Policy responses and statements

Name of organisation:

Department of Health

Name of policy document:

National framework for NHS continuing healthcare and NHS funded nursing care in England

Deadline for response:

22 September 2006

Background: The Government is determined to establish a simpler, fairer and more coherent system of assessment to determine eligibility for NHS funding of long-term care outside hospitals. The documents published in this consultation detail the proposals for a National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care in England. This National Framework has two main purposes:

Firstly, it sets out a single policy on who should receive NHS funding, be that fully funded NHS Continuing Healthcare (where the NHS funds the whole care package) or NHS-funded Nursing Care (where the NHS is responsible for the nursing required from a registered nurse in a care home).

Secondly, it proposes a standard process for assessing eligibility for these services, to help support consistent decision-making.

The consultation document seeks contributions on the policy proposals and comments on taking national policy forward.

The Department has developed several documents which deal with aspects of the National Framework in differing formats:

The main Consultation Document, which details the core policy proposals on eligibility and assessment;
A supporting 'Core Values and Principles' document, which outlines the principles and best practice which underlie the key proposals;
A slide show presentation and an information leaflet which present the key information in a more simple format; and
A Regulatory Impact Assessment, which describes the main costs and benefits to the public sector.

The Department has also published a draft version of the national 'tool' which supports the decision-making process. This is intended to demonstrate how the policy would be applied in practice.

Finally, the Department is planning to publish a short paper which deals with the important links to children's services, and specifically to the particular issues surrounding children's continuing care. Contributions to that discussion were sought as part of this consultation.

COMMENTS ON
DEPARTMENT OF HEALTH
NATIONAL FRAMEWORK FOR NHS CONTINUING HEALTHCARE AND NHS FUNDED NURSING CARE IN ENGLAND

The Royal College of Physicians of Edinburgh is pleased to respond to the Department of Health on its consultation on the National framework for NHS continuing healthcare and NHS funded nursing care in England. 

The College has previously given evidence to the House of Common’s Health Committee in this area and our previous submission to that Committee is attached for reference [RCP Consultation Database Number 374].  As a Scottish College we have also responded to consultations from the Scottish Parliament Health Committee on the system of free personal care in Scotland, which contrasts with the proposed system in England. 

In terms of general principles, however, the College is pleased that the Government is seeking to promote fairness and consistency in the provision of services.  Previously, there have been difficulties in gaining agreement between health and social care partners.  In Scotland, a joint approach has been adopted to this.  In England, the legislation as outlined appears to maintain a separation between Social Services and the Health Service.  Nonetheless, the College is pleased to support proposals, which should simplify and clarify the responsibilities of each partner.  Finally, the College would still promote the concept of holistic care and a pragmatic approach, particularly in regard to the definition of nursing care.  For frail and vulnerable individuals, the totality of care is what matters.  Comments on the specific questions raised by the consultation are as follows:

Question 1

On first reading, the terminology is confusing, as it would seem that “NHS-funded Nursing Care” would form part of “NHS Continuing Healthcare”.  The main difference in the funding appears to be total health funding versus partial health funding and including these, or similar terms, in the description of the type of funding may make them clearer.

Question 2

College Fellows working in England report that the role of Primary Care Trust representatives is crucial in the process already.  We are therefore happy to support the move of responsibility for commissioning from Strategic Health Authorities to Primary Care Trusts.  However, it would be important to ensure that budgets were appropriately ring-fenced, and there is a feeling that the proposed timescales are very tight.  Present practice indicates that nurse assessors may take two to three weeks before carrying out their assessments.  Whether the Primary Care Trust has the resources and governance arrangements to improve on this is, at present, difficult to see.

Question 3

We agree that the basis of assessment should be care needs.  However, factors relating to diagnosis and condition do need to be taken into account, particularly prognosis and if there is likely to be a marked change in condition over the short to medium term, which would alter the assessment.  The statement that NHS Care could be provided in any location ie either NHS hospital or nursing home or, indeed, the patient’s own home, is useful but it is important to ensure that care standards are appropriate in these other locations.

Questions 4 & 5

The key indicators based on the guidance originally issued in 1995 are relevant and appropriate although, again, it is important to note that a patient’s health condition may change.

Question 6

The eleven domains are all appropriate, but one of our Fellows did suggest pain relief as a possible twelfth domain or as a sub-domain of the “drug therapy” domain.

Question 7

There are two areas that need clarification here.  In the hospital setting, it should be made clear who makes the initial screening assessment.  Training for the hospital multi-disciplinary team will be essential, particularly if these arrangements are to be streamlined.  Experience of the Carenap system in Scotland has shown that there can often be delays in completing relevant assessments.  Secondly, there needs to be a considerable change in culture and attitude for assessments to be carried out in primary care.  Frequently, there are long delays when a patient’s care needs can no longer be met in residential care and they are thought to need to be moved to a nursing home.  Ideally, in the area of care of the elderly, we would like to see involvement of medical opinion in a comprehensive geriatric assessment.  There is still a risk that, where medical diagnosis and treatment are omitted from multi-disciplinary assessment, that an opportunity to optimize health and function can be lost and patients put into continuing care who actually have a need for further rehabilitation or treatment.

Question 8

We support the development of the national screening tool with the above noted caveats about treating treatable conditions first.

Question 9

The information required to use the Decision-Support Tool should be easily available in ward nursing care plans in hospital.  The criteria for indicating priority for a primary health need are unavoidably arbitrary, and we note that the guidance stresses that the Tool is there to assist practitioners in determining eligibility.  In passing, we note that the criteria for “priority” are set very high and would generally indicate a need for inpatient hospital care, so the usefulness in determining primary health need for non-hospital premises would be doubtful.

Question 10

We support the principle of individual care planning, and that nursing care should be seen as part of NHS responsibility.  Clearly, there has to be a pragmatic approach to this.  The important point is that social and health partners work well together, and that patients are not disadvantaged by disputes over responsibilities for funding.  In Scotland, this has been simplified to some extent by the concept of free personal care, although there still has to be a boundary between what is considered personal care and what is considered supportive board and lodging type services.  Clearly, there are issues about affordability of this system in Scotland.  However, the NHS in Scotland has had less responsibility for fully funding placements in non-NHS institutions, in patients who might be assessed in England as needing total NHS funding. This to some extent might offset the more generous personal care allowance for all.

Question 11

College Fellows agree that the present system of banding is too complex and very arbitrary.  Any simplification of the process would be supported.  However, there are concerns that private nursing homes might adjust their waiting lists to select “easier cases”, thus disadvantaging those who would be currently classed as highest band.

Question 12

1. In the Core Values Document, the College fully supports the principle in paragraph 6 that the person’s assessed health needs should be the primary indicator and that eligibility for NHS Continuing Healthcare should not be budget or finance led.  However, in practice, we suspect that this will be much more difficult as resource constraints impinge on every service.  In paragraph 6 of the Core Values Document, the governance responsibilities of Primary Care Trusts are delineated.  Would it be possible for these responsibilities to be delegated to an acute Trust or other part of the Health Service as part of a service level agreement?  Although not specifically being consulted upon, the Fellows felt that the Decision Support Tool was an impressive start and in the right direction.

2. Not considered.

3. Not considered.

4. We note that, in paragraph 33, there is likely to be a significant cost impact of the correct application of the legal framework of NHS responsibility.  Will the Government be providing new money to support the necessary resources?

Finally, the implementation of all these proposals will be highly dependent on good working relationships between various departments, particularly between social services and health and we feel that this principle of joint working cannot be over-emphasized.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324    ext 608
Fax: 0131 220 3939

[26 September 2006]