Practice Guidance Notes on the Fast Track Pathway

  • For background information about the Fast Track Pathway Tool, read more here.
  • To access other sections of the Practice Guidance Notes, click here.

PG 44 In a Fast Track case is it the CCG or the ‘appropriate clinician’ who decides  that the individual has a primary  health need?

44.1  In Fast Track cases, Standing Rules state that it is the ‘appropriate clinician’ who determines that the individual has a primary health need. The CCG must therefore decide that the individual is entitled to NHS continuing healthcare and should respond promptly and positively to ensure that the appropriate funding and care arrangements are in place without delay.

44.2   The Fast Track Pathway Tool is used when the individual has a rapidly deteriorating condition and the condition may be entering a terminal phase. For the purposes of Fast Track eligibility this constitutes a primary health need. No other test is required.  Thecompletion of the Fast Track Tool is sufficient evidence to establish eligibility; The Fast Track Pathway Tool for NHS Continuing Healthcare

PG 45 Who can complete  the Fast Track Pathway Tool?

45.1    The Fast Track Tool can  only be  completed  by an  ‘appropriate  clinician’,  and  the Responsibilities Directions define an ‘appropriate clinician’ as a person who is:

(i) responsible for the diagnosis, treatment or care of the person in respect of whom a Fast Track Pathway Tool is being completed,

(ii) diagnosing, or providing treatment or care to, that person under the 2006 Act, and

(iii) a registered nurse or is included in the register maintained under section 2 of the Medical Act 1983.

45.2   Thus  those  completing  the  Fast  Track  Pathway  Tool  could  include  consultants, registrars, GPs and registered nurses. This includes relevant clinicians working in end of life care services within independent and voluntary sector organisations if their organisation is commissioned by the NHS to provide the service.

45.3   Whoever the practitioner is, they should be knowledgeable about the individual’s health needs, diagnosis, treatment or care and be able to provide reasons why the individual meets  the  conditions  required  for  the  fast-tracking  decision.  Others  involved  in supporting an individual with end of life needs, including those working within wider independent or voluntary sector organisations should, with the individual’s consent, contact the appropriate clinician responsible for that individual’s healthcare to request that the Fast Track Pathway Tool be completed. Alternatively they could approach the relevant CCG and make the request.

PG 46 What   is   the   relationship  between   the   Fast   Track   Pathway   Tool   and   the Checklist/Decision Support  Tool?

46.1   Where it is appropriate to use the Fast Track Pathway Tool, this replaces the need for a Checklist and DST to be completed, although a Fast Track Pathway Tool can also be completed after the completion of a Checklist if it becomes apparent at that point that the relevant criteria are met.

PG 47 Do individuals need to consent  to a Fast Track Pathway Tool being completed?

47.1   Yes, individuals need to give informed consent to the completion of the Fast Track Pathway Tool and the clinician completing the Tool should sensitively seek this. It may be useful to link the consent to the completion of a DST where there is a possibility of the need for this to be undertaken at a future date.

47.2   Where an individual is unable to provide consent, the appropriate clinician should make a ‘best interests’ decision on whether to complete the Fast Track Pathway Tool in accordance with the Mental Capacity Act 2005. PG7 above explains more about the necessary actions. This best interests process should be carried out without delay, having regard to the intention that the tool should enable individuals to be in their preferred place of care as a matter of urgency.

PG 48 Is the use of the Fast Track  Pathway  Tool  dependent  on specific timescales in relation  to end of life care?

48.1   No, there are no time limits specified and a decision to use the Fast Track Pathway Tool should not be based solely around an individual’s life expectancy. The phrase ‘rapidly deteriorating’ in the Tool should not be interpreted narrowly as only meaning an anticipated specific or short time frame of life remaining. Similarly the phrase ‘may be entering a terminal phase’ is not intended to be restrictive to only those situations where death is imminent. Also, someone may currently be demonstrating few symptoms yet the nature of the condition is such that it is clear that rapid deterioration is to be expected before the next planned review. It may therefore be appropriate to use the Fast Track Pathway Tool now in anticipation of those needs arising and agreeing the responsibilities and actions to be taken once they arise, or to plan an early review date to reconsider the situation. It is the responsibility of the clinician referring an individual to base their decision on the facts of the individual’s case and healthcare needs at the time. However, a Fast Track Pathway Tool should be supported by a prognosis and/or diagnosis if known, to help enable staff managing the individual’s future care needs to plan the care/support that is likely to be required. Use of the Fast Track Pathway Tool is based on the criteria set out in the Responsibilities Directions, not on diagnosis.

