13 June Implementation of the National Framework for Continuing NHS Healthcare

Transcription

1 13 June Implementtion of the Ntionl Frmework for Continuing NHS Helthcre

2 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre I hve prepred this report for presenttion to the Ntionl Assemly under the Government of Wles Act The Wles Audit Offi ce study tem tht ssisted me in prepring this report comprised Steve Ashcroft, Anne Beegn nd Joy Rees, under the direction of Pul Dimleee. Huw Vughn Thoms Auditor Generl for Wles Wles Audit Office 24 Cthedrl Rod Crdiff CF11 9LJ The Auditor Generl is totlly independent of the Ntionl Assemly nd Government. He exmines nd certifi es the ccounts of the Assemly Government nd its sponsored nd relted pulic odies, including NHS odies in Wles. He lso hs the sttutory power to report to the Ntionl Assemly on the economy, efficiency nd effectiveness with which those orgnistions hve used, nd my improve the use of, their resources in dischrging their functions. The Auditor Generl lso ppoints uditors to locl government odies in Wles, conducts nd promotes vlue for money studies in the locl government sector nd inspects for complince with est vlue requirements under the Wles Progrmme for Improvement. However, in order to protect the constitutionl position of locl government, he does not report to the Ntionl Assemly specifi clly on such locl government work, except where required to do so y sttute. The Auditor Generl nd his stff together comprise the Wles Audit Offi ce. For further informtion out the Wles Audit Offi ce plese write to the Auditor Generl t the ddress ove, telephone , emil: info@wo.gov.uk, or see wesite Auditor Generl for Wles 2013 You my re-use this puliction (not including logos) free of chrge in ny formt or medium. You must re-use it ccurtely nd not in misleding context. The mteril must e cknowledged s Auditor Generl for Wles copyright nd you must give the title of this puliction. Where we hve identifi ed ny third prty copyright mteril you will need to otin permission from the copyright holders concerned efore re-use.

3 Report presented y the Auditor Generl for Wles to the Ntionl Assemly for Wles on 13 June % recycled pper 80% o pur ilgylchwyd

4 Contents Summry 6 Recommendtions 15 1 The Welsh Government developed the CHC Frmework to help ensure tht people re delt with firly nd consistently, ut the Frmework could e improved in numer of res nd its impct monitored more closely 17 Welsh Government policy nd guidnce on CHC hs een revised to reflect key legl judgements nd to ensure people re delt with firly nd consistently 17 Some spects of the Frmework lck clrity, nd there re some key differences with the pproch in Englnd 19 The extent to which the Frmework or the wy it hs een implemented hs contriuted to the recent reduction in the numer of CHC cses nd expenditure is not cler 24 There is opertionl oversight of the Frmework ut strtegic ledership is lcking 29 2 The Frmework hs delivered numer of enefi ts, ut it hs not een fully implemented cross Wles nd sfegurds re not fully in plce to provide ssurnce tht decisions re fir nd consistent within nd etween helth ords 31 Governnce within helth ords in reltion to CHC hs een strengthened, ut provides only limited ssurnce tht people re eing delt with consistently nd firly 31 The Frmework hs provided sis for more consistent ssessment of cre needs nd decisions on CHC eligiility, lthough locl rrngements vry cross Wles nd do not lwys meet the Frmework s requirements 37 Arrngements for reviewing continuing eligiility for CHC hve een strengthened, ut cses re not lwys eing reviewed s frequently or s roustly s required y the Frmework 47 4 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre

5 The effectiveness of joint working etween helth nd socil services is highly vrile 51 There is mixed evidence on the extent to which individuls nd their fmilies re eing involved in the ssessment process, nd processes for gining nd recording informed consent nd ssessing mentl cpcity re very inconsistent 54 3 There is signifi cnt risk tht the ntionl project to del with retrospective clims for CHC will not process ll cses y the greed dedline, nd new cklogs of retrospective clims hve developed in helth ords 59 Mny of the chllenges round CHC eligiility hve not een delt with promptly, nd lthough there is longstnding dedline for clering the cses eing delt with y ntionl project tem, no dedline hs een set for the cses tht helth ords re deling with 59 The ntionl project for deling with retrospective clims hs mde limited progress nd, despite dditionl funding nd ressurnces from Powys Teching Helth Bord tht the June 2014 dedline to cler ll clims will e met, in our view there remins signifi cnt risk tht the dedline to cler ll clims y June 2014 will not e chieved 64 Helth ords re struggling to del with the retrospective clims tht they re responsile for processing 67 Appendices Appendix 1 - Study methods 74 Appendix 2 - Timeline of key events 76 Appendix 3 - Approches to CHC nd pying for socil cre cross the UK 79 Appendix 4 - Improving the Frmework 81 Glossry of terms 82 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre 5

