of care needs concerned, the expectation is that individuals requiring placement will have their needs met in one of these homes. 5.2 The person may wish to move into a home outside of the preferred provider list or their family/representative may wish to place the individual in a home outside of the accredited provider list. As long as the fee for the bed is comparable to the fee agreed with the preferred providers and the home can meet the patients care needs the CHC Service will consider this option. The CCG will make the final decision taking these issues into account. 5.3 If the fee is higher than the fee charged by a care home on the preferred provider list, only where the CHC Service is satisfied that the extra fees are for non-core care costs or for a higher level of accommodation, and that the provider could offer a service to the Patient at the CHC approved rate, will the CHC service proceed to a placement. The provider will only be able to invoice the CCGs for the core care costs and reasonable accommodation costs and will have to invoice the client separately for the non-core care costs and extra accommodation costs. The invoices will detail what the CCG and client is being charged for. 5.4 If the provider refuses to enter into the CCG's contract on this basis, the CCG will not be able to purchase the care at this home and the family will be advised that they will need to consider other homes that are on the preferred provider list. Page 9 of 13
6. Continuing Healthcare Funded Packages of Care At Home 6.1 People who are eligible for continuing healthcare funding have a complexity, Intensity, frequency and unpredictability in their health needs which means it is less common for care to be safely delivered at home. The CHC Service does not have the resources or facilities to provide either a 24-hour registered nursing hospital at home service or the equivalent of nursing/residential care provision. 6.2 The CHC Service will take account of the following issues before agreeing to commission a care package at home: Care can be delivered safely and without undue risk to the person, the staff or other members of the household (including children). Safety will be determined by a written assessment of risk undertaken by an appropriately qualified professional in consultation with the person or their family. The risk assessment will include the availability of equipment, the appropriateness of the physical environment and the availability of appropriately trained care staff and/or other staff to deliver the care at the intensity and frequency required. Where equipment and/or assistive technology can be used to support the safe delivery of care to Home, it is expected that this will be accepted and used appropriately. The acceptance by the CHC Service and each person involved in the person s care of any identified risks in providing care and the person s acceptance of the risks and potential consequences of receiving care at home. Where an identified risk to the care providers or the person can be minimised through actions by the person or their family and carers, those individuals agree to comply and confirmed in writing with the steps required to minimise such identified risk. The person s GP agrees to provide primary care medical support; The suitability and availability of alternative care options; The cost of providing the care at home in the context of cost effectiveness; The relative costs of providing the package of choice considered against the relative benefit to the person; The psychological, social and physical impact on the person; The willingness and ability of family, friends or informal carers to provide elements of care where this is part of the care plan and the agreement of those persons to the care plan. 6.3 Many persons wish to be cared for in their own homes rather than in residential care, especially people who are in the terminal stages of illness. A person s choice of care setting should be taken into account but there is no automatic right to a package of care at home. The option of a package of care at home should be considered if requested, and the CHC service will give reasons for its decision about this option. Page 10 of 13
6.4 A home care package may not be directly comparable to a care home package because of the psychological impact of the place of care. The CHC team will take this into account in considering the most appropriate placement for the individual. 6.5 When a person is discharged into the community the CHC Service as Commissioner takes on the responsibility for the care provision. 6.6 Home care packages in excess of eight hours per day would indicate a high level of need which may be more appropriately met within a residential placement. These cases would be carefully considered and a full risk assessment undertaken. 6.7 Persons who need waking night care may be more appropriately cared for in a residential placement. The need for waking night care indicates a high level of supervision day and night. 6.8 Residential placements are deemed more appropriate for persons who have complex and high levels of need. Residential placements benefit from direct oversight by registered professionals and the 24-hour monitoring of persons. 6.9 If the clinical need is for registered nurse direct supervision or intervention throughout the 24 hours the care would normally be expected to be provided within a nursing home placement. 