Continuing NHS Healthcare The National Framework for Implementation in Wales Welsh Assembly Government in partnership with the NHS and Local Authorities in Wales 2010

Aim of the day All staff to develop an understanding of their responsibilities with regards to the assessment of needs within the continuum of care.

Objectives To enable staff to identify their level of knowledge and their future development needs. To develop knowledge of the continuum of care. To gain knowledge of the legal and political frameworks in which organisations operate and their historical impact. To understand the assessment and decision making process for Continuing NHS Healthcare To understand the role of the Care Coordinator and Multidisciplinary Team To understand how to apply the Decision Support Tool

The Knowledge Barometer

Key Messages The issue is one of need CHC is one part of a continuum of services The sole criterion is whether there is a primary health need Prevention, reablement and rehabilitation Support existing joint strategies not replace them Joint working The NHS is the primary decision maker Decision making based on the outcome of the MDT assessment process Decision Support Tool Carers and relatives must be involved and informed

What is Continuing Care? Continuing NHS Healthcare is a package of care arranged and funded solely by the NHS, where ir has been assesses that the individuals primary need is a health need. CHC is just one part of continuum of services that Local Authorities and NHS bodies need to have in place to support people with health and social care needs. CHC is one aspect of care which people may need as the result of disability accident or illness to address both physical and mental health needs.

NO HEALTH OR SOCIAL CARE NEEDS HEALTH AND SOCIAL CARE NEEDS CONTINUING NHS HEALTH CARE SOCIAL CARE NEEDS Setting the Scene Continuum of Care

Setting the Scene CHC patients v. total population PopulationCHC & FNC Patients Isle of Anglesey68, Gwynedd118, Conwy111, Denbighshire96, Flintshire149, Wrexham132,719468

Background- Responsibilities of the NHS Assessing, arranging and funding a wide range of services to meet the health care needs, both long and short term of the population e.g. acute care in hospital but also some people need care over an extended period of time as a result of disability, accident or illness. These services are normally provided free of charge

Background – Responsibilities of the Local Authorities LA’s provide accommodation, education, personal and social care, leisure and other services. LA’s charge for residential care and may charge for other services.

Legal Framework National Assistance Act 1948 Chronically Sick and Disabled Persons Act 1970 NHS and Community Care Act 1990 Health and Social Care Act 2001 National Health Service (Wales) Act 2006 All care should be delivered in accordance with each agency’s legislative duties

Legal framework –the duties of the NHS Primary legislation governing the NHS does not use the terms “Continuing Healthcare” or primary health need. Section 1 and 3 (1)of the NHS (Wales) Act 2006 What is appropriate to be provided as part of the health service therefore has to be considered in the light of the overall purpose of the health service - to improve physical or mental health and prevent, diagnose or treat illness.

Legal framework – the duties of the Local Authorities LA’s have a duty to assess any person who appears to be in need of community care services. (NHS and Community Care Act 1990, section 47) Community care services can include residential accommodation as well as domiciliary and community based services. National Assistance Act 1948 Chronically Sick and Disabled Persons Act 1970 Section 49 of the Health and Social Care Act 2001

Background and Case Law WHC (95) 7 NHS Responsibilities for meeting Continuing Health Care needs Coughlan Judgement (1999) WHC (2004) 54 NHS Responsibilities for meeting Continuing Health Care needs Grogan Judgement (2006) WHC (2006) 046 Further advice to the NHS and Local Authorities on Continuing NHS Health Care St Helen’s Borough Council v Manchester PCT (2008)

The Coughlan and Grogan Judgments. Coughlan -Home for life, closure of NHS facility -Limits on powers of local authorities to provide nursing services – the “incidental or ancillary” test -Primary Health Need Grogan - Reinforced Coughlan Judgement -Primary Health Need -Reinforced what services the LA are lawfully able to provide -Assessment process

St Helen’s Borough Council v Manchester PCT (2008) Dispute between a PCT and a Local Authority as to the funding of a care package The MDT concluded that the care needs were not primarily health needs but joint funding. The PCT assessment panel confirmed that except for physiotherapy and other specific health care matters, the PCT should not fund the care. LA appealed to the Courts. The Court of Appeal dismissed the appeal on the grounds that the NHS (in this case the PCT) is the primary decision maker when it comes to deciding whether a person has primary health care needs. The National Health Service Act 2006 is the dominant Act and the decision under it is the determinative decision.

