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Investigation into NHS continuing healthcare funding

The National Audit Office has published the findings of its investigation into NHS continuing healthcare. The following is a press release from the NAO:

NHS continuing healthcare (CHC) is a package of care provided outside of hospital that is arranged and funded solely by the NHS for individuals who have significant ongoing health care needs.  Funding for ongoing health care is a complex and highly sensitive area, which can affect some of the most vulnerable people in society and those that care for them.

The number of people assessed as eligible for CHC funding has been growing by an average of 6.4% a year over the last four years.  In 2015-16, almost 160,000 people received, or were assessed as eligible for, CHC funding in the year, at a cost of £3.1 billion. If someone is assessed as not eligible for CHC funding, they may still be entitled to other health and social care services, some of which the individual may have to pay for. Key findings of the investigation include:

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.

  • NHS England estimates that at least 124,000 standard (non fast-track) screenings and 83,000 fast-track tools were completed in 2015-16, and that around 62% of people who were screened using the checklist went on to have a full assessment.
  • NHS England estimates that only about 18% of screenings undertaken led to the person being assessed as eligible for CHC.

In most cases eligibility decisions should be made within 28 days but many people are waiting longer.

  • In 2015-16, about one-third of full assessments (24,901) took longer than 28 days.
  • 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.

Decisions on eligibility for CHC have a significant financial impact on the individual, clinical commissioning group (CCG) and local authority.

  • 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 for CHC were considered not eligible.
  • 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%.
  • 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 are referred and are assessed as eligible.

The number of people receiving CHC funding is rising and the funding of CHC is a significant cost pressure on CCGs’ spending.

  • Between 2011-12 and 2015-16, the number of people that received, or were assessed as eligible for, CHC funding during the year increased from 125,000 to 160,000.
  • Between 2013-14 and 2015-16, spending on CHC increased by 16% and in 2015-16, it 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.
  • NHS England wants CCGs to make £855 million of savings on CHC and NHS-funded nursing care by 2020-21 on its prediction of growth. NHS England told us that it plans to do this by reducing both administrative assessment costs and the overall cost of care through reducing variation in spending, and ensure that CCGs interpret the eligibility criteria more consistently.
  • NHS England has not yet set out a costed breakdown for how it will achieve the savings to the cost of care. 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.

There is significant variation between CCGs in both the number and proportion of people assessed as eligible for CHC

  •  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 judged as eligible ranged from 41% to 86%, excluding the 5% of CCGs with the lowest and highest percentages.
  • NHS England’s analysis 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 are interpreting the national framework to assess whether people are eligible for CHC, due to its complexity.

There are limited assurance processes in place to ensure that eligibility decisions are consistent, both between and within CCGs.

  • There is a shortage of data on CHC, which makes it difficult to know whether eligibility decisions are being made fairly and consistently. For example, no data are collected on how many individuals appeal to the CCG against unsuccessful CHC funding decisions, the first stage of the appeals process.
  • 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 expanded the data it collects on CHC

The Full report can be accessed here:

How can Compass CHC help?

The key to success when taking on the NHS continuing healthcare professionals is to ensure that you have sufficient expertise in your corner to support you through the process so the correct outcome is reached.

If you have encountered problems with your Clinical Commissioning Group or feel you have been given incorrect or conflicting information we, at Compass CHC, can help.

Before any instructions are accepted on a case a full, detailed, free and confidential assessment of the specific circumstances relating to the patient will be undertaken. Only at this stage – and when the expert assessor from Compass CHC is of the view that the evidence relating to the patient’s condition indicates that there is a reasonable prospect of success in securing funding – would we accept instructions to act on a patient’s behalf.

Our team of continuing healthcare experts, comprising lawyers (non-practising) and clinicians (including nurses, tissue viability specialists and pharmacists) will then review and consider all the evidence from a clinical perspective before drafting reasoned arguments to your Clinical Commissioning Group which identify an individual’s entitlement to the funding by cross-referring the medical evidence to the National Framework for continuing healthcare criteria

Should you, or a relative, have any concerns regarding NHS Continuing Healthcare funding, our expert advisors can assist by explaining the ins and outs of what can be a perplexing and complicated process. There is no time limit placed on this free, no obligation consultation. Should you wish to discuss matters further, do not hesitate to contact us directly on 0121 227 8940.

For more information please read our ‘Why should I use a specialist continuing healthcare company? article.

Author: Tim Davies LLB

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