29 Jnury 2015 Archwilydd Cyffredinol Cymru Auditor Generl for Wles Continuing NHS Helthcre Follow-up Report
I hve prepred nd pulished this report in ccordnce with the Government of Wles Acts 1998 nd 2006. Steve Ashcroft delivered the work under the direction of Mtthew Mortlock. Huw Vughn Thoms Auditor Generl for Wles Wles Audit Office 24 Cthedrl Rod Crdiff CF11 9LJ The Auditor Generl is independent of the Ntionl Assemly nd government. He exmines nd certifies the ccounts of the Welsh Government nd its sponsored nd relted pulic odies, including NHS odies. He lso hs the 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, together with ppointed uditors, lso udits locl government odies in Wles, conducts locl government vlue for money studies nd inspects for complince with the requirements of the Locl Government (Wles) Mesure 2009. The Auditor Generl undertkes his work using stff nd other resources provided y the Wles Audit Office, which is sttutory ord estlished for tht purpose nd to monitor nd dvise the Auditor Generl. For further informtion plese write to the Auditor Generl t the ddress ove, telephone 029 2032 0500, emil: info@wo.gov.uk, or see wesite www.wo.gov.uk. Auditor Generl for Wles 2015 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 identified ny third prty copyright mteril you will need to otin permission from the copyright holders concerned efore re-use. If you require ny of our pulictions in n lterntive formt nd/or lnguge plese contct us using the following detils: Telephone 029 2032 0500, or emil info@wo.gov.uk
Contents Summry 6 Recommendtions 12 1 The revised CHC Ntionl Frmework ddresses mny of the weknesses in the previous version, nd ledership nd oversight re eing strengthened 14 The revised Frmework ddresses mny of the issues rised nd recommendtions mde previously y the Auditor Generl nd the Pulic Accounts Committee 15 Some importnt steps re eing tken to strengthen ledership nd oversight, nd lthough sustntil numers of stff hve received trining in the revised Frmework, there is considerle vrition etween helth ords 18 2 There re more retrospective clims outstnding thn ever efore, nd the response from some helth ords hs een unstisfctory 24 The revised Frmework outlines common process for deling with retrospective clims 25 The Welsh Government hs set dedlines for reviewing retrospective clims, ut the pproch could led to helth ords cting in wy tht undermines the timely processing of clims nd performnce monitoring is indequte 27 The Powys Project reviewed s intended ll clims received up to 15 August 2010 y the dedline of 30 June 2014 lthough ll clims were not completed y this dte 33 The responsiility for processing the sustntil numer of clims received since 16 August 2010 now rests with the Powys Project nd helth ords, nd this division of responsiility cretes dded complexity, nd mkes it more difficult to ensure consistency 33 The Powys Project fces n even greter chllenge in processing its shre of the clims received fter 16 August 2010, nd hs een constrined y IT prolems nd delys in the trnsfer of informtion from helth ords nd the greement of ongoing funding 37 Some helth ords hve not demonstrted tht they re le to del in timely wy with the clims they re responsile for, nd some climnts re eing delt with unresonly 38 4 Continuing NHS Helthcre Follow-up Report
3 Pulic informtion on CHC hs een expnded ut needs to e more ccessile, there were weknesses in the pulicity of the July 2014 cut-off for some retrospective clims, nd ccess to dvoccy services remins concern for some helth ords 45 The Welsh Government hs developed rnge of informtion leflets, ut could do more to pulicise them nd mke them more ccessile 46 Although the Welsh Government issued vrious communictions itself, the ction tken y helth ords to pulicise the end of July 2014 cut-off for some retrospective clims ppers to hve een inconsistent 48 Some helth ords remin concerned out the vilility nd funding of CHC dvoccy services 49 Appendices Appendix 1 Summry of rrngements for deling with retrospective clims 51 Appendix 2 Action tken in response to the min recommendtions mde y the Auditor Generl nd the Pulic Accounts Committee 52 Appendix 3 Audit methods 55 Continuing NHS Helthcre Follow-up Report 5
Summry 1 Some people need cre nd support over n extended period, 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 finncil 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 5,778 people cross Wles were in receipt of CHC s t 31 Mrch 2014. 3 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 helthcre 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 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 5,229 people cross Wles were in receipt of NHS-funded nursing cre s t 31 Mrch 2014. 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 significnt finncil impct, with cre costs eing pid from their svings or potentilly from the proceeds from the sle of their home. 5 In June 2013, the Auditor Generl pulished report on CHC 1. The report concluded tht the CHC Frmework in plce t tht time hd delivered some improvements, ut tht more needed to e done to ensure tht people re delt with consistently nd firly. The Pulic Accounts Committee issued its own report on this topic in Decemer 2013 2. The Committee s report concluded tht equitle nd timely ccess to CHC hd not lwys een ville, nd this hd led to some ptients nd their fmilies feeling disenfrnchised nd let down y the system. 1 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre, Auditor Generl for Wles, 13 June 2013 2 Implementtion of the Ntionl Frmework for Continuing NHS Helthcre, Ntionl Assemly for Wles, Pulic Accounts Committee, Decemer 2013 6 Continuing NHS Helthcre Follow-up Report