6 Summry 1 Some people need cre nd support over n extended period of time, s the result of disility, ccident or illness. Helth services re free to ll t the point of delivery, ut depending upon person s needs or fi nncil circumstnces they my e chrged for services provided or funded y locl uthorities. 2 When ssessed s hving primry helth need, people re eligile for Continuing NHS Helthcre (CHC), which is pckge of cre nd support tht is provided to meet ll of the ssessed needs of n individul, including physicl, mentl helth nd personl cre needs. CHC is often long term, lthough it cn e episodic in nture with some people moving in nd out of eligiility. Helth ords reported to us tht 5,447 people cross Wles were in receipt of CHC s t 31 Mrch When someone is eligile for CHC, the NHS hs responsiility for funding the full pckge of helth nd socil cre. Where the individul is living t home, the NHS will py for helth cre nd socil cre, ut this does not include the costs of food, ccommodtion or generl household support. Where person is eligile for CHC nd is in cre home, the NHS pys the cre home fees, including ord nd ccommodtion. 4 Where person is eligile for CHC, locl uthorities still hve continuing responsiilities. These include role in ssessment nd review, providing socil work services nd support for crers, nd meeting housing nd eductionl needs. 5 If n individul is not eligile for CHC, they cn still ccess rnge of helth nd socil cre services. This cn include the NHS pying for the nursing element of cre provided to someone in cre home, known s NHS-funded nursing cre. Helth ords reported to us tht 5,887 people cross Wles were in receipt of NHS-funded nursing cre s t 31 Mrch However, for ny cre provided y socil services, such s personl cre nd ccommodtion in cre home, chrge my e mde depending on the person s income, svings nd cpitl ssets. Therefore, for some people decision tht they re ineligile for CHC cn hve signifi cnt fi nncil impct, with cre costs eing pid from their svings or from the proceeds from the sle of their home. 6 The funding of CHC is signifi cnt pressure on NHS expenditure in Wles. Expenditure incresed signifi cntly from 66 million in to 295 million in , efore reducing for the fi rst time to 278 million in (Figure 1). CHC expenditure now ccounts for fi ve per cent of helth ords net operting costs. Expenditure on NHS-funded nursing cre over the sme period hs een less voltile, rnging etween 32 million yer nd 40 million yer. The historic increse in CHC expenditure prtly refl ects numer of key court judgements which hve led to chnges in policy guidnce nd eligiility criteri. 1 Wles Audit Offi ce nlysis of helth ord fi nl ccounts. 6 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre

7 Figure 1 - CHC expenditure y helth ords to CHC expenditure ( million) / / / / / / / /12 Note Excludes ny in-yer djustments for the potentil future liilities rising from chllenges to pst cses tht were deemed ineligile Source: Wles Audit Offi ce nlysis of helth ord fi nl ccounts to An geing popultion with improved survivl rtes is lso likely to result in n increse over time in the numers of people with complex nd long-term cre needs. The numer of people in Wles who re ged over 65 is expected to rise from 558,000 (18.6 per cent of the popultion) to 864,000 (25.6 per cent) y In Englnd, pulic expenditure on socil services nd continuing helthcre for those ged over 65 is projected to increse y 37 per cent in rel terms etween 2010 nd There hve een concerns over the consistency nd firness of decisions on eligiility for CHC, nd lrge numer of ckdted clims hve een mde to helth ords chllenging erlier decisions on eligiility. The numer of complints received y the Pulic Services Omudsmn for Wles relting to CHC hs incresed, from 33 in to round 50 cses in ech of the lst three yers (Figure 2). Whilst the numer of complints hs not fl uctuted signifi cntly over the lst three yers, the nture of the complints hs chnged. In ddition to complints out eligiility decisions, the omudsmn is now receiving more complints out the dministrtion of some clims once eligiility hs een estlished. 2 Welsh Government Sttisticl Bulletin, SB 103/2011, 2010-sed Ntionl Popultion Projections for Wles 3 Cre for older people, Projected expenditure to 2022 on socil cre nd continuing helth cre for Englnd s older popultion, Nuffi eld Trust, Decemer 2012 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre 7

8 Figure 2 - CHC complints received y the Pulic Services Omudsmn for Wles Numer of complints Note Figure for is projection sed on the numers received to Novemer 2012 Source: Pulic Services Omudsmn for Wles, Novemer In response to funding pressures nd n geing popultion, the Welsh Government hs tken numer of steps. These included estlishing CHC ntionl progrmme ord to deliver improvements in the mngement of CHC. The remit of the progrmme ord included identifying opportunities for redesigning services, more cost-effective provision, nd developing more roust comprtive fi nncil informtion on CHC. The progrmme ord hs now een disnded nd some of its responsiilities hve een ssumed y Ntionl Complex Cre Steering Group. 10 The Welsh Government issued revised frmework for CHC (the Frmework) in My 2010, which ws to e implemented y 16 August The Frmework covers dults nd sets out the Welsh Government s revised policy for eligiility for CHC nd the responsiilities of helth ords nd locl uthorities. The Frmework sets out process for the NHS, working with locl uthority prtners, to ssess helth needs, decide on eligiility for CHC nd provide pproprite cre. The Welsh Government issued seprte guidnce for children nd young people s continuing cre in Novemer Continuing NHS Helthcre, The Ntionl Frmework for Implementtion in Wles, My 2010, Welsh Assemly Government circulr 5 Children nd Young People s Continuing Cre Guidnce, Welsh Government, Novemer Implementtion of the Ntionl Frmework for Continuing NHS Helthcre