PG 49 What evidence is required  when completing the Fast Track Pathway Tool?

49.1   The intention of the Fast Track Pathway is that it should enable an individual to access NHS continuing healthcare quickly, with a minimum of delay, and with no requirement to complete a DST. Therefore the completed Fast Track Pathway Tool is in itself sufficient evidence to establish eligibility.

49.2   As it will be necessary to put support services in place promptly, other information about the person’s needs and their preferred model of support will help the CCG to identify the types of services required. Use of the Fast Track Pathway Tool should be carried out as part of overall local end of life care approaches and should reflect the best practice set out in the national End of Life Care Strategy37. The identification of the individual’s preferences as to the services to be delivered and their locations should be identified using recognised models for end of life care, i.e. the Gold Standards Framework38, Preferred Priorities for Care39. In doing this, it is important to advise the person on the range of options available (e.g. home support, hospice, etc.). CCGs should support clinicians to have up-to-date knowledge of local service options as part of their overall approach to end of life care so that individuals can make an informed choice on their preferences. CCGs are responsible for ensuring that a wide range of service options are available. Work with the individual on their end of life care pathway should be taking place regardless of NHS continuing healthcare eligibility and so should facilitate availability of the required information. NHS continuing healthcare staff should work in

37 http://www.dh.gov.uk/health/2011/07/end-of-life-care-strategy/

38 http://www.goldstandardsframework.org.uk/

39 http://www.endoflifecareforadults.nhs.uk/tools/core-tools/preferredprioritiesforcare

partnership with local end of life care leads in each individual case to ensure there is an agreed pathway and care plan agreed with the individual and/or their carer/representative.  This  should  be  regularly  reviewed  and  amended  to  reflect changing needs.

49.3   It is helpful if an indication of how the individual presents in the current setting is included with the Fast Track Pathway Tool, along with the likely progression of the individual’s condition, including anticipated deterioration and how and when this may occur. However, CCGs should not require this information to be provided as a prerequisite for establishing entitlement to NHS continuing healthcare. The completed Fast Track Pathway Tool is sufficient in itself to establish entitlement.

49.4   It is also important for the CCG to know what the individual or their family have been advised about their condition and prognosis and how they have been involved in agreeing the end of life care pathway (which should reflect the approaches in the End of Life Care Strategy).

PG 50 Can a CCG refuse to accept a completed Fast Track Pathway Tool?

50.1   No, the Standing Rules make it clear that the CCG must accept and action the Fast Track Pathway Tool immediately where the Tool has been properly completed in accordance with the criteria for the use of the Tool as explained above.

50.2   The purpose of the Tool is to ensure that the individual receives the support they need as quickly as possible without there first having to be a full consideration of eligibility by an MDT applying the four key characteristics using the DST. The CCG does not require any additional evidence to support eligibility although, as explained above, additional information to help identify the support package required can be helpful. CCGs should not decline acceptance of a completed Fast Track Pathway Tool when the Tool states that the criteria are met. The individual should not experience a delay in receiving appropriate care just because a CCG questions whether the circumstances of the individual case are appropriate for use of the Fast Track Pathway Tool, i.e. whether an individual’s end of life needs are such that the Fast Track Pathway Tool should have been used.

50.3  On receipt of the Fast Track documentation, the CCG should arrange for the care package to be commissioned without delay.

50.4   However, exceptionally, there may be circumstances where CCGs receive a completed tool which appears to show that the individual’s condition is not related to the above criteria at all, for example if a completed Fast Track Pathway Tool states that the person has mental health needs and challenging behaviour but makes no reference to them having a rapidly deteriorating condition which may be entering a terminal phase. In these circumstances the CCG should urgently ask the relevant clinician to clarify the nature of the person’s needs and the reason for the use of the Fast Track Pathway Tool Where it then becomes clear that the use of the Fast Track Pathway Tool was not appropriate, the clinician should be asked to submit a completed Checklist for consideration through the wider eligibility process.

PG 51 What  actions   can  CCGs  take  if  the  Fast  Track  Pathway  Tool  is  being  used inappropriately?