6 The Welsh Government consulted on revised CHC Frmework etween Decemer 2013 nd Mrch 2014. The Welsh Government then issued finl version of the Frmework in June 2014, for implementtion from 1 Octoer 2014. 7 The Auditor Generl s June 2013 report showed tht, hving risen every yer etween 2004-05 nd 2010-11, CHC expenditure unexpectedly fell ck in 2011-12 y 5.8 per cent 3. Since 2011-12, expenditure hs incresed slightly ut, in 2013-14, remined three per cent elow the level reported in 2011-12 (Figure 1). Figure 1 CHC expenditure in Wles 2004-05 to 2013-14 350 300 250 CHC expenditure ( million) 200 150 100 50 0 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 Source: Wles Audit Office nlysis of helth ords nnul ccounts 3 All CHC expenditure figures in this report exclude ny in-yer djustments to the provisions mde in nnul ccounts for the potentil liilities rising from retrospective clims. Continuing NHS Helthcre Follow-up Report 7
8 Hving fllen ck shrply in 2012-13, the numer of CHC-relted complints received y the Pulic Service Omudsmn for Wles incresed to pek of 70 in 2013-14, with similr numer projected for 2014-15 (Figure 2). The Pulic Service Omudsmn hs confirmed tht more recent complints hve tended to focus on the qulity of the ssessment nd decision -mking processes rther thn on the dministrtion of clim once eligiility is estlished. Figure 2 CHC complints received y the Pulic Service Omudsmn for Wles, 2006-07 to 2014-15 80 70 60 50 Numer of complints 40 30 20 10 0 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13¹ 2013-14 2014-15 (projected)² Notes: 1 The numer of complints received in 2012-13 t 35 turned out to e lower thn the projected 51 complints s included in the Auditor Generl s June 2013 report. 2 2014-15 projection s t Septemer 2014. Source: Pulic Service Omudsmn for Wles 8 Continuing NHS Helthcre Follow-up Report
9 Prepred y Wles Audit Office stff on ehlf of the Auditor Generl, this follow-up report exmines: c how the Welsh Government in revising the CHC Frmework hs responded to the issues rised y the Auditor Generl nd the Pulic Accounts Committee; the progress mde y the Powys Project 4 in clering the cklog of retrospective CHC clims 5 received up to 15 August 2010 nd the progress mde y the Powys Project nd helth ords in clering the clims received from 16 August 2010; nd the steps tken to strengthen communiction nd enggement with individuls nd their fmilies out CHC 6. 10 Overll, we found tht there hs een positive response from the Welsh Government to mny of the issues rised nd recommendtions mde previously y the Auditor Generl nd the Pulic Accounts Committee. However, despite some progress, we still hve significnt concerns over the pproch to clering retrospective clims. In our view, the Welsh Government now needs to tke stronger nd more directive role with helth ords to improve nd speed up the processing of retrospective clims. 11 The revised CHC Frmework ddresses mny of the weknesses in the previous version nd ledership nd oversight re eing strengthened. The revised CHC Frmework ddresses mny of the issues previously rised y the Auditor Generl nd the Pulic Accounts Committee, nd the Welsh Government hs improved the guidnce within the Frmework nd the supporting documenttion. 12 The Welsh Government is strengthening its ledership nd oversight through new Performnce Frmework for CHC, which includes n nnul peer review in ech helth ord (referred to s n nnul udit smple) tht hs the potentil to help ensure consistent decision mking on CHC eligiility. CHC nd the complex cre gend re mjor chllenges for helth ords. The Welsh Government nd helth ords hve developed trining in the revised Frmework. Although sustntil numers of stff hve received the trining, there is considerle vrition in ttendnce numers cross helth ords. 4 Originlly, the Welsh Government set up the ntionl Powys Project, hosted y Powys Teching Helth Bord, to del with ll retrospective clims received cross Wles up to 15 August 2010. It is lso now responsile for shre of the clims held y helth ords received from 16 August 2010. 5 An individul or their representtive my request retrospective review where they contriuted to the cost of their cre, ut hve reson to elieve tht they my hve met the eligiility criteri for CHC, which were pplicle t tht time. 6 Appendix 3 summries the udit methods we hve used to support our findings nd conclusions, including short survey of ll helth ords in Wles. We hve not undertken detiled fieldwork in helth ords. Continuing NHS Helthcre Follow-up Report 9
13 There re more retrospective clims outstnding thn ever efore, nd the response from some helth ords hs een unstisfctory. The revised Frmework outlines common process for deling with retrospective clims, nd the Welsh Government hs now set dedlines for reviewing ll retrospective clims (Appendix 1). However, the dedlines only relte to the internl review of clim nd do not provide n incentive for helth ords to complete ll prts of the clims process promptly. We nd the Pulic Services Omudsmn re of the opinion tht the current pproch is flwed s it does not dequtely focus upon or monitor wht mtters most to individuls the completion nd resolution of their clim. 14 A ntionl tsk nd finish group hs een estlished y the Welsh Government nd helth ords to oversee retrospective reviews. Although the tsk nd finish group hs delivered on numer of fronts, it hs not delivered on its core remit ensuring clims re processed efficiently within the dedlines set nd ttendnce nd memership hs een prolemtic. The performnce monitoring developed y the tsk nd finish group is indequte nd does not identify explicitly whether clims re eing reviewed within the dedlines set. Some helth ords hve lso struggled to provide ccurte nd timely performnce dt. 15 The NHS received 2,525 clims up to 15 August 2010, which were the responsiility of the Powys Project. Since 16 August 2010, the NHS hs received further 4,092 clims, significnt proportion of which were in response to July 2014 cut-off dte nnounced y the Welsh Government 7. The mjority of the clims received since 16 August 2010 re now the responsiility of the Powys Project, ut helth ords hve retined significnt numer of clims. The division of responsiility etween helth ords nd the Powys Project cretes dded complexity, nd this mkes it more difficult to ensure consistency. 16 The Powys Project reviewed s intended ll clims received up to 15 August 2010 y the greed dedline; this ws significnt chievement. Although ll clims were not completed y this dte, prolems estlishing independent pnels pper now to hve een resolved. The Powys Project, lthough it hs demonstrted its ility to deliver, fces n even greter chllenge in processing its shre of the clims received fter 16 August 2010 nd hs een constrined y IT prolems nd delys in the trnsfer of informtion from some helth ords. The Powys Project hs een unle to fill vcncies nd recruit dditionl stff whilst it hs een developing usiness cse for its long-term funding nd seeking its pprovl from helth ords. The Powys Project issued the usiness cse to helth ords in Decemer 2014. 7 The Welsh Government nnounced on 30 April 2014, tht ny clims with clim period relting to 1 April 2003 nd 31 July 2013 needed to e sumitted y 31 July 2014. This led to the sumission of 2,486 clims. 10 Continuing NHS Helthcre Follow-up Report
