NHS Continuing Healthcare Service Provider and Local Authority NHS Continuing Healthcare Inter-agency Disputes Policy Reference No: CG056 Version: Version 0. 6 Ratified by: SWL CCG Governing Body Date ratified: 28 September 2016 Name of originator/author: Name of responsible committee/individual: Arden GEM CSU Head of CHC; Arden GEM CSU Clinical and Business Managers CHC & LCC CHC Co-ordinator Governing Body Date issued: September 2016 Review date: 1 September 2019 Target audience: Distributed via: All staff involved in inter-agency disputes of eligibility for Continuing Healthcare Email and Website
South West Lincolnshire Clinical Commissioning Group Version control sheet NHS Continuing Healthcare Service Provider and Local Authority NHS Continuing Healthcare Inter-agency Disputes Policy Version Section/Para/Appendix Version/Description of Amendments Date Author/ Version Key individuals involved in developing the document: Name Tracy Tyrrell James Bewsher /Louise Newcombe Diane Kelly Amanda Parsons Daphne Barnett Sharon Thompson Sharon Cooper Jane Ross Esther Gaskill Designation Associate Director of Clinical Services Arden GEM CSU Customer Account Director Arden GEM CSU Head of Quality and Patient Safety Arden GEM CSU Clinical Services Change Manager Arden GEM CSU Head of Continuing Healthcare (Central & South) Arden GEM CSU Head of Continuing Health Care Leicester Arden GEM CSU Head of Continuing Healthcare (North) Arden GEM CSU Continuing Healthcare Business Manager (North) Arden GEM CSU Clinical Quality Contract Lead Arden GEM CSU
Sharon Fitton Annie Thorpe Clinical Quality Contract Lead Arden GEM CSU Corporate Governance and Legal Services Support Officer Arden GEM CSU Persons involved in the Lincolnshire specific versions: Name Daphne Barnett Carolyn Dean Sue Pearce Tracy Pilcher Lynne Moody Sharon Robson Wendy Martin Alison Hauton Mathew Fisher Lynne Bucknell Helen Glover Designation Head of CHC Arden GEM CSU Business Manager Arden GEM CSU Clinical Manager Arden GEM CSU Chief Nurse (East) LECCG Ex Chief Nurse (South) SLCCG Ex Chief Nurse (Southwest) SWLCCG Chief Nurse (West) LWCCG LCC CHC coordinator Lead Professional for LCC Adult Care County Manager LCC Adult Care Principal Lawyer LCC
Contents Version control and summary of changes... 4 Equality Statement? impact statement... 5 Glossary of Terms... 5 1.0 Introduction... 7 2.0 Purpose and Remit of the Inter-agency Disputes Policy... 7 2.2 What disputes are covered by this Inter-agency Disputes Policy?... 7 2.3 What disputes are not covered by the Inter-agency Disputes Policy?... 8 2.4 What is the organisational scope of this Inter-agency Disputes Policy?... 8 3.0 Principles Underpinning Disputes Resolution... 8 3.1 Underlying Principles... Error! Bookmark not defined. 4.0 Process in Inter-agency Disputes Resolution... 9 5.0 Monitoring and Review... 14 6.0 Due regard... 14 Version control and summary of changes Version number Version 0.1 Date Comments (description change and amendments) Version 1 has been developed to give a uniform process in dealing with inter-agency disputes Version 0.1-0.7 June 14 Comments and additions/amendments Version 0.8 07.11.14 Updated for CHC meeting Wednesday 12.11.14 Version 0.1-0.4L April/May 2015 Lincolnshire specific drafts Version 0.5 August 2015 Version 0.6 July 2016 LCC re- draft following joint discussion and amendments LCC re-draft following advice from LCC Legal Services All CCG policies can be provided in audio, large print, Braille or other formats and languages, if requested, and an interpreting service is available to individuals who require it. For further information contact: Name: Karen Duncombe, Equality and Inclusion Manager OPTUM CSU Direct dial: 01476 406347 Mobile: 07342 034026
Did you print this document? Please be advised that the organisation discourages the retention of hard copies of policies and can only guarantee that the policy on the organisation s intranet is the most up-to-date version. Equality Statement Clinical Commissioning Groups (CCG) within Lincolnshire have collaboratively worked with Lincolnshire County Council and aims to design and implement this policy document that meet the diverse needs of our services, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account current UK legislative requirements, including the Equality Act 2010 and the Human Rights Act 1998, and promotes equal opportunities for all. This document has been designed to ensure that noone receives less favourable treatment due to their personal circumstances i.e. the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. Appropriate consideration has also been given to gender identity, socio-economic status, immigration status and the principles of the Human Rights Act. In carrying out its functions, CCGs are committed to having due regard to the Public Sector Equality Duty. This applies to all the activities for which CCGs are responsible, whether internal or on behalf of partners, including policy development, review and implementation. Glossary of Terms Policy Principles and/or rules which have been formulated and approved by the relevant CCG Board or by a committee with delegated authority from the Board. It is a set