9 11 Our exmintion focused on the implementtion of the Frmework for dults. We did not exmine in ny detil those spects of the delivery of CHC, such s service redesign, tht were eing progressed y the progrmme ord. When it lunched the Frmework in 2010, the Welsh Government mde commitment to review its opertion. This report is therefore timely in informing the forthcoming Welsh Government review. 12 We set out to nswer the question: Is the Frmework for implementing CHC effective in ensuring individuls re delt with firly nd consistently? Our methodology is descried in Appendix 1, nd we hve set out timeline of key events in Appendix Overll, we concluded tht the CHC Frmework hs delivered some improvements, ut more still needs to e done to ensure tht people re delt with consistently nd firly. To help helth ords etter meet the requirements of the Frmework, we hve developed nd pulished seprtely to this report self-ssessment nd improvement checklist. This is intended to support individul helth ords in identifying wht is working well nd where remedil ction should e trgeted. The Welsh Government developed the CHC Frmework to help ensure tht people re delt with firly nd consistently, ut the Frmework could e improved in numer of res nd its impct monitored more closely 14 Welsh Government policy nd guidnce on CHC hs een revised to reflect key legl judgements nd to ensure people re delt with firly nd consistently. The fi rst ntionl Frmework for CHC ws issued in 2004, ut signifi cnt chnge in cse lw in 2006 necessitted the development of n mended Frmework. There ws considerle dely in the Welsh Government overhuling the CHC Frmework, with fi nl version issued in My There is cler evidence of inconsistent pproches to CHC eligiility decisions cross Wles efore the introduction of the revised Frmework. Helth ords mde provisions of 35.1 million in their ccounts for for the estimted future costs rising from the chllenges to CHC eligiility decisions relting to pre-frmework cses tht hve yet to e concluded. 16 The revised Frmework provides detiled guidnce nd tools for use y helth ords, nd seeks to ensure firness nd consistency in ssessment nd decision mking. Centrl to the rrngements is multidisciplinry ssessment of someone s cre needs tht informs the completion of Decision Support Tool (DST). The DST is designed to ensure tht the full rnge of fctors tht hve ering on n individul s eligiility for CHC re tken into ccount in mking decisions. Implementtion of the Ntionl Frmework for Continuing NHS Helthcre 9

10 17 Some spects of the Frmework lck clrity, nd there re some key differences with the pproch in Englnd. Specific guidnce on how the Frmework should e pplied for people with lerning disility or mentl helth prolem is lcking. Clerer guidnce is lso needed on joint funding rrngements, including for section 117 mentl helth ptients nd for people who self-fund their cre, nd on how helth ords should monitor contrcts with cre homes. The Frmework does not specify how performnce should e monitored, nd Ntionl Complex Cre Dtse tht is eing rolled out cross Wles will not initilly produce performnce mesures for CHC. 18 The pproch to CHC vries cross the UK (Appendix 3), ut there is currently little difference etween the pproches in Wles nd Englnd, nd the frmeworks in plce in ech country re rodly similr. 6 We hve not ssessed the relevnt merits of the different pproches. However, s the Frmework in Englnd hs een reviewed recently, we looked to see whether ny lessons could e drwn to inform the pproch in Wles. In Englnd, screening tool is used to determine whether someone requires CHC ssessment, nd dopting similr pproch in Wles could help ensure consistency in the criteri used to put people forwrd for CHC ssessment. Becuse of differences etween the DST used in Wles nd Englnd, it my e more diffi cult for some people in Wles, most notly those with dementi, to meet CHC eligiility criteri, whilst for people with some other helth conditions it my e esier. 19 The extent to which the Frmework or the wy it hs een implemented hs contriuted to the recent reduction in the numer of CHC cses nd expenditure is not cler. CHC expenditure nd the totl numer of CHC cses hve reduced since the Frmework ws introduced. Across Wles CHC expenditure, hving risen every yer since , fell ck in y 5.8 per cent compred with the previous yer, with fi ve helth ords experiencing reduction, nd nother experiencing no sustntive chnge. Across Wles the totl numer of CHC cses lso reduced in oth 2011 nd This reduction hs not een experienced in Englnd. However, the pttern of chnge in the numers of CHC cses nd the numer of cses per hed of popultion is highly vrile cross helth ords. 20 The extent to which the Frmework itself hs contriuted to the recent overll fll in CHC cses nd expenditure is uncler. This is ecuse t lest prt of the fll is likely to refl ect the 37.5 million of Welsh Government funding mde ville from for schemes to modernise complex cre services; concerted push cross helth ords to identify svings within CHC udgets; nd the nture nd extent of some hospitl nd community services which cn impct onto the numer of CHC cses. 21 There is opertionl oversight of the Frmework ut strtegic ledership is lcking. A Ntionl CHC Implementtion Group ws estlished in 2010 to oversee the implementtion nd opertion of the Frmework. Given its composition nd role, the group (now clled the Ntionl CHC Advisory Group) is not n pproprite ody to provide strtegic ledership for the Frmework. 6 The funding nd chrging rrngements for cre nd support re to chnge in Englnd nd the Welsh Government is considering wht reforms would e pproprite for Wles; this my led to divergence etween the two countries in coming yers. 10 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre

11 22 Ntionl ledership for CHC ws previously provided through CHC ntionl progrmme. However, the progrmme did not hve n explicit role with regrd to the Frmework. The lck of cler strtegic ledership for the CHC Frmework t ntionl level hs een compounded y the slow progress in estlishing effective successor rrngements to the ntionl CHC progrmme. In prticulr, the Ntionl Complex Cre Steering Group hd hd only limited impct to dte. The Frmework hs delivered numer of enefits, ut it hs not een fully implemented cross Wles nd sfegurds re not fully in plce to provide ssurnce tht decisions re fir nd consistent within nd etween helth ords 23 Governnce within helth ords in reltion to CHC hs een strengthened, ut provides only limited ssurnce tht people re eing delt with consistently nd firly. The centrl guidnce ssocited with the Frmework is not s detiled s the corresponding guidnce in Englnd. Over yer on from the lunch of the Frmework, helth ords hd mde vrile progress in developing locl CHC policies nd procedures. There is scope for greter shring of policies nd procedures y helth ords, nd for the development of ll-wles protocols nd documenttion. 24 Responsiilities for CHC re spred cross helth ord, which cn led to inconsistent pproches within helth ord. Stndrd trining on CHC nd the Frmework s requirements hs een rolled out cross Wles to mixed effect, nd roder rnge of trining is needed. The numer of hospitl nd community stff requiring expertise in CHC provides n ongoing chllenge to helth ords. 25 Helth ords cnnot provide ssurnce tht the Frmework is eing pplied fully nd tht they mke fir, timely nd consistent decisions on eligiility oth within nd etween their orgnistions. Individul cses tht re deemed eligile for CHC re scrutinised, ut helth ords do not hve rrngements in plce to routinely monitor or review cses tht re not put forwrd to e ssessed for CHC or tht re deemed ineligile y their stff. Also, there re no peer review rrngements etween helth ords. 26 The Frmework hs provided sis for more consistent ssessment of cre needs nd decisions on CHC eligiility, lthough locl rrngements vry cross Wles nd do not lwys meet the Frmework s requirements. There is evidence tht the Frmework hs led to more consistent, thorough nd detiled ssessments of cre needs. However, ssessments of cre needs re not lwys comprehensive, with input from rnge of pproprite professionl disciplines, nd re not lwys undertken t n pproprite time. The lck of enggement of GPs nd hospitl doctors in CHC ssessment processes is common prolem. The DST is lso not lwys eing used s intended, with prolems in getting the right professionls to ttend meetings to discuss nd gree the DST; vrile stndrds of completion of the DST nd supporting documenttion; nd concerns tht the DST is eing used too prescriptively with lck of professionl judgement eing exercised. 27 Helth ords hve put in plce scrutiny processes to rtify the conclusions of individul ssessments of CHC eligiility, ut some re more effective thn others. Scrutiny pnels re in plce in ll helth ords ut their numer, scope, size nd memership vries. Implementtion of the Ntionl Frmework for Continuing NHS Helthcre 11

12 28 The Frmework sets trget for the time it should tke to complete the CHC ssessment nd decision-mking process. However, there is lck of clrity over the strt point ginst which timescles should e mesured, helth ords re not routinely mesuring timescles, nd our nlysis of cse fi les indictes tht the trget times re unlikely to e routinely met. 29 Fst-trck processes, for the immedite provision of CHC for individuls with rpidly deteriorting condition who my e entering terminl phse of their lives, re generlly working well. In contrst, the Frmework s requirements for plnning the complex trnsition from children to dult CHC services re generlly not eing met. 30 Arrngements for reviewing continuing eligiility for CHC hve een strengthened, ut cses re not lwys eing reviewed s frequently or s roustly s required y the Frmework. There should e periodic review of CHC cses to determine whether n individul s needs hve chnged. A chnge in needs should trigger n pproprite chnge in the pckge of cre nd n ssessment of whether the person continues to e eligile for CHC funding. 31 Since the introduction of the Frmework, helth ords hve mde some progress in deling with cklogs of reviews. However, CHC cses re not eing reviewed in line with the frequency nd timescles outlined in the Frmework, which re more demnding thn the corresponding requirements in Englnd. The roustness of reviews is lso highly vrile, with reluctnce to move people out of CHC evident in some prts of Wles. 32 The effectiveness of joint working etween helth nd socil services is highly vrile. The importnce of joint working etween the NHS nd socil services is stressed throughout the Frmework, ut there re signifi cnt vritions in joint working rrngements cross Wles. Improved joint working nd communiction were evident when socil services ttended scrutiny pnels, lthough this is not routine prctice in ll helth ords. Joint protocols hve een developed in some prts of Wles, ut in others, diffi culties hve een experienced in greeing common pproch. Reltionships etween helth nd socil services cross Wles rnge from positive nd constructive through to diffi cult. 33 The numer of disputes etween helth nd socil services over CHC eligiility decisions vried gretly nd, lthough relevnt policies nd guidnce re mostly in plce, the time tken to resolve disputes is signifi cntly longer thn the trget times set out in the Frmework. 34 There is mixed evidence on the extent to which individuls nd their fmilies re eing involved in the ssessment process, nd processes for gining nd recording informed consent nd ssessing mentl cpcity re very inconsistent. CHC is complex topic with its own distinct lnguge, nd ensuring people re well informed is prticulr chllenge. The Welsh Government hs developed pulic informtion lefl et on CHC. However, the lefl et is not lwys mde ville, nd there re gps in informtion relting to consent, joint cre pckges nd the vilility of locl dvoccy. The Welsh Government, with Age Concern, hs developed more detiled guide for the pulic on the CHC process. Although helth ords do not hnd the guide out routinely, the guide is ville online. 12 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre

13 35 There is very mixed evidence out how well individuls 7 re kept informed out CHC ssessment nd decision-mking processes. The Frmework confi rms the requirement to otin the informed consent of people eing ssessed for CHC, ut the prctice in otining consent vries cross Wles. Helth ords re lso inconsistent in the extent to which they routinely ssess nd record n individul s mentl cpcity to give their consent nd prticipte in decision-mking processes when ssessing them for CHC. There is lso mixed evidence on the extent to which individuls nd their fmilies re eing involved in the ssessment process nd, in some res, the needs of crers re not eing fully ssessed. There is significnt risk tht the ntionl project to del with retrospective clims for CHC will not process ll cses y the greed dedline, nd new cklogs of retrospective clims hve developed in helth ords 36 Mny of the chllenges round CHC eligiility hve not een delt with promptly, nd lthough there is longstnding dedline for clering the cses eing delt with y ntionl project tem, no dedline hs een set for the cses tht helth ords re deling with. Responsiility for deling with retrospective clims ginst CHC decisions is either with ntionl project tem, hosted y Powys Teching Helth Bord, or with individul helth ords, depending upon the dte the clim is mde. 37 In 2004, ntionl rrngements were estlished tht llowed people to clim retrospectively tht they (or decesed reltive) hd een eligile for CHC ut were wrongly chrged for cre etween 1996 nd The scope of the ntionl project hs een extended over time nd now covers ny clim received y August 2010, the implementtion dte of the Frmework. The Welsh Government hs set dedline tht the ntionl project should cler ll these clims y June Helth ord responsiilities for retrospective clims hve chnged over time, ut they re now responsile for deling with ny retrospective clims received fter August 2010 s well s ny requests to reconsider eligiility decisions mde under the revised Frmework (referred to s disputes ). The Welsh Government hs not lwys clerly communicted to helth ords chnges in their responsiilities, nd hs not set cler timescles for helth ords to del with retrospective clims nd with disputes. 39 The ntionl project for deling with retrospective clims hs mde limited progress nd, despite dditionl funding nd ressurnces from Powys Teching Helth Bord tht the June 2014 dedline to cler ll clims will e met, in our view there remins significnt risk tht the dedline will not e chieved. A filure to del promptly with retrospective clims nd disputes is unfir on the individuls concerned. Clims relting to fees dting ck up to 17 yers re still eing delt with y the ntionl project. Progress y the ntionl project in deling with retrospective clims hs een limited, with 32 per cent of clims eing completed 21 months into the ntionl project s plnned lifetime of 36 months. 7 Throughout this report, we use the term individuls to refer to people who re eing, or hve een, ssessed for CHC s covered in the glossry. Implementtion of the Ntionl Frmework for Continuing NHS Helthcre 13

14 The effi cient processing of clims hs een constrined y diffi culties in ccessing clinicl records held y individul helth ords nd y some helth ords not now ccepting the originl proof from climnt tht they hve pid the relevnt cre home fees. 40 The ntionl project hs experienced signifi cnt recruitment nd retention prolems, nd in My 2012 ws projecting to complete ll cses two yers lter thn the June 2014 dedline. To ensure tht the originl dedline could e chieved, the Welsh Government nd helth ords, on 50:50 sis, mde ville n dditionl 1.6 million to increse stffi ng levels in the ntionl project tem. The Welsh Government hs lso strengthened its monitoring of progress. However, due to continuing recruitment nd retention prolems, signifi cnt risks in meeting the dedline remin. 42 It is uncler whether helth ords hve now llocted suffi cient stff resources to del with the lrge numer of retrospective clims nd disputes in timely wy. Some helth ords hd originlly not llocted pproprite stff resources, ut s the numers of retrospective clims nd disputes hs incresed, ll helth ords hve greed to, or re considering, ppointing dditionl stff. However, it is too soon to tell whether the incresed resources re suffi cient to ensure ll outstnding retrospective clims will e completed in timely wy. Some helth ords were lso slow to set up the dispute review processes outlined in the Frmework, nd the independent review pnels tht consider disputes re not lwys operting effectively. 41 Helth ords re struggling to del with the retrospective clims tht they re responsile for processing. Helth ords hve received lrge numers of retrospective clims nd further clims re likely to e mde in the future. By Septemer 2012, only 13 per cent of the 1,264 retrospective clims nd disputes from individuls received y helth ords since August 2010 hd een concluded. Helth ords hve mde most progress with the disputes tht they hve received, lthough these cn tke considerle time to conclude. However, the mjority of cses re retrospective clims nd progress with these hs een very slow. There is no common process cross helth ords for deling with retrospective clims. 14 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre

15 Recommendtions Guidnce provided y the Frmework 1 The Frmework outlines the requirements to e met y helth ords nd their locl uthority prtners in considering people for CHC. We hve identifi ed numer of res where the current guidnce could e improved, which re summrised in Appendix 4. We hve identifi ed opportunities for mking guidnce clerer or more explicit; for ddressing gps in its coverge; nd for ensuring tht guidnce is relistic nd deliverle. We recommend tht the Welsh Government, s prt of its forthcoming review of the Frmework, uses the findings from this report, s summrised in Appendix 4, to improve the guidnce to helth ords provided y the Frmework. Ledership 2 Opertionl oversight of the implementtion of the Frmework is in plce in the form of the Ntionl CHC Advisory Group. But stronger ledership, ntionlly nd within helth ords, is required to ensure tht the Frmework is implemented consistently nd effectively cross Wles. The Ntionl Complex Cre Steering Group hs hd only limited impct to dte. We recommend tht the Welsh Government: strengthens its strtegic oversight of the CHC Frmework, with focus on ensuring incresed consistency in the ppliction of the Frmework nd implementtion of the recommendtions set out in this report; nd requires helth ords to llocte overll responsiility for CHC t ord director level, with specific responsiility for ensuring consistency in the Frmework s ppliction cross the helth ord, the dequcy of stff resources llocted to CHC, nd effective joint working with socil services. Fir nd consistent ppliction of the Frmework 3 The Frmework ims to ensure tht individuls re considered for CHC firly nd consistently. We hve identifi ed risks tht not ll people who should e ssessed for CHC re eing identifi ed, nd tht, in considering n individul s eligiility for CHC, there is potentil for the inconsistent interprettion nd ppliction of the Frmework within nd etween helth ords. 4 To ensure tht ntionl policy nd guidnce further supports consistency nd firness, nd in light of operting the Frmework for lmost three yers, we recommend tht the Welsh Government: reconsiders the enefits of introducing screening tool to determine whether someone requires CHC ssessment; nd reviews the differences etween the DST domins in Wles nd Englnd, prticulrly for cognition, to confirm tht the Welsh domins re resonle. Implementtion of the Ntionl Frmework for Continuing NHS Helthcre 15