51.1  If the CCG has any concerns regarding the way in which particular clinicians/ organisations are using the Fast Track Pathway Tool these should be addressed separately and should not delay the provision of appropriate support for the person concerned.

51.2   Each individual CCG should monitor and audit the use of the Fast Track Pathway Tool according to locally agreed processes, and take appropriate action if inappropriate use of this Tool is identified. Actions could include targeting training for specific individuals, raising the issue through management actions, or addressing the issue through contracting and performance routes.

PG 52 How quickly could  a hospital discharge take place following the completion of the Fast Track Tool?

52.1   Standing Rules state that the CCG must, upon receipt of a completed Fast Track Pathway Tool, decide that the individual is eligible for NHS continuing healthcare. Action should be taken urgently to agree and implement the care package. CCGs should have processes in place to enable such care packages to be implemented quickly. Given the nature of the needs, this time period should preferably not exceed 48 hours from receipt of the completed Fast Track Pathway Tool. CCGs who receive significant numbers of Fast Track Pathway Tools could consider having staff dedicated to implementing fast- track care packages as this will avoid a conflict of time priorities with dealing with non- fast-track applications. Having dedicated staff could also facilitate close working with end of life care teams. CCGs should also consider wider arrangements that need to be in place to facilitate implementation of packages within 48 hours, such as protocols for the urgent provision of equipment. The CCG coordinator and the referrer should communicate effectively with each other to ensure well-coordinated discharge/support provision arrangements.

PG 53 What settings can a Fast Track Pathway Tool be used in?

53.1   It is expected that the Tool will most often be used in hospital settings. However, it can be used in any setting where an individual satisfies the criteria for the use of the Tool and they require an package of support in their preferred location. This includes where such support is required for individuals who are already in their own home or are in a care home and wish to remain there. It could also be used in other settings, such as hospices.

PG 54 Does  the  Fast  Track  tool  need  to  be  completed  if  the  individual  is  already receiving a care package which could still meet their needs?

54.1   Yes. If an individual meets the criteria for the use of the Fast Track Tool this should be used to ensure not only that they receive the care that they require but also that this care is funded by the appropriate body and end-of-life care arrangements are reviewed.

54.2    This is important because the individual may at present be funding their own care or the LA may be funding (and charging) when the NHS should now be funding the care in full.

54.3   The setting where an individual wishes to be supported as they approach the end of their life may be different to their current arrangements (e.g. even though they are currently in a care home setting they may wish to be supported in their family environment). CCGs should seek to respond positively to such preferences, having regard to best practice set out in wider ‘end of life care’ policy40.

54.4   The setting is not the important issue but rather that the individual concerned receives the  support  they need  in  their  preferred  place  as  soon  as  reasonably practicable, without having to go through the full process for consideration of NHS continuing healthcare eligibility.

PG 55 Should  individuals receiving care  via  the  Fast  Track  Pathway  Tool  have  their eligibility for NHS continuing healthcare  reviewed?

55.1   The aim of the Fast Track Pathway Tool is to get an appropriately funded care package in place as quickly as possible. Once this has happened, it will be important to review needs and the effectiveness of the care arrangements, in line with national guidance (i.e. as a minimum within 3 months). In doing this, there may be certain situations where the  needs  indicate  that  it  is  appropriate  to  review  eligibility  for  NHS  continuing healthcare funding. CCGs should make any decisions about reviewing eligibility in Fast Track cases with sensitivity. Where it is apparent that the individual is nearing the end of their life and the original eligibility decision was appropriate it is unlikely that a review of eligibility will be necessary. CCGs should monitor care packages to consider when and whether a review is appropriate.

55.2   Clinicians  completing  the  Fast  Track  Pathway  Tool  should  sensitively  explain  the process to the individual (and/or their representative) and make them aware that their needs may be subject to a review and that the funding stream may change subject to the outcome of the review.

55.3   Eligibility for NHS continuing healthcare can only be ended by a review through the use of the full MDT-led DST process. The individual affected should be notified in writing of any proposed change in funding responsibility.   They should be given details of their right to request a review of the decision. There should be as much continuity as possible in  the care arrangements,  for  example  by carrying  on  with  use  of  the  same  care providers wherever possible.

40 http://www.dh.gov.uk/health/category/policy-areas/social-care/end-of-life/

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