Equity and Choice

This policy describes the way care for people who have been assessed as eligible for fully funded NHS Continuing Healthcare is commissioned to reflect the choice and preferences of those individuals, whilst also balancing the need to commission safe and effective care that makes best use of available resources.

USEFUL INFORMATION

Continuing Healthcare / Fully Funded NHS nursing care

This is free care outside of hospital with ongoing health needs that is arranged and fully funded by the NHS, subject to meeting criteria.

This domiciliary care can be provided in any setting; at home or in a care home. If someone does not qualify for NHS continuing health care, they will still receive mainstream services free of charge, i.e. GP, District Nursing Services, Specialist therapy.

If NHS continuing healthcare is provided in a care home, it will cover the care home fees, including the cost of accommodation, personal care and healthcare costs. If NHS continuing care is provided in the home of the person, it will cover personal care and healthcare costs.

Funded Nursing Care (FNC) is slightly different in that it is based on fixed rates (and therefore may not meet all costs associated with a defined need), and is available only when residing in a registered nursing home. This may be available in circumstances of ineligibility for continuing healthcare.

A change in needs

Where an individual who has been reviewed and is currently receiving a domiciliary care package and it has been assessed that their needs have increased the CCG will consider whether the current care package remains appropriate.

Where the CCG deems that the current care package is not appropriate and does not approve an amended domiciliary care package, then the individual will need to agree to an alternative package of care which is approved by the CCG.

The National framework requires CCGs to review eligibility at 12 weeks and annually thereafter. In the event that a review of an individual establishes that their condition has improved or stabilised to such an extent that they no longer meet the eligibility criteria for NHS fully funded Continuing Healthcare and a CHC assessment confirms that they are no longer eligible then the CCG will no longer be required to fund the service.

What if the individual does not have the capacity to make choices?

If an individual does not have the mental capacity to make an informed choice and is considered to be placing themselves at risk, a mental capacity assessment will be undertaken, in line with the guidance in the Mental Capacity Act 2005.

If the individual does not have the capacity to make an informed choice the CCG will deliver the most cost effective, safe care available based on an assessment of best interests and in conjunction with any advocate, close family member or other person who should be consulted under the terms of the Mental Capacity Act 2005

What if an individual is not happy with the CCG decision on care provision?

If the care provision suggested by the CCG conflicts with the wishes of the individual-al or their representative you have the right to appeal this decision setting out your grounds for appeal.

This will be considered through a CCG appeals process. Further details of this process are available on request. Individuals and family members also have the right to complaint, through the CCG complaints process.

If the complaint cannot be resolved locally the individual or their representative can be referred to NHS England and the Health Service Ombudsman.

Who else has been involved in the development of the equity and choice policy and the preferred provider network?

This policy is informed by national guidance, local legal advice and stakeholder groups as appropriate.

What is the role of the CCG?

In the delivery of CHC the CCG has to ensure consistency in the application of the national policy whilst, implementing and maintaining good practice and ensuring quality standards are met and sustained.

The CCG has developed a preferred provider list of care homes and domiciliary care agencies who have demonstrated that they are able to meet the quality criteria for the provision of healthcare which is safe, efficient and value for money.

Individuals receiving NHS Continuing Healthcare have some of the most clinically complex and severe needs within the local population. The CCG will work with the individually to promote choice and to ensure where required the wider family feel their opinions are considered when commissioning the appropriate provision of care to meet the individuals healthcare needs doing this within the available resources and ensuring the quality of care provision.

The CCG will consider care provision outside of the preferred provider network; how-ever the CCG will not commission care from a provider who does not meet the agreed quality specification for care delivery or where safeguarding concerns have been substantiated and embargos are in place.

What is the role of the hospital?

The hospital has the responsibility to carry out multi-disciplinary assessments and make a recommendation for continuing healthcare funding using the decision support tool. After a decision has been made on eligibility by the CCG, then the discharge team work with the individual / family to put it into place.

For care home placements the discharge team will provide a copy to the individual / family of the CCG preferred provider list from which the family / service user may choose from.

For care within the home the discharge team will work with the individual and the family to develop a holistic care plan which will be sent to the CHC team to enable the commissioning of care provision to meet identified health needs.

What is the role of social services (Local Authority)?

The local authority as part of the multi-disciplinary team work closely with the CHC team and the hospital discharge teams to carry out assessments and support placement provision, The local authority has a responsibility to offer support if the service user is not eligible for continuing healthcare funding.

How does the CCG make its decision on placement provision?

The CCG has the duty to commission services that offer quality, efficiency and value for the whole population they serve, balancing patient preference alongside safety and value for money.

People who are eligible for continuing healthcare funding have a complexity, intensity, and/or unpredictability in their care needs which can mean that it is less common for care to be safely delivered at home.

The CCG will consider if care can be delivered safely to the individual and without undue risk to the individual, the staff or other members of the household. Safety will be determined by a written clinical assessment of risk undertaken by an appropriately qualified professional.

The risk assessment will include the availability of equipment, the appropriateness of the physical environment and the availability of appropriately trained care staff and/or other staff to deliver the care at the intensity and frequency required.

The CCG may refuse to commission home care in the following circumstances.

  • A package of care in excess of eight hours a day which would indicate a high level of need which may more appropriately be met by a care home placement.
  • Individuals who need waking night care would generally be more appropriately cared for in a care home. The need for waking night care indicates a high level of supervision at night.

The CCG will take into consideration the individual’s choice of care setting but there is no automatic right to a package of care at home.

What is a Personal Health Budget and can this be used to pay for care?

Patients eligible for CHC can choose to have a Personal health budget (PHB). A PHB is an amount of money to support the identified healthcare and wellbeing needs of an individual, which is planned and agreed between the individual, or their representative, and the local clinical commissioning group (CCG).

At the centre of a personal health budget is the care and support plan which is completed in partnership with the individual and helps people to identify their health and wellbeing goals. The plan will set out how the budget will be spent to enable individuals to reach their goals and keep healthy and safe.

A PHB can provide more flexibility and choice in care provision within an agreed indicative budget.