of statements, prescriptive by nature, documenting the standards, intentions and/or expectations of how a practice or course of action will be implemented and adopted. A policy is considered binding, and a breach of policy will result in an investigation into the reasons for the breach. Where appropriate, information must be provided for patients and other stakeholders. Framework Eligibility decision Dispute A set of principles, ideas etc. that you use when you are forming your decisions and judgments Considered to be eligible or non-eligible for NHS Continuing Healthcare funding. Disagreement between partners regarding the eligibility decision Due Regard Having due regard to the Public Sector Equality Duty involves a proactive approach to: eliminating discrimination advancing equality of opportunity fostering good relations between persons who share a protected characteristic and those who do not This also includes taking steps to meet the needs of people from
protected groups where these are different from the needs of other people and encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. Independent Arbitration Panel Consists of health and social care practitioners with no link to the areas or agencies involved in the dispute. Aim of the Panel is to provide CCGs and local authorities with an impartial and transparent process for resolving funding disputes. CHC LCC CHC Coordinator Panel logs MDT Panel MDT General /area Manager NHS continuing healthcare, often abbreviated to NHS CHC or CHC. Means a package of care that is provided and funded solely by the NHS. Lincolnshire County Council Continuing Healthcare Coordinator. A member of the Adult Care Lead Professional Team with responsibility for providing advice and support on the council's role in the NHS continuing healthcare assessment process. A written record of the NHS continuing healthcare Panel's process and eligibility decision for an individual case Multidisciplinary team Panel. A panel consisting of a chair person, a registered general nurse and a registered mental health nurse from the Lincolnshire CCG NHS continuing healthcare service provider and a representative from Lincolnshire County Council adult care. Multidisciplinary team. A team consisting of at least two practitioners from different disciplines. For the purpose of addressing interagency disputes regarding eligibility for NHS continuing healthcare this will include, as a minimum, a registered health professional and an adult care worker. Manager in Lincolnshire County Council who is responsible for several teams of adult care workers in a designated geographical area. CHC service provider This is the agency commissioned by the CCGs to manage NHS continuing healthcare on their behalf
1.0 Introduction Under the provisions of the National Framework for NHS Continuing Healthcare and NHS- Funded Nursing Care November 2012 (Revised), hereafter referred to as the National Framework, the Clinical Commissioning Groups (CCGs) are expected to establish local arrangements for the resolution of inter-agency disputes related to NHS Continuing Healthcare (CHC). 2.0 Purpose and Remit of the Inter-agency Disputes Policy The purpose of this Inter-agency Disputes Policy is to ensure that inter-agency disputes between Lincolnshire Clinical Commissioning Groups (CCG s) and Lincolnshire County Council (LCC) regarding CHC are resolved as quickly as possible for the benefit of the individual concerned. The guidance takes account of and where appropriate, makes reference to relevant sections of the following documents:- National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care November 2012 (Revised), hereafter referred to as the National Framework. National Framework part 2 Practice Guidance, hereafter referred to as PG. The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing rules) Regulations 2012. Hereafter referred to as the Standing Rules. NHS England Operating Model for NHS Continuing Healthcare March 2015 The Care Act 2014 The Care and support statutory guidance Feb 2014 Neither the NHS nor a Local Authority (LA) should unilaterally withdraw from an existing funding arrangement without a joint reassessment of the individual, and without first consulting one another and the individual about the proposed change of arrangement. It is essential that alternative funding arrangements are agreed and put into effect before any withdrawal of existing funding, to ensure continuity of care. Any proposed change should be put in writing to the individual by the organisation that is proposing to make such a change. If agreement between the LA and NHS cannot be reached on the proposed change, this Inter-agency Disputes Policy should be invoked, and current funding and care management responsibilities should remain in place until the inter-agency dispute has been resolved. 2.2 What disputes are covered by this Inter-agency Disputes Policy? This Inter-agency Disputes Policy will assist in the resolution of disputes between Lincolnshire CCG s and LCC, which arise from: The determination of eligibility of the individual for CHC Issues of interpretation of the National Framework between Lincolnshire CCG s and LCC.