17 We cknowledge tht delys in processing cn occur due to slow response from individuls or their representtives to requests for informtion. Nevertheless, some helth ords hve not demonstrted tht they re le to del in timely wy with the clims they re responsile for. The performnce of two helth ords is of prticulr concern. The other helth ords hve mde vrile progress with some mking significnt inrods into the cklog of clims. As t the end of Octoer 2014, four helth ords were projecting to tke round two yers or more to review ll outstnding clims. We hve not reviewed progress since the end of Octoer 2014, ut we understnd tht whilst clims continue to e reviewed nd completed, there hs een no step chnge in the rte of progress. Helth ords hve lredy missed the two-yer dedline for significnt numer of clims, nd unless there is chnge of pproch, mny more clims will rech the two-yer dedline. 18 Some climnts re eing delt with unresonly s result of some helth ords not lwys requesting proof of pyment promptly on receiving clim. Susequently, nd through no fult of the climnt, there is risk tht some helth ords my not give priority to some longstnding clims over other clims tht re fr more recent. Some climnts re eing disdvntged due to unfir demnds from helth ords over the extent of the proof of pyment evidence tht they re expected to provide mny yers fter sumitting their clim. 19 Pulic informtion on CHC hs een expnded ut needs to e more ccessile, there were weknesses in the pulicity of the July 2014 cut-off for some retrospective clims, nd ccess to dvoccy services remins concern for some helth ords. The Welsh Government hs developed rnge of informtion leflets, ut could do more to pulicise them nd mke them more ccessile. In prticulr, there is no generl informtion tht is widely ville, for exmple in cre homes, to rise pulic wreness of CHC. Although the Welsh Government issued vrious communictions itself, the ction tken y helth ords to pulicise the end of July 2014 cut-off for some retrospective clims ppers to hve een inconsistent. In ddition, some helth ords remin concerned out the vilility nd funding of dvoccy services for CHC. Continuing NHS Helthcre Follow-up Report 11
Recommendtions Implementtion of the revised Frmework 1 The Performnce Frmework is key to ensuring the effective implementtion of the revised Frmework. We recommend tht the Welsh Government: c d monitors closely the qulity of helth ords self-ssessments, nd qurterly nd nnul reports, requiring helth ords to ddress ny deficiencies; ensures the recent nnul udit smple is reported t n individul helth ord level, requiring helth ords to confirm the steps they re tking to ddress ny issues or inconsistencies in their decision mking on eligiility; prioritises the development of the plnned customer feedck mechnism; nd ensures tht, following the end of the secondment to the role of the ntionl policy nd prctice led for CHC, it hs pproprite internl cpcity to deliver the Performnce Frmework. Retrospective clims processing 2 The performnce of helth ords hs een too vrile. The ntionl tsk nd finish group for retrospective clims, which is helth ord led nd works on collortive sis, hs struggled to gree roust pln nd monitoring rrngements. We elieve tht it is now pproprite for the Welsh Government to tke more directive pproch with helth ords. We hve identified issues with the wy trgets re set for the processing of retrospective clims, nd with the dequcy of performnce monitoring. We recommend tht the Welsh Government within month of the puliction of this report: c Requires ll helth ords to dopt common clims register sed on the Powys Project version, or s minimum, confirms the core informtion tht helth ords should hold on locl registers. Outlines to helth ords the key performnce monitoring informtion they need to provide ech month; this should include the numer of clims tht hve, nd re t risk of, reching the processing dedlines nd should cover ll key steps in the clim process. Considers setting trget times for completing, s well s reviewing, clims. 3 To meet the processing dedlines set y the Welsh Government, there needs to e n immedite step chnge in some helth ords. We recommend tht the Welsh Government: ssures itself tht individul helth ords re llocting sufficient stff resources to enle processing dedlines to e met, nd if this ssurnce is lcking, tke dditionl steps, such s requiring the Powys Project to tke over cklog clims from helth ord; nd stisfies itself tht the long-term funding provided y helth ords for the Powys Project is dequte, including for ny dditionl clims tken over from helth ords. 12 Continuing NHS Helthcre Follow-up Report
4 Helth ords re deling unresonly with some people who sumitted clim numer of yers go over proof they hve pid cre home fees. We recommend tht the Welsh Government: issues guidnce covering longstnding clims in which helth ords hve only recently sked for proof of pyment to ensure helth ords give pproprite priority to reviewing this type of clim; nd extends the guidnce issued in Decemer 2013 to similr clims received fter 16 August 2010 to ensure climnts re not disdvntged y their inility to provide further proof of pyment, which they were not mde wre of t the outset of their clim. Informing individuls, their fmilies nd the pulic 5 To uild upon the steps lredy tken to improve the communiction nd enggement with individuls, we recommend tht the Welsh Government: requires helth ords to mke generl informtion on CHC more widely ville, for exmple through cre homes; nd considers whether more needs to e done to pulicise the rolling cut-off nd the 1 Octoer cut-off dte for clims covering the period 1 August 2013 to 30 Septemer 2014. Continuing NHS Helthcre Follow-up Report 13
