NHS Continuing Health Care and Personal Health Budgets Annual

NHS Continuing Health Care and Personal Health Budgets
Annual Report 1st April 2013 – 31st March 2014
Sarah Flavell- CCG/CHC Commissioning Manager
Bernie Horne: CCG Interim Personal Health Budget Implementation Manager
18th June 2014
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1.
Introduction
1.1
This annual paper sets out what the CCG has achieved in relation to
Continuing Health Care (CHC) and implementing the Personal Health
Budgets. It also seeks to give assurances that positive steps are being made
to improve the CCG’s understanding of CHC/FNC processes, responsibilities
and governance; including an update on current progress and proposals to
meet the CCG requirements for CHC in the future outlining short and long
term goals. The paper will summarise the current risks associated with CHC
and PHB and short and longer term priorities.
NHS Continuing Healthcare (CHC)
1.2
NHS Continuing Healthcare (CHC) is where the NHS funds health and social
care if individuals are assessed as having a “primary health need”. NHS
Funded Nursing Care (FNC) is the funding provided by the NHS to care
homes providing nursing care by a registered nurse for those assessed as
being eligible. CCGs have been legally responsible from 1st April 2013 for
undertaking this assessment process which is prescribed by the Department
of Health underpinned by legislation and must be consistently applied
throughout England.
1.3
Within Bath and North East Somerset there is a CHC/FNC Service
Specification and Operational Policy; Sirona Care & Health are delegated to
provide the CHC/FNC services and meet some of the statutory requirements
associated with CHC and the National Framework, however the CCG retains
the overall responsibility to ensure statutory work is carried out in accordance
with national guidelines.
2.
BaNES Continuing Healthcare and Funded Nursing Care Provision
CHC Provision 2013/14
2.1
BaNES CCG commissions, as part of its contract with Sirona Care & Health,
the assessment, review and case management service through a dedicated
CHC Team and community health services.
3.
FNC Provision 2013/14
3.1
Funded Nursing Care cost is a benefit paid by the NHS on behalf of those
people in a nursing care home who are assessed as requiring oversight or
care from a registered nurse. It is not paid to the person receiving care, but
directly to the nursing home in which they are resident.
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3.2
Funded Nursing Care also includes provision of continence products to
nursing homes, who liaise directly with the supplier; this is currently delivered
via a single supplier (Hartmann) who subsequently invoice the CCG.
4.
South Funded Care Benchmarking Analysis for Q4 2013/14
4.1
The most recent NHS England published report for CHC indicates that
expenditure is above the regional average for Fast Track eligible individuals
and adults under 65 with mental health conditions. The highest areas of
spend overall are Fast Track cases, and adults over 65 with mental health
conditions or physical disabilities.
4.2
For FNC the most recent report indicates that the CCG’s overall spend is in
the middle of the range but that costs per 10,000 weighted population appear
high.
4.3 The profile of End of Life care and services is a national agenda, which gives
rise to greater patient choice, including choosing where End of Life care is
delivered. This increases the requests for domiciliary care provision, which
can be more costly to deliver than a conventional nursing home placement.
5.
CCG statutory responsibilities
5.1
The National Health Service Commissioning Board and Clinical
Commissioning Groups (Responsibilities and Standing Rules) Regulations
2012 (“the 2012 regulations”). Part 6 of the 2012 regulations contain standing
rules in relation to NHS Continuing Healthcare and NHS Nursing Care and
closely follow the NHS CHC Regulations 2012 particularly as regards the
distinction between duties that the relevant body must carry out itself and
duties that the relevant body may arrange to be carried out by another
organisation on its behalf. Assessment of a person’s needs for eligibility of
NHS CHC / FNC and subsequent review regarding ongoing eligibility is set
out in the National Framework for NHS CHC revised version 2012. It is the
responsibility of the CCG to ensure these processes are robust and equitable.

Decision making on eligibility; engaging families and managing disputes.

Commissioning of care and support package, including Personal Health
Budgets.

