The Fast Track Pathway Tool for NHS Continuing Healthcare can be used when a patient’s condition has rapidly deteriorated, and if they are judged by a doctor or nurse to be close to death. Once CHC funding has been approved, the NHS must provide for the care.
- Note the following paragraphs:
3. This tool should be used where an appropriate clinician considers that a person should be fast tracked for NHS Continuing Healthcare because that person has a rapidly deteriorating condition and the condition may be entering a terminal phase. (….)
13 A CCG upon receipt of a completed Fast Track Pathway Tool, must decide that a person is eligible for NHS Continuing Healthcare. Therefore, where a recommendation is made for an urgent package of care via the fast-track process, this should be accepted and actioned immediately by a CCG (….)
14 The purpose of the Fast Track Pathway Tool is to ensure that individuals with a rapidly deteriorating condition, which may be entering a terminal phase, are supported in their preferred place of care as quickly as possible. It means that a CCG takes responsibility for commissioning and funding appropriate care….
- See also the Practice Guidance Notes on the Fast Track Pathway, which answer some of the key questions on how this Tool is used. (They are also reproduced at the end of this article)
Duty of CCGs or the Board…………………………………………………………………………….6
Fast Track Pathway Tool……………………………………………………………………………….9
Equality Monitoring Form……………………………………………………………………………..12
Fast Track Pathway Tool for NHS Continuing Healthcare, published November 2012, with effect from April 2013.
- This revised tool accompanies the National Framework for NHS continuing healthcare and NHS-funded nursing care (the National Framework) and the NHS Continuing Healthcare Checklist and Decision Support Tool. This is the version that CCGs and the Board should use from 1 April 2013, however PCTs should use this version with immediate effect. Please use the tool in conjunction with the National Framework guidance.
- It reflects the new NHS framework and structures created by the Health and Social Care Act 2012 effective from 1 April 2013. Standing Rules Regulations have been issued under the National Health Service Act 2006 and directions are issued under the Local Authority Social Services Act 1970 in relation to the National Framework.
- This tool should be used where an appropriate clinician considers that a person should be fast tracked for NHS Continuing Healthcare because that person has a rapidly deteriorating condition and the condition may be entering a terminal phase. The person may need NHS Continuing Healthcare funding to enable their needs to be urgently met (e.g. to enable them to go home to die or to provide appropriate end of life support to be put in place either in their own home or in a care setting).
- The Fast Track Pathway Tool should be used by an appropriate clinician to outline the reasons for the fast-track decision. Appropriate clinicians are those who are, pursuant to the National Health Service Act 2006, responsible for an individual’s diagnosis, treatment or care and are registered medical practitioners (such as consultants, registrars, GPs) or registered nurses. These can include senior clinicians employed in voluntary and independent sector organisations that have a specialist role in end-of-life needs (for example, hospices) where the organisation’s services are commissioned by the NHS. Others involved in supporting those with end of life needs, such as in wider voluntary and independent sector organisations, may identify that the individual has needs for which use of the Fast Track Tool would be appropriate. They should contact an appropriate clinician and ask that consideration be given to completion of the tool. In all cases the clinician should have detailed knowledge of the patient’s needs. They should also have an appropriate level of knowledge and experience in dealing with the individual’s health needs, such that they are able to reasonably comment on whether the individual’s condition may be entering a terminal phase.
- The completed tool should be supported by a prognosis, if available, but strict time limits basing eligibility on an individual being considered to have a specified expected length of life remaining should not be imposed: it is the responsibility of the appropriate clinician to make a decision based on the relevant facts of the case.
6. Appropriate clinicians should complete the attached fast-track documentation and set out how their knowledge and evidence about the patient’s needs leads them to consider that the patient has a rapidly deteriorating condition and that the condition may be entering a terminal phase.
- Whilst the Fast Track tool itself determines eligibility, a care plan will be required which describes the immediate needs to be met and the patient’s preferences. This care plan should be provided with the Fast Track documentation, or as soon as practicable thereafter, in order for a clinical commissioning group (CCG) or the National Health Service Commissioning Board (the Board) to commission appropriate care.
Duty of CCGs or the Board
10. CCGs and the NHS Commissioning Board (the Board) will assume responsibilities for NHS CHC from 1 April 2013.
11. The Board will assume commissioning responsibilities for some specified groups of people (for example, prisoners and military personnel). It therefore follows that the Board will have statutory responsibility for commissioning NHS CHC, where necessary, for those groups for whom it has commissioning responsibility. This will include case co-ordination, arranging completion of the decision support tool, decision-making, arranging appropriate care packages, providing or ensuring the provision of case management support and monitoring and reviewing the needs of individuals. It will also include reviewing decisions with regards to eligibility where an individual wishes to challenge that decision.
Where an application is made for a review of a decision made by the Board, it must ensure that in organising a review of that decision, it makes appropriate arrangements to do so, so as to avoid any conflict of interest.
12 Throughout the Fast Track Tool where a CCG is referred to, the responsibilities will also apply to the Board (in these limited circumstances).
13 A CCG upon receipt of a completed Fast Track Pathway Tool, must decide that a person is eligible for NHS Continuing Healthcare. Therefore, where a recommendation is made for an urgent package of care via the fast-track process, this should be accepted and actioned immediately by a CCG. It is not appropriate for individuals to experience delay in the delivery of their care package while disputes over recommendations from completed Fast Track Tools are resolved. CCGs should carefully monitor use of the tool and address any specific concerns with clinicians, teams and organisations as a separate matter to arranging the service provision in the individual case.
