When looking at a discharge from hospital, we wanted to share with you the frank thoughts of a specialist nurse advocate (“Nurse”) who approached us with her comments on the latest abuses of the Fast Track Pathway Tool.
Nurse: “NHS Continuing Healthcare is one of the most complex and complicated processes. This is not only the case for individuals but also the professionals who are expected to work at delivering NHS Continuing Healthcare.
NHS Continuing Healthcare is primarily designed to meet the needs of those individuals with complex, intense, and unpredictable health needs (any combination of these will qualify an individual) and the nature of the condition is such that without such care they would be unable to manage independently. This funding was brought about mainly following the closure of long stay hospital facilities and institutions for those who require ongoing care in the community.”
In 2003 NHS Continuing Healthcare was fragmented across the country with each having their own policies to determine eligibility.
In 2007 the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (the National Framework) was introduced. This laid out clearer guidelines and provided a Decision Support Tool (DST) to aid professionals in making a decision in respect of eligibility. The National Framework was modified in 2009, 2012 and more recently again in 2018, in an effort to make decisions more robust and consistent across the country.
The National Framework is merely guidance. It is not law, and as such the onus on decision making lies with the NHS.
Nurse: “Many Clinical Commissioning Group’s (CCGs) and professionals are getting away with manipulating the National Framework to suit their own requirements. The NHS aims to ensure that assessors across the country complete consistent and reliable assessments in an effort to provide fairness in decision making. Whilst the theory is good, unfortunately, this is not what is happening in practice.”
Like all frameworks in any walk of life, they are subject to interpretation, and can be adapted to ‘fit’ the needs of the situation, depending on your perspective.
Nurse: “I have worked in NHS Continuing Healthcare for over 14 years during my career (in addition to other areas) and have witnessed so many different interpretations, and what I would consider blatant misuse of a process which was designed to make things easier.”
One of the most controversial areas in the National Framework is ‘The Fast Track’ process.
The Fast Track
The Fast Track Pathway Tool is designed to identify those individuals who have reached the end of a course of treatment and assessed as requiring a package of care to meet their ongoing healthcare needs. However, these individuals are a minority who are sadly nearing end of life, and are “rapidly deteriorating”. The aim is to ensure that they are transferred to a place of care – whether this is their own home or a registered care facility – at a time when they are most vulnerable and without having to worry about the funding at that particular moment.
“217. Individuals with a rapidly deteriorating condition that may be entering a terminal phase, may require ‘fast tracking’ for immediate provision of NHS Continuing Healthcare.
218. The intention of the Fast Track Pathway is that it should identify individuals who need to access NHS Continuing Healthcare quickly, with minimum delay, and with no requirement to complete a Decision Support Tool (DST). Therefore, the completed Fast Track Pathway Tool, with clear reasons why the individual fulfils the criteria and which clearly evidences that an individual is both rapidly deteriorating and may be entering terminal phase, is in itself sufficient to establish eligibility.”
The National Framework states that, individuals should be reassessed every 3 months after the initial ‘Fast Track’ funding is awarded in order to ensure that an appropriate package of care is in place and that it continues to meet their needs. However, only if there have been significant changes since the initial Fast Track assessment should they be put back through the assessment process.
The difficulty with ‘Fast Track Pathway’ is that the individual has not been put through the full assessment process as such. They have merely been fast-tracked for a package of ongoing care.
Imagine this scenario:
- An individual is admitted into hospital following a stroke.
- They are in hospital for 3 months.
- During this 3 months’ stay they have undergone all the various therapy assessments including Physiotherapy, Speech and Language Therapy (SALT), Dietetics, and have reached a new baseline.
- During their stay they have had 3 episodes of aspiration pneumonia and have almost lost their life but have recovered with intravenous infusions of antibiotics.
- The medical team have no further intervention they can offer and decide the individual needs to be discharged from hospital to make way for another patient.
- The individual’s family are advised that they quickly need to look for a suitable care home for their relative – which can be quite a lengthy process and emotionally upsetting.
Once they have found a care facility then comes the matter of who is going to fund this care.
If your relative has ‘primary healthcare needs’, i.e. basically care needs beyond which the Local Authority are obliged to provide, they may be eligible for NHS Continuing Healthcare. This is a package of FREE care which is fully-funded by the NHS (including accommodation) regardless of wealth, and is not means-tested.
The National Framework requires that an individual should not be assessed for NHS Continuing Healthcare in hospital, as this stressful setting is not an ideal environment and can give a misleading picture of their actual daily care needs. Instead, following discharge from hospital, individuals should ordinarily now be assessed in their place of care.
Abusing the Fast Track Pathway
In order to move individuals out of hospital far quicker, and to avoid ‘bed-blocking’, and also the time and delay of a full assessment for NHS Continuing Healthcare, Fast Track assessments are being carried out instead.
Why is this a problem?
In many cases, a Fast Track Pathway assessment is just not appropriate and is an abuse of the National Framework. It might be a short-term fix for the NHS, but it can often have adverse long-term ramifications for families. The Fast Track Pathway should only apply to certain specific criteria, and not be misused as a tactical tool to free up hospital beds. Read on…
The National Framework clearly states that:
“224. The Fast Track Pathway Tool must only be used when the individual has a rapidly deteriorating condition and may be entering a terminal phase.”