2.3 What disputes are not covered by the Inter-agency Disputes Policy? This Inter-agency Disputes Policy does not cover disputes relating to: Responsible Commissioner Disputes between CCG s. Challenges and Individual Decision Disputes submitted by individuals and/or legal representative Complaints by individuals, their representatives or carers, which should be dealt with by each organisation s complaints procedure The content of a fully or jointly funded care package. 2.4 What is the organisational scope of this Inter-agency Disputes Policy? This Inter-agency Disputes Policy is administered by the Lincolnshire CCGs NHS continuing healthcare service provider (CHC service provider). 3.0 Principles Underpinning Disputes Resolution Lincolnshire CCGs, their CHC service provider and LCC will work within a culture of partnership that supports shared problem solving This Inter-agency Disputes Policy does not apply where an individual and /or their representative is raising a dispute. During the process of the inter-agency dispute, current funding and care management responsibilities should remain in place until the inter-agency dispute has been resolved. The Inter-agency Disputes Policy supports shared learning from experience for the benefit of local communities The disputes policy supports shared learning between agencies The individual or their representative will be informed by a nominated person in LCC Adult Care of the outcome at each stage of the dispute and, where appropriate, of the timescales for the next steps...
4.0 Process in Inter-agency Disputes Resolution Stage 1 Eligibility decision by CCG LCC advised to detail evidence in writing to support their disagreement, within 5 working days of eligibility decision, to local CHC service provider Team. 5 Working Days Local CHC service provider Team to inform relevant CCG, by means of the established eligibility / governance process that this case is in dispute. 5 Working Days IMMEDIATE ACTION As soon as who? we are informed, by any route, that the Local Authority is in dispute of the eligibility decision, an interim arrangement has to be agreed to ensure care services & funding are in place. Stage 2 Resolved CCG informed by CHC service provider Clinical Operational Manager Case escalated tolchc service provider Clinical Operational Manager or deputy who will discuss the case with LCC CHC Coordinator 5 Working Days Stage 3 Resolved CCG informed by CHC service provider Head of Service CHC service provider Head of Service or deputy will discuss the case with the appropriate LCC General Manager and take appropriate legal advice where applicable 5 Working Days Not Resolved CCG immediately informed by CHC service provider Clinical Operational Manager Stage 4 The CCG and LCC will jointly identify an acceptable Independent Arbitration Panel to consider the case. Both parties will commit to accepting the decision of the Independent Arbitration Panel Not Resolved CCG immediately informed by CHC service provider Head of Service to confirm next steps.
Process A formal dispute can only be raised once the CCG have made a decision on eligibility for CHC. It is expected that the majority of disputes will be resolved at stages one and two and only in exceptional circumstances will it be necessary to proceed to Stage Three or an Independent Arbitration Panel. Stage 1 Once the CCG has made an eligibility decision and communicated the outcome to LCC the adult care practitioner can raise a formal dispute if they disagree with the outcome. The practitioner will inform the manager of the CHC service provider of their intention to raise a dispute within 5 working days of the date on the formal notification letter. Within 28 working days the practitioner will submit a written rationale for the dispute addressing the four key indicators of Nature, Intensity, Complexity and Unpredictability. The practitioner should consider whether there is any additional evidence available that will support their case. Where additional evidence is available a copy should be submitted with dispute letter. The practitioner will also submit a current social care assessment if one wasn't previously provided as supporting evidence. CHC service provider action The CHC service provider manager will consider the dispute, and determine the appropriate action to take. This will include one or more of the following:- Manager to Manager Meeting (CHC service provider manager and LCC CHC coordinator) or their deputies to review the case. Have a further evidence collection process Convene a further MDT to review the individual's presenting needs. Submission to an MDT panel with different membership to any previous consideration of eligibility. Once the agreed actions have been undertaken the CCG will communicate their decision in writing to LCC. If the practitioner disagrees with the outcome they have five working days from the date on the formal notification letter in which to inform the CHC service provider Manager of their intention to progress to Stage 2. The practitioner will immediately inform the LCC CHC Coordinator that they wish to progress to Stage 2 of the disputes process and discuss their reasons. Stage 2 The practitioner will telephone the CHC service provider team and request copies of the following documents:- Decision Support Tool All supporting evidence, including the adult care assessment Panel Log The CHC service provider team will provide the documents within 2 working days to LCC. 10
