NAO Investigation into CHC Funding 2017

An investigation into CHC Funding  was published by the National Audit Office on 3rd July 2017. It reports on their findings in nine key points, as well as identifying some of the main issues raised by complainants about the CHC process. (See below)

The full investigation can be accessed here: https://www.nao.org.uk/wp-content/uploads/2017/07/Investigation-into-NHS-continuing-healthcare-funding.pdf

One important point, tucked away at the end of page 38, reads as follows:

“The Department is reviewing the CHC checklist and assessment tool as it recognises that the current process does not make best use of assessment staff. It expects the work will reduce the number of checklists and full assessments that are carried out.”

(Okay ……….)

Appendix 2 (on page 41 of the report) shows the main concerns raised by correspondents. It says:

“Between February 2016 and July 2017, we received over 100 letters from members of the public raising concerns about NHS continuing healthcare (CHC). As the sample is self-selecting, with those who have experienced problems more likely to contact us, we cannot generalise the findings to the whole population that are assessed for CHC funding. However, the concerns raised helped us to understand the nature of potential problems and the impact that these can have on individuals. The table below summarises the most common concerns raised in this correspondence and Figure 17 on page 42 shows how the concerns raised relate to the eligibility process.”

 

Most common concerns and examples of the issues raised by correspondents:

 

The assessment process did not follow the national guidance and/or case law

  • Assessments did not follow or pay due regard to case law established by the Coughlan case.
  • Patient’s health needs were understated during the assessment resulting in ineligibility, despite evidence suggesting a primary health need.
  • Views and judgements of professionals were not requested, or were ignored or a lower score was awarded where professionals disagreed, despite the national framework stating that the higher score should be awarded in these cases.
  • Assessments did not take account of all the relevant information, or used inaccurate information. For example, verbal remarks were recorded incorrectly and written evidence was changed after the assessment.
  • Assessments did not reflect the views of the patient, family or patient representative as they were either not invited, not given adequate notice that an assessment was taking place or not fully involved in the assessment.

 

The quality and composition of the assessment team

  • Assessments did not include professionals involved in the direct care of the individual or did not include the appropriate medical specialist.
  • The assessment team lacked the knowledge or experience to carry out a fair assessment, or took decisions for financial reasons.

 

The process took too long and was subject to delays

  • Assessments exceeded the 28-day requirement or were delayed, for example, by a request for extra information after the assessment meeting.
  • There were long delays between the screening and full assessment. The appeals process and assessment of previously unassessed periods of care took too long, sometimes years.

 

Poor communication with the patient, family and/or patient representative

  • CCGs did not: provide enough information about the process; inform the family that an assessment was taking place; and inform the family of the outcome.
  • CCGs withheld information about the assessment. For example, notes and evidence from the assessment meeting were not distributed.
  • CCGs either did not respond or were slow to respond to queries.

 

Complaints and appeals were mishandled

  • Appeals were ignored and there was a lack of communication about the progress of the complaint.

 

The assessment process is a burden on the patient and their representatives

  • Correspondents have paid for legal advice and help with their applications as well as for copies of medical and care records to support the application.
  • Families and representatives spend considerable amounts of time raising and responding to queries and producing the evidence for the assessment.

 

The Nine Key findings of the investigation:

1 For most people the assessment process for NHS continuing healthcare (CHC) funding involves two stages (paragraphs 1.5, 1.6, and 3.5, and Figures 3 and 4).

  • National data on the total number of people who started the process for CHC funding are not available. However, NHS England estimates that at least 207,000 people started the process for CHC funding in 2015-16.
  • The national framework for CHC states that for most people the assessment process involves an initial screening stage. This uses a CHC checklist to identify people who might need a full assessment.
  • The full assessment should usually be carried out by a group of professionals from across health and social care (known as a multidisciplinary team) who are familiar with the individual’s care needs.
  • There is also a fast-track process, which does not require a full assessment, for individuals with rapidly deteriorating conditions who may be nearing the end of their life. This uses the fast-track pathway tool to determine whether people are eligible.
  • Health and social care professionals must use their professional judgement at both the screening and full assessment stages. They assess the person’s combined healthcare needs across 11 domains in the checklist and 12 domains in the full assessment.

 

2 NHS England recognises that the current assessment process for CHC funding raises people’s expectations about whether they will receive funding and does not make best use of assessment staff (paragraphs 3.5 and 3.6).1

  • NHS England estimates that at least 124,000 standard (non fast-track) screenings and 83,000 fast-track tools were completed in 2015-16.
  • NHS England estimates that around 62% of people who were screened using the checklist went on to have a full assessment in 2015-16.
  • Clinical commissioning groups (CCGs) reported that approximately 29% of people who were referred for a full assessment were assessed as eligible for CHC in 2015-16.
  • Therefore, overall, NHS England estimates that only about 18% of screenings undertaken led to the person being assessed as eligible for CHC in 2015-16. 1 NHS England estimates are based on a one-off data collection from CCGs.

 

3 In most cases eligibility decisions should be made within 28 days but many people are waiting longer (paragraphs 2.1 to 2.5).

  • The national framework states that in most cases people should not wait more than 28 days for a decision about whether they are eligible for CHC, following the CCG receiving a completed checklist.
  • In 2015-16, about one-third of full assessments (24,901 assessments) took longer than 28 days.
  • Approximately 10% of CCGs reported that full assessments took more than 100 days on average between November 2015 and October 2016 (out of 115 CCGs that provided data requested by the Continuing Healthcare Alliance).
  • Delays can cause considerable distress to patients and their families as they wait for funding decisions, and in some cases have resulted in delays in discharging patients from hospital.

