This is the 2nd part of an article from Nurse Andrea (not her real name) giving examples of some NHS antics and flawed assessments.
If you missed Part 1, you can catch up here: Part 1 – Revealing Insights From A Continuing Healthcare Nurse Advocate…
No:7 Underscoring the Care Domains and the 4 Key Indicators when completing the Decision Support Tool (DST)
Andrea: “When completing the Decision Support Tool, it is very clear that, despite all the efforts in amending the National Framework, professionals are interpreting the descriptors in the 12 Care Domains in different ways. It is all too subjective, and it really depends on who has been appointed by the CCG on the day to conduct the assessment.”
Scenario: “An 85 year old gentleman was someone who had always been of large build and his BMI was assessed to be in the obese category. Over a period of 3 months he had lost in excess of 2 stone in weight, but his BMI remained high. The care facility was nutritionally enriching his diet (adding cream, butter etc to meals), were providing snacks in-between meals, and reminding him to chew and swallow his food. Whilst he had the ability to feed himself (provided the food was prepared for him), staff were required to assist as it was taking an increasing amount of time to eat his meals (because he would forget what he was doing). They were spending the vast majority of the day taking food to him and prompting and assisting with his intake. Despite all this, he continued to lose weight.
The nurse argued that his needs met the ‘No needs‘ descriptor in the DST. Her rationale was that he was still eating and drinking and could feed himself if he wanted to, so his needs were being met.
After further discussion she then decided that perhaps a ‘Low’ level of need may be more appropriate, as after all, he did get assistance from the carers.
When I questioned her about the significant and continuing weight loss, she said that was irrelevant as he was still in the obese range of BMI, and that in her opinion he was not nutritionally at risk.
I pointed out to her that this man was not intentionally losing weight. He was not on a diet, and there was nothing documented by health professionals which suggested there was a need to lose weight. In fact, he had been referred to the dietician who had suggested enrichment of his diet!”
Andrea explains that the descriptor of ‘High’ needs, therefore, was appropriate as it states: “Nutritional status at risk and may be associated with unintended, significant weight loss”. This patient was losing a tremendous amount of weight despite all the additional efforts to supplement his diet and maintain his weight.
“When it came to discussing the 4 Key Indicators in conjunction with the food balance charts, not only was CCG’s assessor grossly underscoring the level of need for this Care Domain, but she did not feel that the fact he was being fed approximately every 30 minutes was an intensive level of support!”
Our comment: The above is a typical example of what we often hear from families across the country and comes as no surprise to us. The assessment process is entirely subjective which allows inconsistencies depending on the CCG and the experience (or ‘agenda’) of their appointed assessors on the day. Such subjectivity facilitates the opportunity for some CCGs’ assessors to underscore a patient’s needs and so directly affect the outcome as to whether CHC Funding will be recommended or not.
In a situation like Nurse Andrea’s above, it can be very frustrating to see that the appointed CCG assessors clearly don’t understand the patient’s needs and the correct application of the National Framework, or else appear to deliberately turn a ‘blind eye’ to intense, complex and unpredictable healthcare needs and play them down to affect the outcome as to eligibility for CHC Funding. It smacks of incompetence at its lowest level, or more sceptically, deliberate foul play at its worst – purely to protect the CCG’s financial budget.
No:8 Problems with incomplete care records
NHS Continuing Healthcare assessments are evidence-based.
Unfortunately, the necessary evidence is not always provided within the care records. These omissions could be deliberate or simply due to a lack of time and resources.
Nurse Andrea says, “The most common occurrence of this is the Domain for ‘Behaviour’ and which frequently raises the most arguments when completing the DST.”
“I visited a care facility to carry out an independent assessment on a lady (let’s call her, ‘Mrs X’) who had been assessed by the CCG as having ‘Low’ needs for Behaviour. On examination of the care records, it was documented that during the first three months in the care facility, she had hit, scratched, bit, and pulled the hair of a carer when trying to deliver care three or four times a day. When taken to the dining room she had thrown drinks, food and cutlery at other residents, screamed out throughout the meal, and generally disturbed other residents. She was reviewed by her GP and by Mental Health Services, and had her medication titrated in an effort to manage her behaviour and reduce her symptoms. After some five months there were no incidences documented. However, I noted on one day her records said, “she’d had a really quiet day.”