Equality, Human Rights The Equality Act 2010 brings together discrimination law introduced over the past four decades through legislation and regulations. Protected characteristics e.g age, disability, pregnancy, race religion etc Expected to come into force in October Code of Practice due to be published Public authorities have a duty under the Human Rights Act 1998 LHB’s and LA’s have statutory duties to promote equality of access to care and support, equality of outcomes of care, equality of opportunity

Consent and Capacity The assessment of an individual’s health and/or social care needs cannot take place without informed consent. If they lack capacity, the MDT should identify a Lasting Power of Attorney Deputy appointed by the Court of protection Best Interest decision

Refusing Consent If an individual who has capacity refuses an assessment, the LHB cannot be responsible for solely funding the patient’s care package. The individual should be provided with written information regarding this decision should they wish to reconsider in the future. It must be documented in the individual’s health and social care notes that an assessment has been offered and declined and the GP informed.

Advocacy and Carers Consider the need for an advocate Consider the need for IMCA Carers Assessments

Match up the definitions?

The Primary Health Need The policy and approach of the Welsh Ministers on eligibility for continuing NHS health care is based on whether a person’s primary need is a health need (this is known as the “primary health need approach”). The sole criterion for determining eligibility for CHC is whether a person’s primary need is a health need. This replaces the previous separate criteria

Primary Health Need The definition of a primary health need is based on the following characteristics Nature Intensity Complexity Unpredictability The above characteristics should be considered along with professional judgment when completing the Decision Support Tool.

Primary Health Need Where, following a comprehensive assessment of all needs, a person’s primary need is judged to be a health need, responsibility for providing them with all care services they are assessed as requiring, including, where appropriate, care home accommodation, will rest with the NHS in accordance with sections 1 and 3 of the NHS (Wales) Act 2006.

LA Responsibilities Where a person is eligible for CHC, LA’s still have a role in assessment and review, social work services, support for carers and the meeting of housing and educational needs.

Primary Health Need approach - people cared for at home Where the primary need is a health need, the NHS will fund all the care that is required to meet their health and social care needs to the extent that this is considered appropriate as part of the health service. The NHS would not be responsible for the cost of social work services, accommodation, food, general household support or support for carers

People who are not eligible for CHC – LA responsibilities Where it has been determined that a person is not eligible for CHC, any care plan put in place must not require a local authority to provide services which are beyond its powers to provide

People who are not eligible for CHC – NHS responsibilities Where a person is not eligible for CHC but has health needs which are different from, or additional to, those supported by NHS Funded Nursing Care, the NHS may still have a responsibility to meet those needs as part of a “joint package” in so far as these health needs are beyond the powers of the local authority to provide

NHS and LA responsibilities There should be no gap in the provision of care People should not find themselves in a situation where neither the NHS nor the relevant local authority will fund care, either separately or together

Assessment and Decision Making The Framework focuses primarily on the determination of a primary health need and eligibility for CHC and its consequences and builds on, rather than replaces “Creating a Unified and Fair System for Assessing and Managing Care.”

Assessment and Decision Making Process ContactOverviewSpecialistComprehensive Summary Record LTC ongoing care NHS-FNC Intermediate care Residential care Ongoing hospital care CHC in whatever setting Home and independent Home with SSD package Home and respite Cross border issues Extra care housing Complex Simple From trigger to decision must be completed within 8 weeks

Co-ordinating the Assessment The role of care co-ordinator is pivotal in ensuing continuity and consistency in assessment and care planning. The role is best handled by practitioners with a long term role with the individual Mainly health needs – health worker co- ordinator Mainly social needs – social worker co- ordinator

Group Work In groups, identify the role of the care co-ordinator

Role of the Care Co-ordinator (1) Explain the CHC process to the person/ representative Provide information leaflets and advice on the process Ensure that the primary needs approach is followed, Ensure that the person’s / representative’s wishes are known and documented Obtain informed consent and initiate MCA assessment if necessary Record and document every stage of the process Arrange MDT meeting inviting all appropriate individuals,

Role of the Care Co-ordinator (2) Co-ordinate development of the care plan, Ensure that the MDT meeting is documented and the person / representative is informed of the outcome. Collate MDT assessments, Keep everyone informed of the progress of the application, Work within identified timescales, Identify person responsible for review of the care package