Prt 1 The revised CHC Ntionl Frmework ddresses mny of the weknesses in the previous version, nd ledership nd oversight re eing strengthened
The revised Frmework ddresses mny of the issues rised nd recommendtions mde previously y the Auditor Generl nd the Pulic Accounts Committee The guidnce within the Frmework nd the supporting documenttion hve een improved 1.1 The Auditor Generl s June 2013 report identified 13 res in which the Welsh Government could improve the detiled guidnce in the former Frmework. These hve in the min een ddressed, either fully or prtilly. For exmple, the revised Frmework now includes: c expnded guidnce on how CHC should e pplied to people with lerning disility or with mentl helth needs; more detil on joint funding rrngements etween helth nd socil cre nd on top-ups 8 nd direct pyments 9 ; nd less onerous nd more relistic requirements for the frequency of CHC reviews 10, tht re in line with the requirements in Englnd. 1.2 The revised Frmework lso outlines common process for deling with retrospective clims nd sets dedlines for how long it should tke to process clim (this is covered in more detil in Prt 2 of this report). However, the revised Frmework does not specify the mximum trget time within which helth ords should resolve disputes when n individul chllenges decision on CHC eligiility. The revised Frmework continues to stte tht helth ords should del promptly with dispute nd tht helth ords should gree nd pulicise timescles for deling with disputes. 1.3 The Auditor Generl s report highlighted the scope for the development of more ntionl protocols nd documenttion, nd for greter shring of locl policies nd documenttion etween helth ords. The Welsh Government hs tken steps to ddress these issues, nd creted new wesite, the complex cre informtion nd support site (www.cciss.org.uk), which supports the revised Frmework nd contins rnge of mterils, including exmples of rnge of documents nd policies. 1.4 The Welsh Government intends over time to shre further exmples of documenttion nd protocols on the wesite, which will continue to evolve nd support the implementtion of the revised Frmework. The Welsh Government s focus is on shring protocols nd documenttion etween helth ords. The Welsh Government hs not developed ntionl documenttion for ll helth ords to use. 8 Top ups re dditionl personl contriutions to CHC pckges such s for dditionl services or for higher-cost premium ccommodtion. 9 Direct pyments re mde y socil services to individuls so tht they cn uy cre services for themselves. 10 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. Continuing NHS Helthcre Follow-up Report 15
The revised Frmework promotes the use of screening tool in specific circumstnces ut leves its use to the discretion of helth ords 1.5 The Auditor Generl s June 2013 report identified numer of potentil enefits from dopting screening tool to determine whether someone requires CHC ssessment. In its consulttion document for the revised Frmework, the Welsh Government proposed mndtory screening tool. However, hving considered the consulttion responses, the Welsh Government decided not to mke the tool mndtory. The rtionle for this ws tht screening tool: risks premture ssumptions eing mde regrding the outcome of relement nd ssessment 11 there were concerns tht prctitioners would use the screening tool nd trigger full CHC ssessment efore rehilittion or relement hd mximised the individul s level of independence; nd might e used to screen out individuls who were potentilly eligile, efore comprehensive ssessment hd een undertken ll individuls with complex needs who re likely to require longer-term cre nd support re entitled to comprehensive ssessment. 1.6 The revised Frmework does cknowledge tht there my e specific circumstnces where screening tool would e useful. Should helth ord choose to use screening tool, the Frmework sttes tht this must e the version used in Englnd, nd tht it should e completed y t lest two people, one of whom should e from the relevnt locl uthority. We understnd tht some helth ords hve previously requested greter direction from the Welsh Government on the use of the screening tool. However, the Frmework does set out the two instnces where the Welsh Government elieves it my e pproprite to use the screening tool, which re: cre home residents whose condition hs chnged nd n erlier-thn-plnned review is needed; or to provide structured rtionle where the multidisciplinry tem elieves complex cre pckge is clerly not required. The revised Frmework dopts the decision support tool used in Englnd nd, lthough the Welsh Government hs undertken n initil ssessment, the full impct of the new tool will tke time to estlish 1.7 The Auditor Generl s June 2013 report concluded tht ecuse of differences etween the decision support tool used in Wles nd Englnd, it might e more difficult 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. The Welsh Government hs dopted the decision support tool used in Englnd s prt of the revised Frmework, which should help ensure greter consistency. 11 Consulttion summry of responses, Continuing NHS Helthcre: The Ntionl Frmework for implementtion in Wles, Welsh Government, 30 June 2014 16 Continuing NHS Helthcre Follow-up Report
