To consider a briefing paper on NHS Continuing Healthcare by NHS Herefordshire Clinical Commissioning Group.

The chairperson said that the purpose of this item was for Herefordshire NHS Clinical Commissioning Group (CCG) to report on progress since NHS Continuing Healthcare (NHS CHC) was last considered by the committee on 20 September 2018; minute 15 of 2018/19 refers.  Linda Allsopp, associate director of nursing and quality, and Nikki Warman, head of CHC, were invited to introduce the briefing paper on behalf of the CCG.

 

The principal points of the introduction included:

 

i.             NHS CHC was a package of care that was funded solely by the NHS for an individual that had been assessed as having a ‘primary health need’; the associated test focused on nature, complexity, intensity and unpredictability.

 

ii.            There was a national framework, updated in October 2018, and the CCG’s CHC process was fundamentally a whole system approach, working with local authority colleagues in terms of assessing an individual's need and whether that goes beyond the responsibilities of the local authority.

 

iii.          This update focused on NHS England key performance indicators, including:

 

·              The target was being met in Herefordshire and Worcestershire for making a decision on eligibility within 28 days of a referral.

 

·              The target was being met for no more than 15% of assessments taking place in an acute hospital setting; there was an expectation that no assessments would be undertaken in this setting but fast track referral for an individual entering the terminal phase of life could be accepted.

 

·              The target was being met for accepting all appropriately completed fast track applications.

 

iv.          In line with the national framework, only when there was deemed to be a change in healthcare need would a review of eligibility take place.

 

v.           As part of the merger between the Herefordshire and Worcestershire CCGs, the CHC policies would be reviewed to ensure that systems were working as efficiently as possible to provide quality of service to all patients.

 

The chairperson drew attention to the recommendations made at the 20 September 2018 committee meeting and invited officers to provide appropriate updates:

 

a)           a small number of senior social workers be upskilled to ensure that there is a common understanding of the medical terminology when dealing with disputes

 

The assistant director all ages commissioning advised that interactions between the council and the CCG on CHC were progressing well.  The associate director of nursing and quality advised that adult social care employed social workers to work on CHC and there were positive working relationships.  The head of CHC added that the joint training of multidisciplinary teams on the national framework was being explored.

 

b)           the CCG be requested to commit to seeking to lift Herefordshire out of its current position of 6th from the bottom in the national CHC eligibility by 50k population and to report its progress against this commitment at a future adults scrutiny committee

 

c)           the CCG be called back to the committee to report on progress made against their action plan recommendations in six months’ time

 

d)           the CCG be requested to influence the report of the NHS England to be a system review and to include the local authority within that review

 

The chairperson noted that, in response, the CCG had committed to ‘share the outcomes from the NHS England review with the local authority and the committee once it has been received and reviewed by the CCG internal governance processes’ and would ‘raise the issue of LA [local authority] engagement in NHS England review’. 

 

The head of CHC advised that NHS England had reviewed performance in October 2018 and it was understood that the outcomes of the review had been shared with the local authority.  The assistant director all ages commissioning was not aware that this report had been received and requested that it be sent to him.

 

Referring to recommendation d), the chairperson questioned the involvement of the local authority in the review in terms of triangulation of experience.  The associate director of nursing and quality advised that NHS England had undertaken a ‘deep dive’ into eligibility within Herefordshire and no anomalies were identified which caused them to be concerned; a commitment was given to share the report.  The chairperson observed that such reviews could be perceived to be too insular and there was a need for a more partnered approach.

 

The chairperson, referring to concerns expressed by the committee in 2018 and by members of the public subsequently about the drop in the figures during 2016, queried why Herefordshire appeared to be an outlier in terms of comparator areas.  The associate director of nursing and quality said that: the CCG was regulated by NHS England; CHC was for people with exceptional health needs; and the CCG was striving to apply the framework fairly and consistently, involving local authority colleagues within the assessment and review processes.

 

The chairperson questioned whether self-funders were at an additional disadvantage and were vulnerable to slipping between the various processes.  The head of CHC said that all nursing homes were required to notify the CCG of all new admissions and about any individual that had a significant change in need, and this would trigger consideration for CHC.  The associate director of nursing and quality outlined the funded nursing care review and CHC checklist processes.