Case Management of complex cases and reviews of support care plans.

Governance and system management to ensure legal compliance
including, monitoring eligibility levels, training and support to staff.

If a CCG delegates functions, it continues to have statutory responsibility
and must, therefore, have appropriate governance arrangements in place.
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
The CCG cannot delegate its final decision making function in relation to
eligibility decisions and remains legally responsible for all eligibility
decisions made.

Unlike Social Care assessment, there is less/little scope to amend or
interpret the criteria that will attract CHC/FNC; therefore it does lead to
less ability to manage costs.
6.
Progress 2013/14
6.1
There has been some positive progress in relation to CHC/FNC service
progress in this period including;

CHC/FNC Service specification and Operational Policy have been updated
to reflect current national guidelines as per the updated National
Framework 2012.

A dedicated CHC Commissioning Manager and administrator have been
appointed and took up post in March 2014, with the aim of raising quality
within Continuing Healthcare.

An Internal Audit was completed in November 2013, identifying areas of
potential risk associated with CHC/FNC service provision. From this report
an action plan has been completed, implemented and updated. Both
reports have been presented at the Quality Committee and Audit
Committee.

The CCG is working closely with Sirona Care & Health CHC team to
ensure individuals accessing the service have an experience that is
positive and quality assured. This is being achieved through monthly
Quality Assurance meetings, and on an adhoc basis as day to day issues
arise.

Working practices and processes have been changed to ensure the CCG
is meeting its statutory requirements associated with agreeing eligibility,
when a full CHC assessment is completed using a Decision Support Tool,
and when a Fast Track (End of Life) referral is made.

A clear Retrospective assessment process and recompense pathway has
been agreed and implemented with Sirona and the Central Commissioning
Support Unit (CSU).

Three CHC mapping meetings have been held to consider current and
future working practices.

Personal Health Budgets (PHB) have been introduced and by the end of
Q4 in BaNES two personal health budgets had been agreed.
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
A review of the Single Funding Panel has been commenced to review how
health funded care provision is agreed, which is particularly important now
Personal Health Budgets are being implemented. The Joint Senior
Commissioning Managers have been instrumental in maintaining the panel
and it is anticipated that the review will further support them in reducing
the workload appropriately

The CHC Commissioning Manager has a delegated limit to agree funding
for Fast Track eligible patients to avoid delay in arranging services.

Members of the Nursing & Quality team have ‘shadowed’ members of
Sirona’s CHC team to ensure understanding of CHC/FNC.