 

4 Decisions on eligibility for CHC have a significant financial impact on the individual, clinical commissioning group and local authority (paragraphs 1.2, 1.3 and 3.7).

  • During 2015-16, nearly 101,000 people were assessed as newly eligible for CHC, of which 79,000 were referred through the fast-track process.
  • During 2015-16, approximately 59,000 people referred through the fast-track or standard CHC process were considered not eligible.
  • If someone is assessed as eligible for CHC their health and social care costs are paid for by the CCG. But if they are assessed as not eligible, the local authority and/or the individual may have to pay their social care costs instead.
  • If a person is assessed as eligible for CHC funding, the CCG must legally provide that funding, irrespective of the number of people that apply and are assessed as eligible.

 

5 The number of people receiving CHC funding is rising although the proportion assessed as eligible for standard (non fast-track) CHC has reduced since 2011 (paragraphs 3.1 to 3.3 and 3.7).

  • The population of people receiving CHC funding changes during the year as some people are newly assessed as eligible, some are reassessed and considered no longer eligible, and many patients die, particularly those assessed through the fast-track process.
  • Between 2011-12 and 2015-16, the total number of people that received, or were eligible to receive, CHC funding at some point during that year increased from 125,000 to 160,000.
  • NHS England’s snapshot data shows that on 31 March 2016, 59,000 were receiving, or assessed as eligible to receive, CHC funding, compared with 63,000 people on 31 March 2015. 10 Key findings Investigation into NHS continuing healthcare funding
  • There are no data to track how long people receive CHC funding for, but the above trends indicate that since March 2015, people have received funding for shorter periods. The Department does not have data on the reasons for this changing trend. It may indicate that people tend to apply for, or be assessed as eligible for, CHC funding at a later stage of their illness, or that more people are found to no longer be eligible when they are reassessed.
  • Between 2011-12 and 2015-16, the estimated proportion of people referred for a full assessment that resulted in that person being assessed as eligible for standard CHC during that year fell from 34% to 29%.

 

6 The funding of CHC is a significant cost pressure on CCGs’ spending (paragraphs 3.3, 4.1, 4.2, 4.5 and 4.6).

  • The costs of CHC are met by CCGs, from their overall funding allocation from NHS England. Between 2013-14 and 2015-16, spending on CHC increased by 16%. In 2015-16, CHC accounted for about 4% of CCGs’ total spending.
  • NHS England estimates that spending on CHC, NHS-funded nursing care and assessment costs will increase from £3,607 million in 2015-16 to £5,247 million in 2020-21, when historical growth and population demands are applied to previous CCG spending.
  • Although the Department assures us that there is no quota or cap on access, NHS England’s efficiency plan includes asking CCGs to make £855 million of savings on CHC and NHS-funded nursing care by 2020-21 against the above prediction of growth. Savings may be made by reducing the administrative assessment costs (total spend of £149 million in 2015-16) or by reducing the overall cost of care.
  • NHS England has not yet set out a costed breakdown for how it will achieve the savings to the cost of care, but it intends to reduce variation in spending and ensure that CCGs interpret the eligibility criteria more consistently. NHS England assumes that increasing both consistency and the number of people assessed after being discharged from hospital will result in CCGs providing CHC funding to fewer patients overall compared with NHS England’s predicted growth in eligibility. It assumes that it will also make savings through better commissioning of care packages.

 

 7 It is not known how many people appeal against unsuccessful CHC funding decisions (paragraphs 1.11 and 3.8).

  • If a patient is unhappy with the outcome of their assessment they can ask the CCG to review their case, but NHS England does not collect data on how many appeals are made to CCGs, how long they take or how many are successful.
  • In 2015-16, 448 cases were reviewed by an independent review panel, because the patient was unhappy with the outcome of the CCG’s own review. In 27% of cases, NHS England recommended a different eligibility decision for part or all of the period reviewed.
  • In 2015-16, the Parliamentary and Health Service Ombudsman received 1,250 complaints about CHC funding decisions. It investigated 181 of them and partly or fully upheld 36 cases.

 

 8 There is significant variation between CCGs in both the number and proportion of people assessed as eligible for CHC (paragraphs 5.1 and 5.2).

  • In 2015-16, the number of people that received, or were assessed as eligible for, funding ranged from 28 to 356 people per 50,000 population. • In 2015-16, the estimated proportion of people that were referred and subsequently assessed as eligible ranged from 41% to 86%, excluding the 5% of CCGs with the lowest and highest percentages.
  • NHS England’s analysis of population data at a CCG level shows that the variation cannot be fully explained by local demographics or other factors it has considered so far. This suggests that there may be differences in the way CCGs and local authorities are interpreting the national framework to assess whether people are eligible for CHC due to the complexity of this framework.

 

9 There are limited assurance processes in place to ensure that eligibility decisions are consistent, both between and within CCGs (paragraphs 6.1 to 6.6).

  • NHS England’s assurance mechanisms for CHC include quarterly reporting and self-assessment by CCGs, overseen by NHS England’s Directorate of Operations and Information and regional assurance boards. However, there are limited mechanisms for ensuring that individual eligibility decisions are being made consistently across CCGs.
  • There is a shortage of data on CHC, which makes it difficult to know whether eligibility decisions are being made fairly and consistently.
  • NHS England and the Department have recently started work aimed at providing more consistent access to CHC funding and supporting CCGs to make efficiency savings. From April 2017, NHS England has expanded the data it publishes on CHC (see Appendix Three on CHC data).

Read the full report here: https://www.nao.org.uk/wp-content/uploads/2017/07/Investigation-into-NHS-continuing-healthcare-funding.pdf 

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