16 5 To ensure consistent interprettion nd ppliction of the Frmework cross helth ords, we recommend tht the Welsh Government: requires helth ords to estlish rrngements for peer review of the processes for reching CHC eligiility decisions, nd of smple of CHC decisions; nd promotes mens of shring cross Wles the lerning from peer reviews. Assessment, decision mking nd review 6 Whilst some strengths nd weknesses re common cross Wles, the performnce of helth ords in meeting the requirements of the Frmework is vrile. There is lso scope for helth ords to lern from one nother, nd for common tools or documenttion to e developed. We recommend tht the Welsh Government: requires helth ords to complete nd ction the self-ssessment nd improvement checklist developed y the Wles Audit Office in support of this report; nd works with helth ords to develop ntionl protocols nd documenttion, for exmple for fst-trck rrngements nd for otining consent, nd encourges greter shring of locl policies nd documenttion etween helth ords. Retrospective clims 7 The effective nd consistent hndling of chllenges to CHC eligiility decisions is importnt to ensure firness nd mintin pulic confi dence in the system. There re signifi cnt risks tht the ntionl project will not cler ll retrospective clims y the greed dedline. The position with helth ords is even more uncertin, with lck of clrity over how retrospective clims should e processed. We recommend tht the Welsh Government: c sets dedline for the completion of ll retrospective clims tht re eing processed y helth ords; works with helth ords to gree detiled nd common pproch to deling with the retrospective cses eing processed y helth ords, nd ensures the pproch is rodly in line with the pproch dopted y the Powys project tem; nd estlishes tsk nd finish group with executive-level representtion from cross ll helth ords nd chired y helth ord chief executive, to ensure tht ll retrospective cses, whether these re eing hndled y the Powys project or individul helth ords, re processed efficiently nd to the set dedlines. 16 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre

17 Prt 1 - The Welsh Government developed the CHC Frmework to help ensure tht people re delt with firly nd consistently, ut the Frmework could e improved in numer of res nd its impct monitored more closely Welsh Government policy nd guidnce on CHC hs een revised to reflect key legl judgements nd to ensure people re delt with firly nd consistently A significnt chnge in cse lw in 2006 required mended guidnce, ut there ws considerle dely in overhuling the CHC Frmework 1.1 The fi rst ntionl Frmework for CHC nd ssocited guidnce ws issued in It outlined the key criteri nd issues to e tken into considertion when mking decisions out eligiility for CHC. The 2004 Frmework looked to ddress rnge of issues with the provision of CHC tht hd een highlighted y 1999 Court of Appel judgment, referred to s the Coughln judgment 8 ; the Helth nd Socil Cre Act 2001, which introduced NHS-funded nursing cre; nd 2003 report y the Helth Service Omudsmn A further legl judgement in 2006, referred to s the Grogn judgement, required tht, in deciding upon eligiility for CHC, NHS odies needed to hve cler process in plce to ssess whether there ws primry helth need (Figure 3). In simple terms, n individul hs primry helth need if, hving tken ccount of ll of their needs, it cn e sid tht the min spects or mjority of the cre they require is focused on ddressing nd/or preventing ill helth. Figure 3 - The Grogn judgement R v. Bexley NHS Cre Trust ex prte Grogn Mureen Grogn hd multiple sclerosis, dependent oedem with the risk of ulcers reking out, ws douly incontinent, nd hd some cognitive impirment. After the deth of her husnd, her helth deteriorted nd she hd numer of flls. Following n dmission to hospitl with dislocted shoulder, it ws decided tht she ws unle to live independently nd she ws trnsferred to cre home providing nursing cre. Assessments indicted tht Mrs Grogn s condition ws such tht she did not qulify for CHC, ut did qulify for NHS-funded nursing cre. Mrs Grogn rgued tht the decision to deny her full NHS funding ws unlwful, due in prt to the level of her nursing needs indicting primry need for helth cre which should e met y the NHS. The court concluded tht in ssessing whether Mrs Grogn ws entitled to CHC, the cre trust did not hve in plce or pply n pproch to test whether her primry need ws helth need. The trust s decision tht Mrs Grogn did not qulify for CHC ws set side nd the question of her entitlement to CHC ws remitted to the trust for further considertion. 8 The Coughln judgement ruled on the limits of nursing cre provided y locl uthorities for person living in residentil ccommodtion. 9 NHS funding for long term cre, Helth Service Omudsmn, Ferury 2003 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre 17

