Annex G: Local NHS Continuing Healthcare Protocols

Annex G:         Local NHS Continuing Healthcare Protocols

The following provides a best practice guide for what to include when drawing up and updating local protocols and procedures regarding NHS continuing healthcare.

Referrals, Assessments and Recommendations

•     A statement about the principles underlying the process to ensure that it is ‘person-centred’, equitable, culturally sensitive, robust, transparent and lawful. This includes ensuring equitable access to assessment for NHS continuing healthcare based on need (not on client group, current funding arrangements, etc.) and using the Checklist as a basis for identifying those who require full assessment to inform completion of the DST.

•     Arrangements for ensuring that the patient/client and their family are kept informed and involved at every stage, including being informed of their right to appeal if they are not satisfied with the eligibility decision regarding NHS continuing healthcare.

•     Arrangements (and possibly local forms) for obtaining consent to the different stages of the process where the individual has capacity. Also arrangements for dealing with situations where an individual with capacity refuses consent to assessment for NHS continuing healthcare.

•     Local  arrangements  for  dealing  with  situations  where  the  individual  appears  to  lack capacity, in order to ensure compliance with the Mental Capacity Act 2005 and the associated Code of Practice, including how to access the IMCA service where necessary.

•     Local  arrangements  regarding  how  individuals   can   access  advocacy,   advice   and information.

•     An  explanation  of  who  can  complete  the  Checklist  (and  what  training  they  need beforehand), bearing in mind that the aim is to allow a variety of people, in a variety of settings, to refer individuals for a full assessment for NHS continuing healthcare. The Checklist clarifies (paragraph 3) that it is for each organisation to decide for itself who are the most appropriate staff to participate in the completion of a Checklist.

•     Arrangements to ensure that individuals/representatives are informed in writing about the outcome of the Checklist and given a copy, whether or not they cross the threshold for full consideration of NHS continuing healthcare eligibility.

•     How and in what situations Fast Track arrangements are to operate, including a statement that the Fast Track Pathway Tool is to be completed by an ‘appropriate clinician’ as defined in the Standing Rules Regulations [DN – this is at Reg 23(12)]  and is to be acted on by the Board or the CCG without delay. It is important to ensure that decision-making around NHS continuing healthcare does not in any way compromise the provision of good end of life care.

•     Arrangements  for  the  timely  provision  of  care/support  in  fast-track  cases,  including provision of equipment where necessary.

•     The referral process being clear where cases requiring full consideration of eligibility using the DST are to be directed (this may well differ depending on whether the individual concerned is currently in hospital, in a care home or in the community). Clarity on the method of delivery of paperwork is needed to minimise delay but ensure confidentiality.

•     An  agreement  that  the  key  agencies  will  make  staff  available  to  participate  in  the assessment and decision-making processes, including making staff available to sit on Independent Review Panels.

•     Any specific local arrangements around appointing coordinators, identifying members of the MDT and convening MDT meetings. These arrangements need to ensure as far as possible that both NHS and social care colleagues are involved in the assessment process.

•     Arrangements for dealing with people subject to section 117 of the Mental Health Act 1983, with reference to paragraphs 188 – 122.

•     Clarity  on  how  the  NHS  continuing  healthcare  process  fits  with  hospital  discharge arrangements, with reference to paragraphs 62 – 67 of the National Framework.

•     Arrangements for care/support and funding (including ‘without prejudice’ funding) whilst the decision-making process is carried out, noting that if someone is being discharged from hospital then the CCG retains funding responsibility whilst the DST is being completed and the eligibility decision is being made.

•   How transfers of care are to be handled, including effective risk management.

•   Arrangements for reviewing:

Ø care  packages/placements  where  an  individual  is  in  receipt  of  NHS  continuing healthcare.

Ø Joint packages of care

Ø Individuals in receipt of NHS-funded nursing care

•   Timeframes for each stage of the process.

N.B. visual representation of the process in flow-charts is often very helpful.


Arrangements must be in place to ensure that (so far as is reasonably practicable) the LA’s views regarding needs and eligibility are obtained before decisions are made regarding eligibility for NHS continuing healthcare. There should be robust arrangements for joint decision-making between the CCG and LA. This may or may not include a panel arrangement, but care should be taken to ensure that panels are not used unnecessarily (see PG39).

•     Terms of reference for panel (where these exist)– purpose of panel, which cases are to be referred, client groups covered, limitations of decision-making powers, bearing in mind that the National Framework states that ‘only in exceptional circumstances, and for clearly articulated reasons, should the multidisciplinary team’s recommendation not be followed (see paragraph 91).

•     Arrangements and process for obtaining the LA’s views where a panel process is not in place.

•     Membership and chairing arrangements (some have independent chairs).

•     Arrangements for panel members to have sight of case documentation in advance.

•     Whether/how  the  individual  and/or  their  representative  is  to  be  involved  in  the  panel arrangements.

•     What counts as a quorum.

•     Frequency of meetings.

•     Access to specialist input/advice.

•     Paperwork expected (including DST) to inform discussion.

•     Arrangements for recording main points of panel discussion and decisions.

•     Clarity on decision-making, voting arrangements (if any), etc. On some panels LA members have an equal say (which is good practice); others limit LA involvement to advice from a social care perspective. There is a need to be clear that financial considerations do not influence the decision regarding eligibility for NHS continuing healthcare.

•     Procedure for dealing with disagreement over eligibility within the panel meetings.

•     Local resolution process where an individual or their representative is unhappy with the eligibility decision.

Dispute Avoidance and Resolution between Agencies

Good  communication,  effective  joint  working  and  mutual  respect  are  key  to  avoiding unnecessary disputes. Any local protocols should consider:

•     Clarity on what counts as a disagreement and what counts as a formal dispute – some protocols include disagreements/disputes at Checklist and DST stage as well as at panel decision-making stage.

•     Different levels of dispute resolution – the aim is usually to resolve disputes at practitioner level but most procedures have the option of escalating the dispute through appropriate levels to senior management level where necessary. Some dispute resolution processes include referring the case to a second panel to check the original decision; in some cases there are agreements to refer to a panel in another area. It is important that dispute resolution processes have a clear end, final resolution point.

•     What  types  of  dispute  are  covered  –  protocols  should  deal  with  disputes  over  NHS continuing healthcare eligibility, joint funding arrangements and refunds.

•     What paperwork/information is needed at each stage.

•     Timescales at each stage of the process.

•     Arrangements to ensure individuals get the care/support they need whilst disputes are being resolved, bearing in mind the principle of ‘no unilateral withdrawal of funding’.

•     Clarity on what happens over interim or ‘without prejudice’ funding – including over any backdating arrangements for reimbursing costs and how charging the service user will be handled in a variety of possible situations, having regard to the approaches set out in Annex F above.


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