Comprehensive Assessment Eligibility for Continuing NHS Healthcare should be ruled in / out at the following stages of the assessment process. Requirement for a comprehensive assessment Reviews When planning a complex discharge from hospital When requested by the patient / family/ carer or advocate or any other professional During or following a major health episode Significant change in care needs Emergencies e.g. carer breakdown Parliamentary Select Committee 2005

Comprehensive Assessment Eligibility for Continuing NHS health care should not be based on The setting of care The ability of the care provider to manage the care The use or not of NHS staff to provide care The need for / presence of specialist staff in care delivery The existence of other NHS Funded care The diagnosis and /or the services available but should consider the actual needs of the individual

Comprehensive Assessment Assessments must Be multi disciplinary, multi agency Be holistic Be detailed Include patient/ family/ carer or advocate Consider Mental Capacity Act, Deprivation of Liberty Safeguards, Consent, Human Rights Consider eligibility for Continuing NHS Healthcare

The Decision Support Tool This is a Decision Support Tool and not an assessment tool. It covers the domains or sub domains of the UAP. It should not be applied mechanistically. It is not a score sheet, It is an aid to assist identification of a primary health need. This tool should not take the place of professional or clinical judgement 39

Decision Support Tool Section 1 – Personal details Section 2 – Domains Behaviour, Cognition, Mental Health (Psychological /Emotional needs), Communication, Mobility, Nutrition- Food and Drink, Continence, Skin (including tissue viability), Breathing, Drug Therapies and Medication: Symptom control, Altered states of consciousness, Other significant Care Needs Section 3 - Recommendation 40

Completion of the DST – Process (1) The LHB has responsibility for co-ordinating the DST process and must identify a care co-ordinator The Care Coordinator must identify appropriate individuals to comprise the MDT The individual’s consent must be obtained The individual/ representative must be invited to be present when the DST is completed. Decisions and rationales must be transparent from the outset Consider the MCA, inter agency data sharing protocols A copy of the completed DST must be made available to the individual along with an explanation of the process 41

Completion of the DST – Process(2) All sections must be completed Each domain is subdivided into statements of need ranging from – no needs, low, moderate, high, severe or priority. MDT must determine and record the extent and type of need, then decide which level describes the individual’s needs. The wording of each domain must be carefully considered – assumptions should not be made. A condition described as severe does not mean that the individual is placed in the severe level of the relevant domain

Completion of DST – Process (3) Needs may interrelate across more than one domain. It should be recorded in both but care taken on reaching decisions on eligibility. The levels are relative to each other and to other domains. Justify in each domain why a particular level is appropriate, based on the available evidence. Needs should not be ignored because they are well managed. ‘Other significant Care Needs’ domain should be used when needs are not covered by the 11 defined care needs.

DST Recommendation A level of priority needs in any one of the three domains that carry this level (Behaviour, Breathing, Drug therapies and medication control). A total of two or more incidences of identified severe needs across all care domains (Behaviour, Mental health, Mobility, Nutrition – food and drink, Continence, Skin including tissue viability, breathing, Drug therapies and medication, altered states of Consciousness.) If there is: one domain recorded as severe, together with needs in a number of other domains, or a number of domains with high and/or moderate needs, 44

Decision Support Tool The level of needs available vary as some care domains are considered never to reach a level which could trigger eligibility on their own. They would form part of a set of needs which could indicate a primary health need. Don’t place anyone between levels if in doubt choose the higher level. 45

Decision Support Tool The tool cannot describe every individual circumstance therefore any additional evidence of the extent and type of need should be provided on the DST document. It is important to describe the needs in measurable terms using clinical expertise therefore results from appropriate and validated assessment tools should be included if necessary. If all domains indicate low or no needs this would indicate no eligibility. 46

DST Case Study – Group Work You are members of the MDT, using the information available, identify a care coordinator complete the DST for your patient determine eligibility for CHC care coordinator to present the rationale for your decision

Documentation Standards Must Be Consistent Be Legible Be Current Be In accordance with professional standards Justify outcomes Ensure a copy is kept in the patient’s file Provide details of the care required and costs. Provide detailed records of discussions and case conferences.