219. In Fast Track cases, Standing Rules state that it is the ‘appropriate clinician’ who determines that the individual has a primary health need. The CCG must therefore decide that the individual is eligible for NHS Continuing Healthcare and should respond promptly and positively to ensure that the appropriate funding and care arrangements are in place without delay.
236. In order to comply with Standing Rules a CCG must accept and immediately action a Fast Track Pathway Tool where the Tool has been properly completed.
238. Action should be taken urgently to agree and commission the care package. CCGs should have processes in place to enable such care packages to be commissioned quickly. Given the nature of the needs, this time period should not usually exceed 48 hours from receipt of the completed Fast Track Pathway Tool. CCGs should ensure that they have commissioned sufficient capacity in the care system to ensure that delays in the delivery of care packages are minimal. It is not appropriate for individuals to experience delay in the delivery of their care package while concerns over the use of the Fast Track Pathway Tool are resolved.”
So, an ‘appropriate clinician’ (most often a GP or registered nurse) can decide that an individual is nearing end of life.
They then complete the Fast Track Pathway Tool for the NHS and send to the CCG for approval.
They will state that, in their opinion, they do not expect the individual to live longer than 3 months and is deteriorating health. (This is because the next review is not for 3 months and not that it is a specific requirement for Fast Track). In theory, they are not saying anything wrong, as this statement could apply to anyone, regardless of age, health or any circumstance.
The CCG has got to accept that Fast Track recommendation for funding unless there is sufficient evidence to contest it.
The hospital will then advise the individual’s family to find a care home and not to worry as the CCG will be paying for their assessed care package and accommodation (i.e. NHS Continuing Healthcare Funding).
This then frees up a hospital bed as the individual is more likely to discharge from hospital quicker once funding is awarded.
Families then make enquiries to consider the most suitable care home for their relative as they do not necessarily have to worry about budget. Understandably, they will want to choose the best care home for their relative.
VITAL: But what isn’t made clear to them, is that 3 months down the line, their relative is going to be reassessed and may not meet the criteria for ongoing NHS Continuing Healthcare Funding at that stage. This scenario creates untold anxiety, stress and panic for families!
The National Framework clearly states:
“228. When completing the Fast Track Pathway Tool clinicians should sensitively explain to the individual that their needs may be subject to a review, and accordingly that the funding stream may change subject to the outcome of the review.”
Nurse: “From what I have witnessed this is not happening, and at this point families and individuals are finding that they will then have to find the money for their relative’s care!”
Bluntly speaking, if your relative has outlived the 3 months initial Fast Track funding, it could be arbitrarily withdrawn!
During this initial 3 months period whilst Fast Track funding is awarded, families will be transferring their relative’s belongings to the new care facility and may even dispose of the remaining personal items and assets – including selling their relative’s home.
If funding is removed on reassessment, the individual may not be able to stay in the care home and could potentially become homeless. This scenario will inevitably cause great distress as families seek to find alternative accommodation for their relative at short notice. Funding this care may involve selling assets (a home), using lifetime savings, or paying excessive fees (including ‘top up’ fees) which they can ill afford. It could also be very distressing for their relative if they are moved to yet another new care setting. Had families been aware from the outset that Fast Track funding could be withdrawn, they could have looked at alternatives – which might have included a home care package or simple adaptations at home etc.
The Fast Track process works well in theory, when used appropriately, for example, for someone who is clearly terminally ill and rapidly deteriorating and does not want to die in a clinical surrounding, on a ward full of strange people. However, in reality, it can actually be a cruel and uncaring process which causes unnecessary stress on families, and more so on the individual, who is often frail, elderly and without the mental capacity to understand what is happening.
Nurse: “More recently as the NHS, Government and Social Services are being instructed to pull in the purse strings and make savings where they can, I have found that across the country I am reviewing cases where those who have been Fast tracked are being reviewed and taken off NHS Continuing Healthcare funding. It appears that they are an easy target. They considered to be stable, and in many cases, suggested that they have ‘outlived’ the Fast Track.”
Similarly, if a professional ‘appointed clinician’ is considering that an individual is rapidly deteriorating and meets the ‘Fast Track criteria’ – what they are effectively saying to families is that “your loved one is dying and won’t be here in a few months, so go and put them into care.” However, it is now becoming increasingly common to find out, a few months down the line, that Fast Track funding was inappropriate, leaving families to pick up the pieces.
Nurse: “9 times out of 10, those individuals who made the original application for NHS Fast Track funding and decided an individual meets the criteria for NHS Continuing Healthcare are not a part of the review process. They step out of the process the day they sign that Fast Track Pathway Tool, all in order to free a hospital bed, and leaving the families to cope when funding is withdrawn upon reassessment.”
If your relative has had their Fast Track funding withdrawn following reassessment at 3 months, leave a comment below and share your experiences. Tell others how it affected them (and you!) and what you did to reinstate funding…
For further information, read our blogs: