On 1 March 2018, the Department of Health and Social Care published revisions to the National Framework for NHS Continuing Healthcare (CHC) and NHS-funded Nursing Care (read it here). Clinical Commissioning Groups (CCGs) have until October 2018 to adopt the new rules.
The Framework has been updated to reflect the implementation of the Care Act 2014. As such, it makes clear that the eligibility criteria must be applied to everyone equally, regardless of where they receive their care. This removes the opportunity for interpreting the criteria differently for people who receive care at home. The Framework’s new wording removes this double standard, which is welcome news for patients whose needs can be met in their own home.
The definition of a social care need has been revised in accordance with the Care Act 2014. This should make it easier to differentiate between whether a care need is ‘social’ or ‘health’, and to judge whether the health needs of the patient are more than incidental or ancillary to their social care needs and therefore count as ‘primary health needs’. There is no definition of a primary health need however.
Guidance on CHC reviews has been updated for the better. Reviews being primarily to check that the patient’s care package is working well, not about reviewing eligibility. Eligibility should only be reviewed if the CCG can demonstrate that the needs have changed significantly. Where eligibility reviews are carried out, they must involve a multidisciplinary team and use the Decision Support Tool.
There is finally some clarity on top-up fees(when the CCG does not meet the full cost of care so the patient or their family pays the excess). The update makes it clear that it is the responsibility of CCGs to meet assessed health and wellbeing needs in full. It also provides guidance around the very limited circumstances in which patients can legitimately pay a top-up, i.e. for non-needs-based services such as hairdressing. I am not sure this goes far enough but time will tell
The make-up of the multidisciplinary team has been clarified, The whole process must be multi-disciplinary and not dominated by the nurse assessor
The description of the remit of CCG ratification of eligibility decisions has been improved, emphasising that‘Only in exceptional circumstances, and for clearly articulated reasons, should the multidisciplinary team’s recommendation not be followed.
The Framework strengthens the guidance around CCGs’ commissioning responsibilities. The Framework outlines the rights of individuals to have their assessed health and social care needs fully met by the CCG, allowing them to be cared for in the setting of their choice
It has been made clear that where CHC processes are outsourced to Commissioning Support Units, CCGs remain responsible for all decisions of eligibility.
The obligations on CCGs in respect of local resolution of appeals have been improved. For example, the introduction of a two-step process whereby a first attempt at bespoke, collaborative and genuine resolution should be made by the CCG. If that does not answer the individual’s concerns, the decision can be reconsidered by a panel.
The definition of well managed needs still lacks clarity.
The central test of a Primary Health Need remains unclear. For example, we feel there is still too much opportunity for CCGs to say that if the threshold of 2 x Severe or 1 x Priority levels is not hit in assessment, the person is not eligible. In fact, Primary Health Need is about whether the totality of a person’s health needs are more than incidental or ancillary to their social care needs – regardless of whether arbitrary thresholds are met.
In our view the update falls short of bringing enough clarity to the complex concepts involved in making decisions about each patient’s eligibility for funding. This leaves the door open for the postcode-lottery to continue.