6.10 Each assessment will consider the appropriateness of a home based package of care, taking into account the range of factors in paragraph 6.2 and underpinned by the principles in 4.2. 7. Circumstances to be Taken into Consideration 7.1 The CHC Service will seek to take account of the wishes expressed by persons and their families when making decisions as to the location(s) of care packages and residential placements to be offered to satisfy the obligations of the CCGs to provide continuing healthcare. The CCGs accept that many persons with complex medical conditions wish to remain in their own homes and to continue to live with their families, with a package of support provided to the person in their own homes. Where a person or their family expresses such a desire the CHC Service will investigate to determine whether it is clinically feasible and cost effective to provide a sustainable package of continuing care for a person in their own home. 7.2 Packages of care in a person s own home are bespoke in nature and thus can often be considerably more expensive for the CCGs than delivery of an equivalent package of services for a person in a care home. Such packages have the benefit of keeping a person in familiar surroundings and / or enabling Page 11 of 13
a family to stay together. However, the CCG needs to act fairly to balance the resources spent on an individual person with those available to fund services to other persons. 7.3 The CCG has resolved that, in an exceptional case and in an attempt to balance these different interests it will be prepared to support a clinically sustainable package of care which keeps a person in their own home provided the anticipated cost to the CCG is ordinarily no more than 10% higher than the anticipated cost of a care package delivered in an alternative appropriate location such as a care home. The CCG will consider the cost comparison on the basis of the genuine costs of alternative models. A comparison with the cost of supporting a person in a care home should be based on actual costs that would be incurred in supporting a person with the specific needs in the case and not on an assumed standard care cost. 7.4 Exceptionality is determined on a case by case basis and would require Director level agreement using the delegated authorisation process for high cost case. 8. Appeal Regarding Care Provision 8.1 By reference to the Individuals personalised care plan an indicative level of funding/care setting can be identified by the CHC Service. If this conflicts with the wishes of the Individual or their representative the CHC Service will refer the decision to members of the CCG Executive Team in the first instance for reconsideration. The CCG may need to consider further where the person lacks capacity and the potential for a DoLS requirement, least restrictive means and potential application to the Court if the personal objects with the potential for a 21a challenge. 8.2 If the decision of the CHC Service is upheld, the Individual or their representative will be advised of this and their right of complaint through the CCG complaints process. 8.3 If the complaint cannot be resolved locally the Individual or their representative can be referred directly to the Health Service Ombudsman. 9. Capacity 9.1 If a person does not have the mental capacity to make a decision about the location of their commissioned care package and suitable placement, the CHC team will consult any person who has the power under a Lasting power of Attorney, Social and Welfare, or as a Court Appointed Deputy to take personal care decisions on behalf of the patient in the same way that they would consult the patient. A Best Interest Meeting should take place to determine the most appropriate discharge destination, and subsequently the CHC Service will Page 12 of 13
commission the most cost effective, safe care available. This will be carried out in consultation with any appointed advocate, Attorney under a Lasting Power of Attorney or a Court Appointed Deputy or the Court of Protection directly, family member or other person who should be consulted in line with guidance within the Mental Capacity Act 2005. 10. Agreement to Fund 10.1 The authorisation for the commissioning and funding of packages of care at home lies with the CCGs. There is a process for the delegated authorisation of eligibility and the authorisation of care packages and placements. 11. Review 11.1 Individuals and their families need to be aware that there may be times where it will no longer be appropriate to provide care at home. For example, deterioration in the person s condition may result in the need for clinical oversight and 24-hour monitoring. 11.2 The care package will be reviewed three monthly and then annually as a minimum requirement alongside the continuing healthcare review to ensure that it is still meeting the person s needs at that time. 11.3 If the weekly cost of the care increases due to an Individual s deteriorating condition and consequent increase in health needs, apart from a single period of up to two weeks to cover either an acute episode or for end of life care to prevent a hospital admission, the care package will be reviewed and other options (for example a nursing home placement) will be explored following consideration of the issues outlined in paragraph 6.2. Revised March 2018 Page 13 of 13