The practitioner will provide the LCC CHC Coordinator (or their deputy) with the above documents within 2 working days. The LCC CHC Coordinator (or their deputy) will review the documents within 5 working days and decide whether it is appropriate to continue with the dispute. The LCC CHC Coordinator (or their deputy) will inform the practitioner of their decision. If the decision is not to proceed with the dispute the LCC CHC Coordinator (or their deputy) will inform the CHC service provider manager in writing and the dispute will be recorded as resolved. Where the LCC decision is to proceed with the dispute the LCC CHC Coordinator (or their deputy) and the CHC service provider Operational Manager (or their deputy) will agree a date to meet and discuss the case within a further 5 working days. LCC CHC Coordinator (or their deputy) will inform the practitioner by email of the outcome. The CHC service provider team will send out a formal notification letter to LCC within 5 working days of the CCG's decision advising them of the outcome. Where there is no resolution the case will progress to Stage 3 of the disputes process. Stage 3 Within 2 working day of non-resolution at Stage 2 the LCC CHC Coordinator (or their deputy) will inform the appropriate LCC General Manager that the dispute has now progressed to Stage 3. The LCC CHC Coordinator (or their deputy) and General Manager will meet to discuss the case within a further 5 working days. The LCC General Manager will prepare any additional notes they wish to use. During these 5 days the LCC General Manager will be contacted by the CHC service provider Head of Service (or their deputy) to arrange a meeting inviting LCC & responsible CCG to discuss the case. The LCC General Manager can choose to seek advice from LCC Legal Services. The CCG can choose to seek legal advice. The LCC General Manager will inform the LCC CHC Coordinator and practitioner by email of the outcome. The CHC service provider team will send out a formal notification letter to LCC within 5 working days confirming the outcome. Where there is no resolution the case will progress to Stage 4 of the disputes process. Stage 4 Cases progressing to Stage 4 will be referred to an independent arbitration panel. The CHC service provider will be responsible for sourcing the services of an independent arbitration panel. Panel membership will be agreed with LCC Adult Care. This panel will be funded equally between the responsible CCG and LCC Adult Care. The CCG, their CHC service provider and LCC Adult Care will provide the arbitration panel with copies of all the relevant documents. This will include the following:- DST All the evidence collated to support the DST Any additional evidence collated during the dispute process 11
Written communication between the CCG, their CHC service provider and LCC regarding the dispute. Ratification and Panel logs Rationales from both the CHC service provider team and LCC Adult Care to support their perspective of the individual's eligibility. The CCG, their CHC service provider and LCC Adult Care will accept the outcome of the independent arbitration panel. Where the resolution at any stage of the process results in a change in funding stream the CHC service provider team will send a formal notification letter to the individual and/or their representative within 5 working days advising them of the change and, where appropriate, the reimbursement process. Interim Care Provision In cases where there is a dispute about an individual's eligibility for NHS continuing healthcare paragraph 143 of the National Framework says 'If agreement between the LA and NHS cannot be reached on the proposed eligibility change, the local disputes procedure should be invoked, and current funding and care management responsibilities should remain in place, until the dispute is resolved'. Annex F of the National Framework provides further details on responsibilities when a decision on NHS continuing healthcare is awaited or is disputed. Paragraphs 2-7 say that no individual should be left without appropriate health or community care services while waiting a decision on their eligibility for NHS continuing healthcare. Therefore, if in the NHS continuing healthcare assessment process it is identified that an individual has an urgent need for services they should not be left without care simply because there is an organisational dispute regarding the decision on their eligibility for NHS continuing healthcare. Where the individual is already in receipt of a care package consideration must be given as to whether additional services need to be provided while waiting resolution of the dispute. In cases, where at the time the dispute is raised, the individual has not been receiving a package of care interim services should be provided to meet assessed needs. Where interim services are required to meet newly assessed needs the CHC service provider Operational Lead (or their deputy) and Principal Practitioner for the appropriate area will jointly consider the needs of the individual that have been identified and agree responsibility for the provision and funding of the services. Both parties must consider whether any of the needs identified are above the lawful limits of what LCC as a local authority can be expected to provide. Following this consideration LCC will provide the interim community care services and the CHC service provider team, on behalf of the CCG, will provide any interim healthcare that is required to ensure that the individual receives appropriate support. The funding of any care services during the dispute process will be on a 'funding without prejudice' basis i.e. providing and funding interim care services does not commit either organisation to the ongoing provision and funding of care following resolution of the dispute. Individual's financial contribution for interim community care provision If at the time LCC raise a dispute the individual is in receipt of community care services both LCC and the individual will continue to pay their agreed contributions. Where it is identified that the individual requires additional community care services to meet their assessed needs LCC will pay the full cost of the additional services. The individual will not be required to pay towards the cost of the additional care provision. 12