1.8 The Pulic Accounts Committee ws concerned out the impct of mending the decision support tool upon those people ssessed under the previous version, s individuls might hve een disdvntged nd therefore potentilly le to mke retrospective clim. The Welsh Government rrnged for smple of helth ords to ssess the potentil impct of the new decision support tool on eligiility decisions mde under the former version of the tool. The report on this exercise confirms tht: c two helth ords ssessed 10 cses ech ( third helth ord withdrew due to lck of cpcity to undertke the ssessments); the results indicted tht whilst the new decision support tool my increse some scores, the overll outcomes were not ffected; nd ecuse the smple size of the evlution ws smller thn nticipted, the report concluded tht there is need for ongoing monitoring y helth ords of the impct of the new tool. 1.9 In response to our survey, five helth ords rised the potentil impct of the new decision support tool s one of their concerns with implementing the revised Frmework. Their concerns relted to the potentil for incresed numers of individuls eing ssessed s eligile for CHC nd the ssocited cost pressures; nd for the potentil for incresed worklod through requests for reviews of cses previously considered ineligile. 1.10 The revised Frmework lso seeks to reduce the demnds on prctitioners y them void duplicting nd trnscriing informtion on vrious records. The Frmework mkes cler tht prctitioners must consider every domin in the decision support tool, ut tht if the ssessment nd cre pln documenttion re sufficiently roust there is no requirement to duplicte pperwork y copying informtion into decision support tool document. In these circumstnces, it will e cceptle to only complete the decision support tool summry sheet; the summry record of the multidisciplinry tem decision on eligiility nd the rtionle; nd the equlity monitoring form. This tkes wy dupliction from front-line stff, ut mkes the scrutiny process more time-consuming for CHC mngers. Some helth ords told us tht they would welcome greter direction from the Welsh Government on when it is pproprite not to fully complete the decision support tool. However, the Welsh Government informed us tht the nnul udit smple did not indicte ny prolems with ccurcy or completeness of the recorded evidence on eligiility nd the decision-mking process. Continuing NHS Helthcre Follow-up Report 17
Some importnt steps re eing tken to strengthen ledership nd oversight, nd lthough sustntil numers of stff hve received trining in the revised Frmework, there is considerle vrition etween helth ords The Welsh Government is strengthening its ledership nd oversight through new Performnce Frmework for CHC which includes nnul peer review of CHC eligiility decisions 1.11 The previous reports y the Auditor Generl nd the Pulic Accounts Committee identified the need to strengthen ledership nd governnce round CHC, oth t n ll-wles level nd within helth ords. The Welsh Government hs susequently greed revised governnce rrngements s prt of the revised Frmework, with: helth ords hving nmed executive director responsile for monitoring CHC performnce nd mintining strtegic oversight; nd ech locl uthority hving nmed link with equivlent orgnistionl sttus to liise with the helth ord nmed director nd to report to the relevnt locl uthority scrutiny committee. 1.12 All helth ords confirmed to us tht they hve greed n executive led for CHC. However, Betsi Cdwldr University Helth Bord confirmed tht it hd greed two executive leds the Director of Nursing, Midwifery nd Ptient Services, nd the Director of Primry, Community nd Mentl Helth Services. We hve not exmined led rrngements within locl uthorities s prt of this follow-up work. 1.13 The Welsh Government is estlishing complex cre stkeholder reference group to provide policy officils nd helth ords with ccess to expertise in CHC nd in other res of long-term cre. Representtion is likely to include locl government, service provider orgnistions, specilist dvisory groups for lerning disility, mentl helth nd children s services, nd policy leds from relevnt prts of the Welsh Government. The group is likely to hold its first meeting in Jnury 2015. 1.14 In ddition, the Welsh Government hs greed new Performnce Frmework with helth ords which comprises of four key mechnisms: self-ssessment; strengthened performnce reporting; nnul peer review nd smple udit; nd service user feedck (Figure 3). The purpose of the Performnce Frmework is to monitor the implementtion of the revised Frmework; provide ssurnce tht CHC eligiility decisions re consistent nd fir cross Wles; nd provide opportunities for shred lerning nd service improvement. 18 Continuing NHS Helthcre Follow-up Report
Figure 3 New Performnce Frmework for CHC Mechnism Orgnistionl self-ssessment Detils Ech helth ord is to undertke n nnul self-ssessment, using the tool we issued longside the Auditor Generl s June 2013 report. Strengthened reporting rrngements Annul peer review nd smple udit Service-user feedck The nmed helth ord director is to present (s minimum) qurterly performnce report with prescried coverge to their ord, nd copied to the Welsh Government. An nnul report is to e prepred y the nmed helth ord director (gin with prescried coverge), nd ntionl puliclly ville report is to e collted y the Welsh Government. Qurterly reporting is due to commence in 2015-16, with nnul reports commencing in June 2015 (initilly covering the six months from Decemer 2015). Some of the required dt is not currently collected, ut the Welsh Government expects helth ords to ddress these gps. Annul peer review of CHC decision mking in ll helth ords to determine whether there is consistency cross Wles. The udit involves reviewing smple of recent CHC nd funded nursing cre cses, together with smple of retrospective clims. The udit ssesses whether the helth ord hs followed the correct process nd interpreted eligiility criteri ppropritely nd consistently. To support improved user experiences, the Performnce Frmework commits to developing feedck rrngements. The Welsh Government is considering the options ville for gthering service user feedck, nd in prticulr is looking t developing questionnire tht helth ords would hnd out to ll people who hve CHC ssessment. Individuls would return the questionnire to n independent ody for nlysis nd reporting. Source: Welsh Government, Performnce Frmework for the Implementtion of Continuing NHS Helthcre in Wles, 2014 1.15 Helth ords sumitted their first self-ssessment nd ction pln to the Welsh Government in Ferury 2014. Feedck from the Welsh Government nd helth ords on the self-ssessment tool hs een positive, with them finding it to e cler, concise nd not time-consuming whilst successfully identifying key ntionl nd locl res for service improvement. 1.16 We hve not sought to review fully the Ferury 2014 self-ssessments, ut some spects pper to e overly positive. For exmple, five helth ords concluded tht ll relevnt helth nd socil services stff hd ttended initil CHC trining. However, we hve found tht the prolems highlighted in the Auditor Generl s June 2013 report with ensuring ll stff re trined re still evident (prgrph 1.26 to 1.27). Continuing NHS Helthcre Follow-up Report 19