“I was in an adjoining room reading the records and gaining evidence prior to meeting with this lady. There was a lot of screaming and what sounded like objects being thrown around a room. I asked the nurse who was with me, what was going on. She said, “Oh that will be Mrs X. She’s always like that.” I pointed out that there was no documentation of these incidences and no evidence of further referral for advice or management. She responded that they have got used to Mrs X. Mrs X was already in an EMI (Dementia Behavioural Unit) so there was nowhere else for her to go.”
Andrea says,“I understand that if the staff continued to document her behaviour and every single episode, they would be there constantly writing and would not have the time to deliver her care. However, for the purposes of assessment, unfortunately, this lack of critical evidence and documentation will not help Mrs X’s case to get CHC Funding.”
Our comment: Generally speaking, if an individual’s daily needs are not written down in their care records in ‘black and white’, then it can become an uphill struggle to try and argue the case for eligibility for CHC Funding without written corroborative evidence. The absence of written documented evidence of healthcare needs just makes it easier for the CCG to reject funding.
No:9 Misusing the Fast Track Pathway
“One of the most widely misused tools is the Fast Track Pathway tool. This tool is used to fast track someone and get quick access to a package of care from the place where they are (most frequently hospital) to the place they ‘want to die’.
It is supposed to be used when ‘an appropriate clinician’ has assessed an individual to be at ‘end of life’ and have a rapidly deteriorating condition. Hospitals are under-staffed and there are not enough beds for the acutely unwell. Once an individual has reached a point in their care where there is nothing acute that can be done for them, then they are sent out into the community for ongoing care.
Some clinicians are regularly telling families that their loved one is being ‘fast tracked for NHS Continuing Healthcare’, and to go and find a bed in a care facility, and not to worry as the NHS are picking up the bill. However, what they are not telling people is that, following discharge from hospital they will be reviewed again in 3 months and undergo another full CHC assessment to see if the package of care in place is working. In a large proportion of cases, if the individual no longer has a rapidly deteriorating condition or does not have other healthcare needs that meet the criteria for ongoing NHS Continuing Healthcare Funding, then CHC Funding will be withdrawn – leaving the individual to pick up the ongoing bills for their care home fees.
The majority of those fast tracked are placed in aesthetically pleasing care facilities, chosen by families as a final resting place for their relative. Some care homes are priced out of reach, which means that the family have to find an alternative home in a more affordable price range to relocate their very frail and vulnerable relative. Often this upheaval is very unsettling and causes them (and their family) great stress and anxiety, at the prospect of being uprooted and moved.”
Our comment: Abusing the Fast Track Pathway has become an effective and simple way for the NHS to discharge patients into a care facility and unblock hospital beds. Families are no doubt relieved that CHC Funding is granted for their frail relative who is at at ‘end of life’. But, if CHC Funding is immediately withdrawn following reassessment at 3 months, it can cause huge distress, financial worry and resentment.
No:10 Best Interests decisions
Andrea says, “What we have to bear in mind here is that the majority of residents in a care facility may be frail and elderly, and unable to make these choices for themselves.”
A ‘best interests’ decision is made on behalf of an individual by a team of professionals, for example, in circumstances where care cannot continue be delivered in the individual’s own home – perhaps because they need 24 hour care. So, if these professionals have made a best interests decision that the individual has no choice but to go into a care facility, then why do they not have a health need and why should they have to pay for their care?”
Andrea: “Many individuals do not understand the CHC process and do not realise that their loved one may well have been inappropriately assessed by a process which was designed to be consistent and robust, open and transparent for all, and to make healthcare easier to access – a system which delivers healthcare at no cost to the individual by an NHS service.
However, the National Framework remains open to individual subjective interpretation, and is a barrier to an individual receiving the free healthcare which they require as a result of long-term medical conditions which have given rise to ongoing healthcare needs.
It is confusing, not only for individuals, but also for the many professionals who have been commissioned to impose it. It is time for change and a more prescriptive, objective clear concise and fairer process.”
CTBD wish to thank ‘Andrea’ for getting in touch and setting out her forthright views and for sharing some of her experiences with us.
If you are going through the NHS assessment or appeals process and want help, buy our book, “How to Get the NHS to Pay for Care” or contact us directly on 0161 979 0430 or visit our one-to-one page direct professional support.