 

Attendees were invited to ask questions and make comments, the key points included:

 

1.           In view of capacity issues, a committee member questioned whether the CCG was training non-clinicians to undertake appropriate duties usually undertaken by nurses, or to train nurses to undertake appropriate duties usually undertaken by doctors, such as perinatal mental health referrals.

 

In terms of CHC, the associate director of nursing and quality said that there was strict guidance within the national framework about the health and social care professionals involved in multidisciplinary teams.  Scott Parker, director of performance, said added that the NHS was looking at other roles which could be undertaken by non-clinicians, including within Primary Care Networks, to release the time capacity of nurses and doctors.  On the issue of perinatal mental health, it was reported that a service was being designed and commissioned to support patients who were between basic and high levels of need, and this piece of work could be shared at an appropriate time.

 

2.           The vice-chairperson asked whether the CCG was confident that everyone who was eligible to have a CHC review was picked up within the diverse systems and not just through hospital pathways.

 

The associate director of nursing and quality: reiterated points about the timing of reviews, with assessments made when long term health needs were clear, and the fast track referral process; advised that the systems were supported through training on when it was appropriate to refer an individual for a CHC assessment; said that the CCG would only become aware of an individual when a checklist was received to request an assessment; and reported that the CCG was working on communications around CHC eligibility.

 

3.           Referring to the CCG Governing Body paper of 28 May 2019 on the Herefordshire and Worcestershire Sustainability and Transformation Partnership draft operational plan 2019/20 which identified savings targets from CHC, the vice-chairperson questioned whether the need to make savings was the most important driver.

 

The associate director of nursing and quality emphasised that the CCG had statutory responsibilities and said that any savings would be delivered through efficiencies within the provider market, for instance by working jointly with the local authority to reduce variances in the costs of care packages.

 

4.           The vice-chairperson commented that the presentation of figures in terms of percentages made it difficult to understand the position in terms of the Herefordshire population and suggested that it would be helpful to understand the position for Worcestershire also.

 

The associate director of nursing and quality reported that the Worcestershire CCGs were also required to submit data to NHS England.  It was also reported that a monthly quality and performance meeting for Herefordshire and Worcestershire had been introduced.  In response to a question from a committee member, the associate director of nursing and quality clarified that this was an internal meeting which challenged delivery around CHC and considered learning from appeals and complaints, and said that a briefing paper could be provided.

 

5.           Referring to recommendation b) and to the questions from a member of the public, a committee member considered the responses provided to be inadequate, and asked for an explanation of the reasons why CHC eligibility in Herefordshire was consistently below the national average and what would be done about it.

 

The associate director of nursing and quality: reiterated that the national framework had to be applied fairly and consistently; said that a local appeal process had been introduced, chaired by an independent person and involving people who had not had prior dealings with the relevant case, before going to NHS England; reiterated that a review had been undertaken by NHS England in 2018; and commented on the process to identify people with primary health need, with regular reviews to ensure that the package of care met that need.

 

The committee member expressed concern that the responses did not address the specific reasons for the position in Herefordshire, especially considering that population demographics would suggest that CHC eligibility might be expected to be higher than the national average.

 

The associate director of nursing and quality said: it did not necessarily follow that there would be a correlation between demographics and eligibility for CHC; the national framework was followed, the CCG could not make individuals eligible if they were not eligible; it was important to ensure that there was a process for referring people for an assessment; and the involvement of local authority colleagues in assessment and dispute processes was reiterated.

 

The chairperson said that it would be helpful to have a deeper understanding, as the numbers suggested that Herefordshire was an outlier statistically and it was significantly adrift of comparator areas.  It was not considered that the committee had been provided with the narrative for the reasons behind this.

 

The assistant director all ages commissioning suggested that the CCG and the council should work together as partners to produce statistics which showed, based on current demographics: the anticipated levels of CHC that would be expected; the levels that Herefordshire was actually achieving; the levels that Worcestershire and relevant comparator areas were actually achieving; and provide compelling rationale for any similarities or differences.  It was acknowledged that the perception of Herefordshire being an outlier needed to be addressed.  The associate director of nursing and quality said that the CCG was happy to do this; it was noted that there was a cohort of patients not eligible for CHC but who did have needs above what core services could provide.  The chairperson welcomed this suggestion.