Role of the MDT Recommend eligibility for CHC and provide written evidence / rationale for decision. Recommend a suitable care package and provide risk assessments and care plans Determine whether the assessed needs can be met from within core services or is additional funding required? See flowchart in framework

Care Planning The MDT must consider Where, how and by whom Right level of care, type of service and right provider. Care package plans must consider Accommodation, medical input- in/out of hours, nursing input- in/out of hours, therapy services, pharmacy services, equipment, diagnostics/investigations, transport, social care, domestic care, respite care.

Joint Packages of Health and Social Care Primary healthcare Assessments involving doctors and registered nurses Rehabilitation and recovery (where this forms part of an overall package of NHS care as distinct from intermediate care) Community health services Specialist support for healthcare needs Additional support for episodic higher needs in joint care packages e.g. additional registered nurse input into behaviour management assessment/care planning Palliative care and end of life care Specialist transport (i.e. ambulances )

Role of the LHB The NHS is the primary decision maker on questions of eligibility for CHC LHB’s may need a further stage beyond the MDT which will finally determine eligibility e.g panels Only in exceptional circumstances should panels not accept the MDT recommendations Panels should not make decisions in the absence of a recommendation from the MDT Finance officers should not be part of the decision making panel.

Reviews It should be made clear to the individual and their family that the NHS does not have an indefinite responsibility to commission care as health needs may change and remove eligibility for CHC. Regular reviews will be built into the process to ensure that the care package still meets the persons needs and that they are still eligible for NHS Continuing Health Care. Where there is an obvious deterioration in circumstances, reviews should also be held within 2 weeks, and acted upon appropriately. 53

Dispute resolution within the Multidisciplinary Team LHB’s and local authorities should have in place locally agreed procedures for dealing with disputes. Disputes should be resolved between appropriate staff who are as close to the dispute as possible. In the event that a dispute cannot be resolved in this way, arrangements should be established for appropriate senior managers from each organisation to jointly address the problem. Use of bodies or persons to act as mediators should be a last resort. The aim will be to resolve any disputes in the minimum time. This is particularly the case where the dispute affects the care of patients. 54

Dispute resolution within the Multidisciplinary Team Decisions about care should not be delayed unnecessarily whilst disputes are being resolved. It is expected that all stages of disputes procedures will normally be completed within two weeks. All stages will be appropriately documented. Disputes should not delay the provision of the care package and the protocol should make clear how funding will be handled during the dispute.

Dispute Challenges from Individuals An individual may apply to the LHB for an independent review of the decision if they are dissatisfied with the procedure followed by the LHB in reaching its decisions around the individuals eligibility for CHC or the application of the primary health need consideration

Independent Review Panel and Complaints. Additional safeguard for patients who consider that the criterion for Continuing NHS healthcare (the primary health need approach) has not been correctly applied or that appropriate procedures have not been followed IRP is NOT designated to review the content of the care plans, only the decision making process LHB will administer the procedure on behalf of all persons residing within the area The procedure will also be used for reviewing NHS Funded Nursing care decisions. NHS should deal promptly with any request 57

Independent Review Panel and Complaints. The NHS should in the first instance Try to resolve the situation informally Ensure appropriate assessments have been undertaken Ensure the decision support tool has been applied Where the patient remains dissatisfied the LHB will consider whether it is appropriate to convene the review panel Patients may also make use of the NHS Complaints Procedure 58

Independent Review Panel The review procedure does not apply when patients or their families wish to challenge The content rather than the application of the criteria The type and location of any offer of Continuing NHS Healthcare The content of any alternative care package which they have been offered Their treatment or any other aspect of the services they are receiving or have received

Governance Local Health Boards are responsible for: Ensuring consistency in the application of the national policy on eligibility for continuing NHS healthcare, Promoting awareness of Continuing NHS Healthcare, Implementing and maintaining good practice, Ensuring quality standards are met and sustained, Providing training and development opportunities for practitioners, Identifying and acting on issues arising in the provision of continuing NHS healthcare, and; Informing commissioning arrangements, both on a strategic and individual basis. Ensuring best practice in assessment and record keeping

Audit Local Health Boards should in place a data base to record: individuals in receipt of continuing NHS healthcare timing of assessments outcome of assessments undertaken the costs of continuing NHS health care packages. performance indicators for Continuing NHS Health Care will be introduced for 2010/11

The Knowledge Barometer