18 1.3 In 2006, the Ntionl Assemly issued initil guidnce to NHS odies nd locl uthorities to help them comply with the Grogn judgement 10. This ws followed in Decemer 2007 y drft revised Frmework, which ws sed on the Frmework tht hd een developed in Englnd. The drft Frmework ws issued in Ferury 2008 for three months consulttion. However, the fi nl version of the Frmework ws not issued until My The sustntil dely refl ected the need to consider further legl judgement in August 2008, referred to s the St Helens judgement 11 ; the consequent need to circulte n mended drft of the Frmework for further comment; nd the limited cpcity within the Welsh Government to consider the consulttion responses nd fi nlise the Frmework. There is cler evidence of inconsistent pproches to CHC eligiility decisions cross Wles efore the introduction of the Frmework 1.4 The inconsistent ppliction of CHC eligiility criteri ws fi rst highlighted y the Helth Service Omudsmn in 2003, nd susequently y the Pulic Services Omudsmn for Wles through vrious nnul reports nd investigtions of individul complints. 1.5 Also, efore the Frmework ws introduced in August 2010, there hd een lrge numer of chllenges y individuls nd their fmilies ginst helth ord decisions on CHC eligiility; these re referred to s retrospective clims. In cses where decision tht someone is ineligile for CHC hs resulted in the individul funding ll or prt of their cre home fees, there is cler incentive to chllenge the decision. More thn four in every fi ve retrospective clims tht hve een concluded hve een fully or prtilly successful, either ecuse the ppliction of the eligiility criteri ws found to e incorrect or due to lck of evidence to support the originl decision. Helth ords mde provisions of 35.1 million in their ccounts for for the estimted future costs rising from the remining retrospective clims tht hd not een concluded. The revised Frmework provides detiled guidnce nd tools for use y helth ords, nd seeks to ensure firness nd consistency in ssessment nd decision mking 1.6 The 2010 Frmework sets out process for the NHS, working with locl uthority prtners, to ssess helth needs nd to decide on eligiility for CHC. The Frmework mkes cler tht the sole criterion for determining eligiility for CHC is whether person s primry need is helth need. The Frmework lso sets out: c d e f trining requirements nd governnce rrngements; how helth ords should gin informed consent nd ensure people hve the mentl cpcity to give consent nd mke decisions; the process y which decisions on eligiility should e scrutinised y helth ords; how disputes over eligiility decisions should e resolved etween helth ords nd their prtners; the rrngements to e followed when n individul wnts to dispute decision; nd the rrngements for reviewing individul CHC cses over time. 10 Welsh Helth Circulr (2006) 046, Further dvice to the NHS nd Locl Authorities on Continuing NHS Helth Cre, Ntionl Assemly for Wles 11 The St Helens judgement confi rmed tht the NHS is the primry decision mker when deciding whether person hs primry helth cre needs. 18 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre

19 1.7 Centrl to the rrngements is multidisciplinry ssessment process tht informs the completion of DST. The DST is designed to ensure tht the full rnge of fctors tht hve ering on n individul s eligiility re tken into ccount in mking decisions. The tool provides prctitioners with frmework to ring together nd record the needs of n individul in 11 cre domins. Most domins re sudivided into sttements representing low, moderte, high, or severe level of needs; with three domins lso including priority level of need. The result of completing the DST should e n overll picture of the individul s needs, to inform decisions on eligiility. 1.8 The Frmework is supported y seprte prctice guidnce document 12 tht is sed on frequently sked questions, nd is intended to provide prcticl explntion of how the Frmework should operte on dy-to-dy sis. As prt of the ltest revision of CHC policy in Englnd, the Deprtment of Helth hs now incorported its prctice guidnce into the min Frmework document 13. This should help improve clrity nd ensure tht people using the Frmework do not lose sight of the prctice guidnce. Some spects of the Frmework lck clrity, nd there re some key differences with the pproch in Englnd Specific guidnce nd trining on how the Frmework should e pplied for people with lerning disility or mentl helth prolem is lcking 1.9 A common view from oth NHS nd socil service prctitioners tht we interviewed during the review is tht the Frmework is diffi cult to pply to people with lerning disility nd, to lesser extent, to those with mentl helth prolem. Unlike in Englnd, the Frmework in Wles does not include specifi c guidnce on how the DST nd primry helth need eligiility test pply to people with lerning disilities At workshop we rn for helth ord CHC leds, they identifi ed the diffi culties in pplying the Frmework to people with lerning disilities s one of their top-priority issues. This issue ws lso highlighted y socil services stff, nd one locl uthority commented in their survey response tht the defi nition of primry helthcre need is especilly prolemtic in pplying the criteri to people with lerning disilities, mentl helth issues nd dementi There re different cre needs ssessment nd cre plnning requirements for people with lerning disility or mentl helth prolem, which do not fi t esily into the domins in the DST. Both nurses nd socil workers told us tht, whilst the domins work well for someone with physicl helth prolem, they re diffi cult to use for someone with lerning disility or mentl helth 12 Continuing NHS Helthcre for Adults, Prctice Guidnce to support the Ntionl Frmework for Implementtion in Wles, Novemer Ntionl Frmework for NHS Continuing Helthcre nd NHS-funded Nursing Cre, Novemer 2012 (Revised), Deprtment of Helth Implementtion of the Ntionl Frmework for Continuing NHS Helthcre 19

20 prolem. Nurses nd socil workers lso told us tht CHC trining nd support mterils re focused on someone with physicl helth prolem, nd hve not een tilored for lerning disility or mentl helth cses. Clerer guidnce on joint funding rrngements is needed, including for section 117 mentl helth ptients nd for people who self-fund their cre 1.12 The Frmework specifi es tht where person hs een deemed not eligile for CHC ut requires n lterntive pckge of cre (such s NHS-funded nursing cre in cre home, or joint pckge of cre in the community), the led role will normlly lie with the locl uthority. The Frmework sttes tht, in these circumstnces, helth ords should work in prtnership with the locl uthority to gree their respective responsiilities in joint cre pckges Helth ord CHC leds ttending our workshop nd four socil service deprtments in their response to our survey rised concerns out lck of clrity out how joint pckges of cre should e funded. They considered tht the lck of clrity cn led to inconsistent pproches to funding joint pckges of cre. Some greements re sed on stndrd formul, such s 50 per cent of costs picked up y ech orgnistion. Alterntively, joint cre pckges cn e negotited on cse-y-cse sis, which cn led to disputes etween orgnistions. Arrngements cn vry within helth ord re At our workshop, helth ord CHC leds lso identifi ed need for greter clrity over joint service provision relting to one group of people with mentl helth prolem. Under section 117 of the Mentl Helth Act 1983, helth nd socil services uthorities hve duty to provide services in the community for individuls detined under certin provisions of the ct following their dischrge from hospitl. Helth nd socil service uthorities jointly hve duty to provide these community services, referred to s fter-cre services, until they re stisfi ed tht the person is no longer in need of these. At the workshop, helth ord CHC leds greed tht there is lck of clrity out which services should e provided s n fter-cre pckge under section 117, nd which services should e provided through CHC funding; nd out how these joint pckges of cre should e funded Another re where clrity is lcking is whether people who py for ll of their cre home fees, referred to s self-funders, should e routinely offered n ssessment for CHC or NHS-funded nursing cre. As self-funder s needs nd circumstnces chnge, they my ecome eligile to hve prt or ll of the costs of the cre home pid y the NHS or locl uthority. However, there is lck of clrity over whether people who self-fund should e routinely offered such n ssessment. This issue ws highlighted y the Helth nd Socil Cre Committee s inquiry into residentil cre services for older people 14, which found tht some people who self-fund receive no informtion or dvice from their locl uthority, nor ny ssessment of their needs. 14 Residentil cre of older people in Wles, Ntionl Assemly for Wles, Helth nd Socil Cre Committee, Decemer Implementtion of the Ntionl Frmework for Continuing NHS Helthcre