 

6.           In response to a question from a committee member about the target for no more than 15% of assessments taking place in an acute hospital setting, the associate director of nursing and quality clarified that NHS England expected there to be an alternative discharge pathway in place, so that an individual had a period of time to recover from their acute illness.

 

7.           The cabinet member – health and adult wellbeing commented on the need to explain to individuals why they were not eligible for CHC and what other options were available to them.

 

8.           The chairperson questioned whether there were statistics on the total number of appeals and the number of appeals that were successful.

 

The associate director of nursing and quality confirmed that this information was recorded; for 2019, 690 referrals into the CHC service had been received, with 15 appeals.  It was noted that there was a local dispute resolution policy to manage disputes between the CCG and the council around eligibility.

 

9.           The chairperson also questioned the signposting and advocacy that was available, particularly for self-funders and / or their carers.

 

The associate director of nursing and quality advised that: NHS England had been leading on a strategic improvement programme to ensure that materials were available to explain CHC to the general public; as part of the quality and performance meeting, a communications group had reviewed the letters sent out to individuals to explain CHC eligibility; and the multidisciplinary teams signposted people to resources, including advocacy services, to support people through the CHC process.

 

In response to further comments from the chairperson, the head of CHC advised that individuals were informed of their right to appeal the CHC outcome and were signposted to Beacon, an independent information and advice service on CHC.

 

10.        The vice-chairperson sought clarification that, as assessments were not being made in an acute hospital setting, health and social care teams were following up to ensure that assessments were being offered rather than making assumptions about patients being part of different pathways.

 

The director of performance commented that it was better for people to go back home following acute episodes of care and for assessments to be made there in their normal environment.  The joint discharge team worked across health and social care, and referrals were passed through to appropriate teams.  In addition, community based teams were trained to understand when referrals should be made around CHC and other kinds of eligibility.

 

The vice-chairperson sought assurance that the training did not result in teams erring on the side of caution in terms of the number of referrals.  The director of performance suggested that this assurance could be provided in the next paper.

 

11.        Referring to the jointly commissioned ‘Herefordshire Continuing Healthcare Review: Final Report’ by Angela Parry in June 2018, the chairperson drew attention to the review observation that ‘CCG colleagues accept that changes to practice went ahead without ongoing discussion with the Council which may have resulted in budgetary implications and relationship difficulties’.  It was questioned why the local authority had not been involved in that change, particularly given the possibility of pressure being moved to other parts of the system.

 

The chairperson also drew attention to the review recommendation for ‘Clarity from the CCG that there has been change to the CHC approach in Herefordshire and clarity for the Council as to where, within the process, this change has taken place. This will give the Council and understanding of why numbers have fallen so dramatically.’  The chairperson said that this did not appear to have been taken forward and considered it essential to arrive at a mutual, joint understanding of needs and how best to meet them.

 

The director of performance suggested that these matters could also be picked up in the next report but did comment that joint working well in the local system, with senior level involvement in the Herefordshire Integrated Primary and Community Services Alliance Board, and collaboration would be further developed through the Primary Care Networks and other initiatives.  The assistant director all ages commissioning confirmed that good progress had been made and there was an opportunity for partners to work more closely from an operational commissioning perspective.

 

There was a short adjournment to prepare draft recommendations. The resolution below was then discussed and agreed by the committee.

 

Resolved:  In collaboration with Herefordshire Council, where appropriate, it be recommended to the clinical commissioning group:

 

(a)         To provide a rationale, with data (in numbers), as to why Herefordshire is not achieving the expected levels of NHS Continuing Healthcare when compared with other clinical commissioning group and local authority comparator areas.

 

(b)        To follow up the request from the adults and wellbeing scrutiny committee on the commitment to provide responses to the recommendations set out in the jointly commissioned Parry report.

 

(c)         To provide details on the numbers of NHS Continuing Healthcare appeals and the number of successful appeals before and since 2016.

 

(d)        To explain how the various discharge pathways are able to pick up the patients where NHS Continuing Healthcare is deemed, or not deemed, to apply and how further assessments of NHS Continuing Healthcare are triggered.

 

(e)         Where there are changes to services that are likely to impact on the wider system, that partners are engaged in conversations at the earliest opportunity.