1.17 The Welsh Government co-ordinted the first nnul smple udit in Octoer 2014, which involved the Welsh Government ntionl policy nd prctice led for CHC, the ntionl director for complex cre 12, nd the director of the Powys Project, ll of whom hve clinicl ckground. The roll out of the nnul udit smple ws significnt step forwrd. At the time of prepring this follow-up report, the Welsh Government ws writing up nd discussing with individul helth ords the results from the nnul smple udit. As result, we re not in position to confirm the specific outcomes. However, the Welsh Government confirmed to us tht the exercise hd een very worthwhile nd tht it hd identified: c d rnge of good prctice tht would e shred cross helth ords; the need for greter clrity over when people with lerning disility should e eligile for CHC or for joint funding etween the helth ords nd the locl uthority; generlly consistent nd pproprite decision mking on eligiility, with sustntive issues in only one helth ord; nd generlly consistent implementtion of the ntionl process for retrospective clims, with sustntive issues in only one helth ord ( different helth ord from the one where the udit identified issues with eligiility decision mking). 1.18 The revised Frmework lso stipultes other situtions in which helth ords should look to use peer review of individul cses, nmely: c where the multidisciplinry tem is unle to rech consensus view on CHC eligiility, it should esclte the dispute to the pproprite mnger nd ccess peer review from within, or outside of, its helth ord; where the individul or their representtive disputes the clinicl ssessment of the multidisciplinry tem, externl peer review (from nother directorte or helth ord) should e offered s mtter of course; nd s prt of their udit nd continuous service improvement progrmmes. 12 The Ntionl Director for Complex Cre, post tht ecme full time in April 2014, hs remit to work cross helth ords on mtters relting to CHC, complex cre, nd integrted helth nd socil cre services. 20 Continuing NHS Helthcre Follow-up Report
1.19 CHC nd funded nursing cre expenditure ptterns continue to vry significntly cross helth ords (Figure 4), nd indicte the need for ongoing peer review. As outlined in the Auditor Generl s June 2013 report, there re numer of resons tht cn explin reductions in CHC expenditure t some helth ords, including investment in modernising complex cre services; push to identify svings within CHC udgets; nd chnges to the nture nd extent of some hospitl nd community services. The Auditor Generl s recent report on NHS finncil nd service performnce 13 identified CHC s the fourth lrgest re of reported svings y helth ords, with 24 million of svings identified in 2013-14. However, the Auditor Generl s June 2013 report on CHC concluded tht it ws uncler whether the wy helth ords were interpreting eligiility for CHC hd lso contriuted to the differing expenditure ptterns. Figure 4 Percentge chnge in CHC nd NHS-funded nursing cre expenditure 2010-11 to 2013-14 (csh terms) 50 40 CHC expenditure (net) FNC expenditure 41.6% 30 20 13.2% 15% 13.4% 10 Percent 0 5.2% 4.2% 3.4% 1.5% -10-4.1% -20-13.5% -9.8% -16.5% -15.3% -30-28% -40 BCU Powys Hywel Dd ABMU C&V Cwm Tf Aneurin Bevn Source: Wles Audit Office nlysis of helth ord finl ccounts 13 NHS Wles: Overview of Finncil nd Service Performnce 2013-14, Auditor Generl for Wles, 14 Octoer 2014 Continuing NHS Helthcre Follow-up Report 21
1.20 The successful implementtion of the Performnce Frmework will require pproprite cpcity within the Welsh Government. The ntionl policy nd prctice led for CHC, working on secondment from NHS Wles, currently provides this cpcity. However, the secondment is due to end in Ferury 2015. In considering its options, the Welsh Government will need to tke into ccount the resources nd skills needed to drive nd deliver the Performnce Frmework, including the nnul smple udit. CHC nd the complex cre gend re mjor chllenges for helth ords 1.21 In Octoer 2014, helth ords greed revised governnce nd ccountility rrngements for complex cre 14 with the Welsh Government, which included estlishing ntionl complex cre ord 15 jointly chired y the led helth ord chief executive nd the director of socil services t the Welsh Government. We understnd tht the ord will hve strtegic oversight of relevnt policy mtters nd their implementtion, long with other key issues such s the retrospective CHC clims process. The ord will hve no executive decisionmking mndte, ut it will provide dvice, guidnce nd recommendtions to helth ord chief executives. 1.22 We hve not reviewed the governnce rrngements within individul helth ords s prt of this work, ut the prominence of CHC nd complex cre hs incresed in recent yers nd helth ords will continue to fce significnt demnds nd chllenges. For exmple, nlysis undertken y the ntionl director for complex cre indictes tht NHS Wles now funds s mny plcements in cre homes s it provides inptient eds. Working with helth ords, the Welsh Government hs developed trining in the revised Frmework nd sustntil numers of stff hve received the trining lthough there is considerle vrition in ttendnce levels cross helth ords 1.23 The Auditor Generl s June 2013 report found tht helth ords hd rolled out stndrd trining on CHC to mixed effect, nd tht they needed to provide roder rnge of trining. Although the Pulic Accounts Committee welcomed the Welsh Government s commitment to the provision of trining, it recommended etter monitoring of trining nd its outcomes. 14 Complex cre services would include long-term cre, relement nd recovery services, integrted helth nd socil cre, nd NHS-funded nursing cre s well s CHC. 15 Helth ords nd the Welsh Government re lso estlishing ntionl complex cre performnce nd opertions group. This group would tke the led on performnce nd opertionl spects of complex cre, nd would provide expertise, dvice nd informtion to the ntionl complex cre ord to enle it to crry out its strtegic oversight role. 22 Continuing NHS Helthcre Follow-up Report