The CCG supported the Children’s Commissioners with the recruitment of
a delegated CHC Children’s Lead Nurse.
7.
Performance Information
7.1
Sirona Care & Health have reviewed the reporting processes during the year
and the CCG is working with them to identify clearer ways of recording and
reporting data with a programme of audits agreed and in place. The CCG is
aware of overall increases in work load, including the implementation of
Personal Health Budgets and complex case management which all impact on
the ability to meet essential criteria. This increased workload has been
reported by CHC teams nationally and is a significant concern
8.
Retrospective CHC – Previous Unassessed Periods of Care (PUPoC)
8.1
The CHC team has reviewed requests for retrospective assessment, 210 in
total were considered by 31 March 2013; the number of retrospective CHC
assessments to be undertaken is 116. These patients will require checklists to
be completed and decisions made by the CCG as to eligibility for CHC for
periods of time from 1 April 2001 - 31 March 2013. NHS England has set
guidance that patient’s still in receipt of care / services are prioritised over
deceased patients. There is increasing challenge from solicitors acting on
patients’ or representatives’ behalf which is impacting on the ability of the
Nurse Assessors to complete core retrospective work. The CCG is working
with Sirona Care & Health to positively deal with these challenges, including
using guidance and formal correspondence from the NHS England legal
advisors Cap Sticks.
9.
Appeals – Local Resolution / Locality Appeal / NHS England
Independent Review Panel
9.1
As set out in the local CHC policy the first stage in the appeals process is via
Local Resolution meetings and these are delegated to Sirona Care & Health.
9.2
Since April 2013 there have been 10 Local Appeal Panels. The Sirona
administration team provide administration support for Local Appeals but a
member of the CCG Nursing and Quality team attends and can potentially
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chair the panels. This also includes review of in-depth patient medical records
and care notes to ensure they are fully aware of the details of the case.
9.3
Since April 2013 there have been eight NHS England Independent Review
Panel (IRP’s).The appeals process is set out in the National Framework for
the NHS England Appeal stage, both representatives from the CHC Team
and the CCG will be required to attend these panels.
10.
Complaints
10.1
Complaints relating to the assessment, review or case management
processes are managed by Sirona Care & Health who have reported there
were four complaints associated with these aspects of CHC in 2013/14, and
are now resolved.
10. 2 Complaints regarding the outcome of the eligibility decision are managed by
the CCG. It is likely complaints relating to CHC will relate to either failures in
the CHC assessment / review process or to eligibility decisions made by the
CCG.
11.
Children’s CHC Commissioning
11.1
Children’s commissioners are also currently reviewing Continuing Care and
appropriate oversight of Special Educational Needs and Disability (SEND
Reforms) and have recruited a dedicated CHC Commissioning Nurse. The
aim is to promote joint working relationships between adult and children’s
CHC Commissioning Managers to consider Transition cases and CHC
Personal Health budgets. Both adult and children’s commissioning managers
came into post in March / April 2014.
12.
Personal Health Budgets (PHBs)
12.1
A key objective of NHS England (outlined in the Government's Mandate to the
NHS) was that the NHS improves dramatically at involving people in decision
making affecting the services to meet their health and social care needs;
essentially empowering them to manage and make decisions about their own
care and treatment. This has included the implementation of Personal Health
Budgets.
12.2
From April 2014 people eligible for NHS Continuing Healthcare (including
parents of children) across England have the right to be offered / ask for a
Personal Health Budget. Others with long term health conditions (LTC’S) or
disabilities may also benefit from PHB’s when they are rolled out across
England from April 2015, along with the Personalisation Agenda.
12.3
CCGs have been responsible for ensuring PHBs have been available from
1 April 2014 and that there is support to help implementing them. NHS
England put a delivery programme in place, led by a national delivery team,
which aimed to help all CCGs meet the April 2014 deadline. BaNES CCG
has ensured preparation for PHBs by recruiting an interim Project Manager
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and PHB Lead Nurse to design and implement policy and practice guidelines.
£59,000 has been spent to date on project delivery of which £20,000 was
supported by NHS England. To ensure PHBs continue to be implemented
effectively it is important the Board acknowledge the additional work the
Nursing & Quality team may need to incorporate into their everyday work, as
PHBs will need quality monitoring along with all other services. In 2013/14
there were two PHBs agreed and set up.
12.4 Budget Setting
The CCG needs to be able to provide an upfront allocation or an “indicative
budget” to those people taking up a PHB. This “indicative budget” should be
based on the level of need as indicated in the Decision Support Tool and
provide sufficient funding for all assessed needs to be met.
Following some investigation into the widely used Manchester Setting Tool we
have concerns about the robustness of it to provide appropriate indicative
budget and this needs further exploration. Some regions are using the current
package costs as a benchmark for setting “indicative budgets and this
approach was used for the two packages recently agreed.
12.5
Support Planning and Brokerage
The CCG has a responsibility to provide assistance to patients who are taking