The individual will not pay towards the cost of any interim community care services if they were not in receipt of any such services prior to LCC raising the dispute. LCC will not backdate any charges to the individual for new / additional community care services where the outcome of the resolution is that the individual is not eligible for NHS CHC. Hospital Discharge It is essential that an organisational dispute regarding an individual's eligibility for NHS continuing healthcare does not cause a delay in their timely discharge from hospital. Where the individual was not receiving any care services prior to their admission to hospital the NHS (this is outside of CHC agreement and will be agreed with the responsible CCG) will provide and fund the care package required to meet their assessed needs while awaiting resolution of the dispute. This may be in the individual's own home or in a care home. Where the individual was receiving a care package, either in their own home or in a care home, prior to their admission to hospital the care package and funding will continue on discharge. A review will then be arranged. Consideration will be given as to whether additional services are required to meet any newly identified / increased needs and the process given above followed. (when fully formatted paragraphs will be numbered can refer to appropriate paragraph numbers). In cases where the individual was in a care home placement for personal care (residential placement) and the outcome of the DST being disputed is that they are eligible for NHS-funded Nursing Care (FNC) and therefore require a placement in a care home with nursing (nursing placement) arrangements will be made for them to be discharged to an appropriately registered nursing home. LCC will increase funding from residential to nursing care and make any adjustments to the individual's financial contribution. The CHC service provider, on behalf of the CCG will pay the FNC contribution. Reimbursement Process Annex F of the National Framework provides some guidance on the process for CCGs on reimbursing costs to LAs and individuals. Based on this when the resolution of a dispute results in the CCG needing to reimburse costs to the individual and LCC the gross cost of the care package, which includes the individual's financial contribution, will be paid to LCC as the refund of contributions is a matter between LCC and the individual ( Annex F section 12 ). The CCG will reimburse LCC within 28 days of the date resolution was reached. LCC will refund any financial contributions made to it by the individual within 28 days of the dispute resolution. In cases where the individual has been self-funding the total cost of their care package the CCG will reimburse the costs, including any assessed interest, directly to the individual within 28 days of the dispute resolution. Individuals should not be disadvantaged in relation to their health and wellbeing or financial situation by the dispute resolution. Where the CCG are required to reimburse costs to LCC and the individual funding will be backdated to the date the original decision was made. 13
In cases where a Nurse Assessor completed the DST the funding will be backdated to the date of the multidisciplinary team meeting. For cases where the DST was completed by a health professional other than a Nurse Assessor (e.g. District Nurse, Community Psychiatric Nurse, hospital nurse) funding will be backdated to the date the case was presented to the CHC service provider for ratification. In cases where the CHC service provider on behalf of the CCG has continued to provide and fund the care package in the interim period and the outcome of the dispute resolution is that the individual is not eligible for NHS continuing healthcare LCC will become responsible for funding four weeks from the date on the final outcome letter sent out by the CHC service provider to LCC and the individual or their representative. The disparity in the timescales takes into account the following:- The individual will require formal notification of the resolution outcome including a period of notice from the CHC service provider on behalf of the CCG that NHS continuing healthcare funding is going to be withdrawn. LCC cannot make a retrospective charge on the individual's personal contribution. LCC will need to undertake a financial assessment to determine what the individual's financial contribution will be or whether they will be self-funding the total cost. ( the disparity also takes into account everyday practice that NHS CHC funding commences from the day the decision on eligibility is made and in cases where fully funded NHS CHC is being paid GEMCSU give 4 weeks / a months notice to LCC and individuals of their intention to withdraw funding) 5.0 Monitoring and Review The CCG, their CHC service provider and Lincolnshire County Council should jointly consider lessons learned and implement strategies to reduce future disputes Following completion of the first three stages of the Inter-agency Disputes Resolution process with no resolution, a report will be written by the Head of Service to the Chief Nursing Officer for a strategic decision to be made and copied to the A/GEMCSU Clinical Services Quality and Safety Committee for learning and monitoring of themes. 6.0 Due regard This policy has been reviewed in relation to having due regard to the Public Sector Equality Duty (PSED) of the Equality Act 2010 to: eliminate discrimination, harassment, victimisation; advance equality of opportunity; and foster good relations. This can be evidenced in Sections 2.1 and 3.1 of this policy. 14