1.24 The Welsh Government hs developed with helth ords ntionl trining modules for helth nd socil services stff. The trining modules, which were modified s the result of testing t trin the triner workshops, involve: priority module this covers the key differences in the revised Frmework nd hs een delivered to stff from ech helth ord who re to cscde trining loclly; nd foundtion module n updted one-dy sic trining course in the revised Frmework with delivery to helth ord representtives commencing in Septemer 2014, nd then cscded down loclly. 1.25 In ddition, the Welsh Government is plnning to develop specilist trining on key issues, such s on co-ordinting pckge of cre or on plnning the trnsition etween children nd dult services. The specilist trining will e provided centrlly rther thn through cscde rrngements within individul helth ords. 1.26 In their responses to our survey, ll helth ords expressed concern out ensuring ll pproprite stff receive timely trining in the priority or foundtion modules. The two jointly developed trining modules were finlised t the end of July 2014 (the priority module this ws one month lter thn plnned) nd the strt of Septemer 2014 (the foundtion module). The revised Frmework s implementtion dte ws 1 Octoer 2014, nd helth ords hve een working towrds ll stff tht routinely ssess CHC eligiility receiving updte trining y the end of Decemer 2014. In order to ssist helth ords, experienced triners from the Powys Project hve provided dditionl support. 1.27 The Performnce Frmework requires helth ords to report on the numer of stff who hve completed the different trining modules. The Welsh Government confirmed to us tht t lest 1,500 NHS Wles stff hve ttended the priority module trining nd over 900 hve ttended the foundtion trining. However, the Welsh Government lso confirmed tht there is considerle vrition in ttendnce numers cross helth ords nd tht it is continuing to monitor the sitution. 1.28 In ddition, the Welsh Government is to re-lunch the complex cre forum 16 to support prctitioners nd with the intention tht this forum will hve greter focus on shred lerning. The Welsh Government is lso plnning to run n nnul conference or lerning event on CHC. The first conference, likely to tke plce in the first qurter of 2015, will include feedck on the nnul smple udit results. 16 The complex cre forum, for multidisciplinry tems supporting people with complex needs, fcilitted shred lerning nd provided forum for dete. It lst met in My 2012. Continuing NHS Helthcre Follow-up Report 23
Prt 2 There re more retrospective clims outstnding thn ever efore, nd the response from some helth ords hs een unstisfctory
The revised Frmework outlines common process for deling with retrospective clims 2.1 The Auditor Generl s June 2013 report identified tht there ws no common pproch cross helth ords for deling with retrospective clims. The revised Frmework now outlines common process for helth ords to follow, sed on the pproch used y the Powys Project. The responsiility for processing retrospective clims rests with either the Powys Project or individul helth ords (Appendix 1). 2.2 The Auditor Generl s report highlighted tht CHC is complex topic with its own distinct lnguge. In this report, we hve used the following terms to refer to the different steps involved in deling with retrospective clim (Figure 5): c d closed clim refers to where climnt is unle to provide proof of pyment or proof of legl uthority, or where they hve decided to withdrw their ppliction; reviewed clim refers to clim tht hs een reviewed nd recommendtion mde, nd there re potentilly numer of further steps to e tken including negotition with the individul or n independent pnel hering; completed clim refers to clim in which decision hs een rtified nd which is redy for the re-imursement process to commence (if pplicle); nd fully resolved clim refers to when no further ction is required on clim with the re-imursement mde (if pplicle). Continuing NHS Helthcre Follow-up Report 25
Figure 5 Retrospective clims process Cse is received Individul registers intent to mke clim with helth ord Helth ord requests proof of pyment/proof of legl uthority from climnt Cse is ctivted nd the clock strts for monitoring time tken to process the cse Helth ord checks proof of pyment/proof of legl uthority nd writes to climnt confirming these re cceptle Climnt hs five months to provide helth ord with proof of pyment/proof of legl uthority Clock stops for monitoring time tken to process the cse Processing of clim commences chronology produced, cse reviewed nd recommendtion mde Cse is reviewed Direct to rtifiction if eligiility period mtches the clim Negotiting with climnt if prtil eligiility or no eligiility Cses my go to pnel fter negotition Independent review pnel if reviewer is unle to mke decision or peer review indictes n element of dout Cse is completed Decision is rtified nd pssed to the helth ord finnce deprtment which clcultes re-imursement nd sends clcultion nd indemnity letter to climnt On receiving indemnity letter, re-imursement is sent to climnt Cse is fully resolved Source: Wles Audit Office nlysis of vrious Welsh Government documents 26 Continuing NHS Helthcre Follow-up Report