up a PHB with the planning and brokerage of their care and support. Prior to
PHBs there was only a requirement that the Case Manager completed a Care
Plan which showed how the care and support would be commissioned and
provided to meet a patient’s needs. Under PHBs there is a requirement that a
Personalised Care Plan be completed for everyone which would show how
the person would like their support to be provided and how they would use
their PHB. Learning from the Pilot has shown that the CCG will need to
commission a range of options from where support with planning and
brokerage could be delivered. It will not be possible (or appropriate) for the
Sirona CHC Team to provide all this support.
The evaluation of the PHB Pilots provides the following information on cost of
Support Planning and Brokerage
“An important element of implementing personal health budgets is to ensure
that there is adequate support planning and brokerage. Where this works well,
it enables individuals and their families to be more involved in planning the
support that meets the needs identified in the support plan, rather than relying
on the PCT’s own local processes. This is clearly, therefore, key to the
implementation of personalisation and personal health budgets. The six pilot
sites reported a mean cost of £21,850 (median £21,380) to cover the
development of support planning and brokerage that was in addition to what
would have been incurred without personal health budgets.”
12.6
Direct Payment Management Services
It is likely that most people who take up a PHB will choose the Direct Payment
option for managing their money. The CCG is responsible for ensuring that
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there is support provide for the patients who want to take up this option. Some
people may only require information and advice and then choose to manage
the Direct Payment themselves. Other may require more intensive support
including having their Direct Payment managed by a provider and may include
payroll and employment support service.
12.7
Workforce Development
The introduction of PHBs requires a change in culture across the CCG and
CHC practitioners. There are also significant changes in practice that the
Project Team has been addressing with practitioners through the
development of the PHB Toolkit.
17 staff attended a one and a half day training session in February and a
further two days have been commissioned
There will certainly be a need for more training when PHBs are rolled out to
people with Long Term Conditions.
The PHB Pilot Evaluation Report stated
“Eleven pilot sites reported that on average £13,050 would be required to
meet the training needs of the workforce (median £7,400). Out of these 11
sites, eight reported an average mean cost of £15,880 that was additional to
what would have incurred without personal health budgets (median £9,220)”
We are fortunate in BaNES to have systems in place for the payment and
auditing of PHBs. The Council Client Finance Team has been operating a
social care Personal Budget Finance system for several years and is familiar
with the requirements that will come with administering PHBs. The SLA with
the Council was reviewed in March and there is an agreement in pace for the
Finance Team to provide support to the CCG on the future administration and
financial auditing of PHBs.
13.
CCG Action Plan 2014/15
13.1
The CCG Director of Nursing and Quality is responsible for ensuring the
responsibilities of the CCG are met in line with the National CHC/FNC
Framework. The CCG recruited a dedicated CHC Commissioning Manager in
March 2014 to identify areas of risk, quality improvement and monitoring of
the CHC/FNC contractual obligations.
13.2
Areas of improvement, risk management and actions required were discussed
and agreed at the CCG Audit and Assurance meeting(s) in April and May
2014.
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14.
Conclusion
14.1
BaNES CCG is committed to improving the quality and performance of
Continuing Healthcare and Funded Nursing Care processes, putting quality
assurance, patient safety and monitoring of delivered services at the heart of
the individual patient’s care provision and experience; ensuring these
principles are embedded into the core principles of CHC. The CCG
acknowledges there are areas within CHC which require review and
improvement if national guidelines and criteria are to be adhered to, however
the Nursing and Quality Directorate are working closely with Sirona Care and
Health and with the Council to ensure the CCG meets its statutory
responsibilities and improves services for patients and their carers’ in the Bath
& North East Somerset locality.
14.2
Positive steps have been taken to ensure immediate concerns are addressed
and longer term goals are set to continue to build on the work already initiated
and completed. These initiatives include:

The organising of a CHC Work Shop for health & social care workers in
September 2014.

Raising the profile of CHC to ensure everyone accessing health and social
care services are screened for CHC.

Working towards a clear assessment process for people referred to CHC
which will ensure an equitable service is delivered to everyone.

Personal Health Budgets are positively being implemented – BaNES
currently has six patients in the process of accessing a PHB.

Quality audits of high cost cases and Fast Track cases is currently
underway which can highlight areas of good practice as well as consider
areas for improvement. This includes meeting patients to gain their
individual view of the CHC services they access.

Individuals who are considered to be near the end of their life can access
CHC via the national Fast Track process. BaNES CCG has set up a robust
process to ensure CHC is agreed in a timely manner, avoiding
unnecessary delays.
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