14 The purpose of the Fast Track Pathway Tool is to ensure that individuals with a rapidly deteriorating condition, which may be entering a terminal phase, are supported in their preferred place of care as quickly as possible. It means that a CCG takes responsibility for commissioning and funding appropriate care. Once this has happened, a CCG, and its partners can proceed, where appropriate, with reaching a decision on longer-term NHS continuing healthcare eligibility. No one who has been identified through the fast-track process as being eligible for NHS continuing healthcare should have this funding or support removed without their eligibility being reviewed in accordance with the review processes set out in the National Framework. The review should include completion of the Decision Support Tool (DST) by a multidisciplinary team, including a recommendation on eligibility. This overall process, including how personal information will be shared between different organisations and healthcare professionals involved in delivering care, should be carefully and sensitively explained to the individual and, where appropriate, their family. Careful decision making is essential to avoid the undue distress that might result from a person moving in and out of NHS continuing healthcare eligibility within a very short period of time. Where an individual receiving services through use of the Fast Track Pathway Tool is expected to die in the very near future, CCGs should continue to take responsibility for the care package until the end of life.
14 It should be noted that this is not the only way that individuals can qualify for NHS continuing healthcare towards the end of their lives. The DST encourages practitioners to document deterioration (this could include both observed and likely deterioration) in a person’s condition to allow them to take this into account when determining eligibility using the DST. However, this should not be used as a means of circumventing use of the Fast Track Pathway Tool when individuals satisfy the criteria for its use. Where deterioration can be reasonably anticipated to take place before the next planned review, including where the individual is presently asymptomatic, this should also be taken into account in making a decision on eligibility.
15 There may be some situations where the fast-track process is later found to have been inappropriate, for example because the decision was made after an acute episode of a condition which was subsequently found to be treatable. In such situations the completion of the DST may lead to a decision to cease NHS continuing healthcare funding. However, no one who has been identified through the fast-track process as being eligible for NHS continuing healthcare should have this funding removed without the completion of a full DST, taking account of any deterioration that is present or expected. The National Framework states:
Neither the NHS nor an LA should unilaterally withdraw from an existing funding arrangement without a joint reassessment of the individual, and without first consulting one another and the individual about the proposed change of arrangement. It is essential that alternative funding arrangements are agreed and put into effect before any withdrawal of existing funding, in order to ensure continuity of care. Any proposed change should be put in writing to the individual by the organisation that is proposing to make such a change. If agreement between the LA and NHS cannot be reached on the proposed change, the local disputes procedure should be invoked, and current funding and care management responsibilities should remain in place until the dispute has been resolved.
16 CCGs should audit use of the Fast Track Pathway Tool carefully and discuss any concerns over its use with organisations, clinicians and teams as appropriate. However, this should be carried out separately from decision making in any individual case.
17. CCGs and LAs should operate person-centred commissioning arrangements so that unnecessary changes of provider or of care package do not take place purely because the responsible commissioner has changed from a CCG to a LA or vice versa.
18. NHS continuing healthcare assessments, care planning and commissioning for those with end-of-life needs should be carried out in an integrated manner as part of the individual’s overall end-of-life care pathway. They should reflect the approaches set out in the National End of Life Care Strategy with full account being taken of each patient’s preferences through a needs-led approach, including those preferences set out in their advance care plan.
19. The equality monitoring data form should be completed by the patient who is the subject of the Fast Track Pathway Tool. Where the patient needs support to complete the form, this should be offered by the clinician completing the Fast Track Pathway Tool. The clinician should forward the completed data form to the appropriate location, in accordance with the relevant CCG processes for processing equality data. If the form has not been completed, the referring clinician should be asked to arrange with the patient for it to be completed. However, this should not delay consideration of the fast-track recommendation.
 The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 (the Standing Rules Regulations)
 National Health Service Act 2006 (c.41), as amended by the Health and Social Care Act 2012
 As defined in regulation 23(12) of the Standing Rules Regulations
 Paragraph 143 of National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care
NB The three pages for completion by the doctor or nurse are on Pages 9 – 11 of the document.
It includes a page for the patient’s name, date of birth and NHS number.
The key question for the clinician is here –
The individual fulfils the following criterion: He or she 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.
Brief outline of reasons for the fast-tracking recommendation:
Please set out below the details of how your knowledge and evidence of the patient’s needs mean that you consider that they fulfil the above criterion. This may include evidence from assessments, diagnosis, prognosis where these are available, together with details of both immediate and anticipated future needs and any deterioration that is present or expected.
When outlining reasons why a clinician considers that a person has a rapidly deteriorating condition that may be entering a terminal phase, the clinician should consider the following definition of a primary health need:
Primary health need arises where nursing or other health services required by the person are
(a) where the person is, or is to be, accommodated in a care home, more than incidental or ancillary to the provision of accommodation which a social services authority is, or would be but for the person’s means, under a duty to provide; or
(b) of a nature beyond which a social services authority whose primary responsibility is to provide social services could be expected to provide.
See also the Practice Guidance Notes on the use of the Fast Track Pathway Tool
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
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.