The Welsh Government hs set dedlines for reviewing retrospective clims, ut the pproch could led to helth ords cting in wy tht undermines the timely processing of clims nd performnce monitoring is indequte The revised Frmework sets dedlines for the sumission of clims nd for the mximum processing time which reduces over time from two yers to six months 2.3 The Auditor Generl s June 2013 report highlighted tht the Welsh Government hd not set timetle for clering the retrospective clims tht were the responsiility of helth ords. The Pulic Accounts Committee considered tht ll clims should e delt with within mximum of two yers. 2.4 The revised Frmework sets out dedlines for people to register nd for the NHS to process ll current nd future retrospective clims (Appendix 1). The Frmework sttes tht the current cklog of clims those relting to clim period etween 1 April 2003 nd 31 July 2013 tht hve een received etween 16 August 2010 nd the 31 July 2014 dedline set y the Welsh Government should tke individully no longer thn two yers to process. 2.5 The revised Frmework then reduces the mximum processing time for other clims, s follows: for those relting to clim period etween 1 August 2013 nd 30 Septemer 2014 tht re received etween 1 August 2014 nd 1 Octoer 2015, the mximum time tken to process is reduced to 12 months; nd for those relting to clim period fter Octoer 2014, there is rolling cutoff for people to sumit clims (within 12 months of the clim period), nd the mximum time to process is reduced to six months. 2.6 If clim spns two periods, then the full clim period is considered t the time the cse is first processed. For exmple, for clims sumitted efore 31 July 2014, the whole clim period would e considered even if this extended pst July 2013. The complexity of the requirements nd the reducing timefrmes for processing clims is significnt chllenge for helth ords. This will require helth ords to monitor closely progress ginst these requirements nd the dequcy of the resources deployed on clims processing. Continuing NHS Helthcre Follow-up Report 27
Clims re only expected to e reviewed rther thn completed within the prescried dedlines nd there is potentil for helth ords to ct in wy tht undermines timely processing 2.7 Processing clim commences when n individul registers n intent to mke clim nd is fully resolved when the individul receives re-imursement (Figure 5). However, the Welsh Government dedlines for deling with clim only relte to prt of this process. The revised Frmework refers to the dte of ppliction s the point t which the clock should strt in mesuring the time to process clim; nd to clim then eing processed within the stted timefrme. The Frmework does not define these terms explicitly. However, Welsh Government officils told us tht, s outlined in pulic leflet on CHC retrospective cses 17 : the dte of ppliction is when helth ord issues letter to the climnt confirming tht the proof of pyment nd proof of legl uthority 18 evidence tht they hve sumitted is cceptle, nd not the point t which the ppliction is sumitted; nd clim is processed when it hs een reviewed nd recommendtion mde, nd not when finl decision is communicted to the climnt or the reimursement (if pplicle) is mde. 2.8 The Welsh Government s rtionle for strting nd stopping the clock t these stges is tht progress efore nd fter these points ecomes more dependent upon the climnt or their representtive. Specificlly: Before the clock strts: the helth ord needs to request proof of pyment nd proof of legl uthority from the climnt; the climnt then needs to provide proof of pyment nd proof of legl uthority prior to the clim eing processed climnts re currently given up to five months to provide this; nd the helth ord needs to review the proof of pyment nd proof of legl uthority, nd confirm the dequcy of this to the climnt. After the clock hs stopped: the mjority of clims require negotition phse nd/or n independent review pnel hering, this cn tke three months or longer to complete; helth ords re routinely tking two to three months to clculte the reimursement due, nd send out the indemnity letter to the climnt; nd on receiving the indemnity letter, helth ords hve up to 30 dys to issue the re-imursement. 17 Continuing NHS Helthcre: Cut-off dtes for ssessment of eligiility for cses during the period 1 April 2003 to 31 July 2013, Welsh Government informtion leflet, 2014 18 A key prt of the initil process of deling with retrospective clim is ensuring tht the person mking the clim is le to provide proof tht they hve pid the relevnt cre home fees nd tht they hve legl uthority to pursue the clim. 28 Continuing NHS Helthcre Follow-up Report
2.9 In prctice, clim tht meets the two-yer dedline my ctully tke three yers or more to go from the climnt registering n intent to clim to them receiving reimursement (if pplicle). The wy the dedlines re set could lso led helth ords to not del with ll prts of the process in timely wy. There is risk tht helth ords could focus on reviewing outstnding clims nd: not devote resources to requesting nd reviewing proof of pyment nd proof of legl uthority, or to issuing letters to climnts confirming tht these re cceptle this would lso reduce the numer of clims tht re ctivted with the clock strted; nd not prioritise the negotition nd independent review pnel process or the clcultion nd pyment of re-imursements. 2.10 As helth ords re not necessrily cpturing informtion on, nd do not report ll key stges in the process (prgrphs 2.17 nd 2.19), there is mixed evidence on whether they re tking ll steps in the process in timely wy. There is some evidence tht they re not lwys deling with clims promptly in the erly stges of processing. In the pst, some helth ords hve not requested proof of pyment in timely wy (prgrphs 2.49 nd 2.52). The Welsh Government told us tht the smple udit indicted tht proof of pyment is now generlly eing requested promptly ut tht there ws vrition etween helth ords. 2.11 There is no reporting or evidence on how promptly helth ords complete clim once they hve reviewed it. The time they tke to fully resolve clim is, however, eing reported. This dt shows tht in the pst there hve een prolems with helth ords tking extended time to reimurse climnts, ut tht this now seems to hve een resolved. By the end of Octoer 2014, ll helth ords were tking etween eight to 12 weeks to clculte the mount to e reimursed nd send the indemnity letter to the climnt; nd then, on receipt of the indemnity letter, ll helth ords were mking the reimursement within 30 dys. 2.12 We hve discussed this issue with the Pulic Services Omudsmn for Wles, whose views the Welsh Government hs regulrly sought over the resonleness of dedlines for deling with retrospective clims. We nd the Pulic Services Omudsmn re of the opinion tht the current pproch is flwed s it does not dequtely focus upon, or monitor, wht mtters most to individuls the completion, rther thn the review, of their clim. Continuing NHS Helthcre Follow-up Report 29