21 More explicit guidnce out how helth ords should monitor contrcts with cre homes is needed 1.16 The Frmework provides some high-level guidnce on the responsiilities of helth ords for rrnging nd monitoring services, such s cre home plcements, to meet the needs of those with CHC. However, helth ord leds for CHC ttending our workshop reported tht contrcting nd monitoring rrngements re generlly underdeveloped, nd tht more specifi c guidnce thn tht currently set out in the Frmework would e enefi cil Such guidnce could drw upon good prctice exmples of where roust rrngements hve een put in plce. For exmple, when Aneurin Bevn Helth Bord reviews cses in nursing homes, it lso monitors whether the cre home is providing the cre pckge s outlined in the contrct. The helth ord hs lso reviewed the trends of dmissions, dischrges nd deths in cre homes nd investigted ny outlying results. The Frmework does not specify how performnce should e monitored, nd the Ntionl Complex Cre Dtse will not initilly produce performnce mesures for CHC 1.18 The Frmework does not specify ny performnce indictors for CHC ut sttes tht they my e introduced for NHS orgnistions t some point in the future. In the sence of ny ntionl performnce indictors for CHC, individul helth ords hve mde little progress in developing locl mesures of performnce. We found little evidence of ny routine performnce mngement informtion relting to CHC in most helth ords Over recent yers, ll helth ords hve put in plce one or more CHC dtses to hold sic informtion on CHC cses nd relted costs. Helth ords generlly cknowledged tht their dtses were not fi t for purpose. As result, tsk group, consisting of helth ord representtives supported y NHS Wles Informtics Service, hs developed nd is now implementing ntionl dtse. The dtse, referred to s the Ntionl Complex Cre Dtse, cptures CHC-relted ctivity nd costs, s well s informtion on NHSfunded nursing cre, retrospective clims, nd ny joint funding rrngements in plce with locl uthority prtners NHS Wles Informtics Service rolled out to ll helth ords the Ntionl Complex Cre Dtse, which is sed on the version developed nd used in Hywel Dd Helth Bord, etween Jnury nd Mrch However, the requirement to generte stndrdised performnce informtion hs not initilly een uilt into the dtse. The tsk group nd NHS Wles Informtics Service considered tht it would e too complex to gree nd develop this cpility within the timescles set for the initil lunch of the dtse. Implementtion of the Ntionl Frmework for Continuing NHS Helthcre 21

22 In Englnd, screening tool is used to determine whether someone requires CHC ssessment 1.21 In Englnd, CHC screening tool is in plce (Figure 4), which is designed to ensure clrity nd consistency in the criteri used to put people forwrd for CHC ssessment. Although the screening tool in Englnd is strightforwrd to complete, screening tool hs not een dopted within Wles. In the pst the Welsh Government, in discussion with helth ords, hs concluded tht CHC screening tool is not required s the Unifi ed Assessment Process, the common ssessment process for helth ords nd locl uthorities, should identify those people who require CHC ssessment. This rgument did not previl in Englnd, which lso hs Single Assessment Process for Older People tht is incresingly eing used for ll people over 18 yers of ge. Figure 4 - Screening tool in Englnd Key fetures of the CHC checklist A checklist hs een developed in Englnd to help prctitioners identify people who need full ssessment for CHC. The checklist is sed on the DST. It llows vriety of people, in vriety of settings, to refer individuls for full ssessment for CHC. For exmple, the tool cn form prt of the dischrge pthwy from hospitl; GP or nurse could use it in n individul s home; nd socil workers could use it when crrying out routine socil services ssessments. The intention is for the checklist to e completed s prt of the wider process of ssessing or reviewing n individul s needs. The checklist should lso e completed when n individul requests n ssessment for CHC The doption of screening tool in Wles could led to numer of enefi ts. Firstly, oth NHS nd socil services stff rised concerns with us during our fi eldwork visits over diffi culties they hd encountered in getting collegues to identify when someone needed to e ssessed for CHC. We lso identifi ed lck of consensus in some res etween socil services nd NHS stff out when CHC ssessment is needed. One locl uthority reported to us tht they were moving towrds forml dispute with the helth ord over continued prolems with getting people ssessed for CHC. Also, some nurses told us tht socil services stff cn e uncler s to when CHC ssessment should e triggered when there ws no NHS involvement with the individul Secondly, helth ord CHC leds ttending our workshop identifi ed tht the resons in support of decision tht CHC ssessment is not wrrnted often re not fully documented, leving such decisions open to the risk of chllenge. The sence of common pproch to recording the considertion of whether to ssess someone for CHC eligiility limits the extent to which helth ords re le to monitor, nd provide ssurnce, tht people re eing considered ppropritely nd consistently. 22 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre