2010-01-19 16:38:18

Assessment Using the NHS National Framework

In June 2007, the Department of Health published the “National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care”. This replaced all previous published guidelines for deciding who qualifies for continuing care funding. The Framework became active policy on 1 October 2007.

The key aims of the Framework are to:

• Set out clear principles and processes for establishing a Primary Health Need
• Clarify the relationship between NHS Continuing Healthcare and other types of care, especially nursing care
• Make the assessment process for continuing care fair and consistent across the country and to stamp out the “postcode lottery” that had developed.

The Framework hopes to achieve these aims by:

• Introducing a single set of guidance to be followed by all Primary Care Trusts (PCTs) and Local Authorities in England
• Introducing a national assessment process supported by national assessment tools that will help with decision-making and consistency
• Introducing common paperwork to record all evidence that supports decision-making
• Removing the need for separate assessments to be carried out for different types of care, e.g. nursing care.

The Framework clarifies that it is the duty of the PCT and / or Local Authority Social Services to identify when it is appropriate for a continuing care assessment to take place, for example when a patient is discharged from hospital. This aims to prevent cases that have occurred in the past where a patient or family has been unaware that they may be entitled to continuing care funding because no one had mentioned it to them. The Framework also urges the PCT and Social Services to involve the patient and / or their family or carer in all stages of the assessment process and to provide full written details of the reasoning behind the decisions taken at each stage of the process. You can download a copy of the National Framework from the Department of Health’s website. When the National Framework should be used The National Framework should be applied whenever it is identified that a patient has a potential need for continuing care. This includes the following situations:

• If the patient has a rapidly deteriorating condition which may be terminal
• If a patient is about to be discharged from hospital, especially if it looks like they may need to move into a care home
• When a patient’s care needs are being formally reviewed, usually on an annual basis
• If the patient’s physical or mental health deteriorates significantly and their current care package no longer meets their needs. In this instance, the patient could be living at home or in a care home.

A PCT is obliged to arrange an assessment under the National Framework:

• When it becomes apparent that there is a need for continuing care, as defined above, or need for variation in who provides care for the patient, e.g. a move from home into a care home
• Before a patient is discharged from hospital into a nursing home so that their nursing needs can be properly assessed as well as their eligibility for continuing care funding
• When a patient is about to be discharged from hospital, but not into a nursing home, and may be eligible for continuing healthcare – in this instance, the patient cannot be discharged until the assessment has taken place and a care plan / funding has been agreed.

If the PCT fails in its duties as listed above, then the PCT will be in breach of The NHS Continuing Healthcare (Responsibilities) Directions 2007(items 1 and 2) or The NHS Delayed Discharges (Continuing Care) Directions 2007 (item 3). The Three Tools of the National Framework The National Framework consists of three tools to help with consistent decision-making during the assessment process:

• The Fast Track Tool
• The Checklist
• The Decision Support Tool, used during the Multi-Disciplinary Assessment.

The sections below give more information about each of these tools.

• The Fast Track Tool

The PCT approves use of the Fast Track Tool when a patient’s need for continuing care is urgent, for example if their condition is rapidly deteriorating and may be entering a terminal phase. The Fast Track Tool is usually applied in hospital by a member of a multi-disciplinary team but can also be used in other settings. Where possible, it should be followed by the full assessment process.

• The Checklist

Unless a patient is fast tracked, the first step of the assessment process is the completion of the Checklist or Screening Tool. This is a basic tick-list that takes account of 11 areas of patient need and groups them into categories of A - “Meets / Exceeds Need”; B - “Borderline”; and C - “Does not meet need”. The patient will be referred for a full continuing care assessment if:

• There are 2 or more ticks in column A, or
• Five or more ticks in column B, or
• One tick in A and four in B.

The referral threshold has been set at a deliberately low level to reduce the risk of valid cases for continuing care being overlooked. But this can serve to raise false expectations as many patients that are referred for a full continuing care assessment will not qualify for funding. The Checklist can be used by a nurse, doctor, other qualified healthcare professional, or a social worker within a hospital or community setting. In most cases, the Checklist would be completed when the patient is on the point of discharge from hospital. Patients and their families can ask to see the checklist themselves to get an idea of whether the patient will qualify for a full continuing care assessment.

• The multi-disciplinary assessment (MDA) using the Decision Support Tool

If the Checklist indicates that the patient may qualify for continuing care funding, the next stage is the multi-disciplinary assessment or MDA. It is called “multi-disciplinary” because the assessing team will consist of at least two staff members from different disciplines, such as a doctor and a social worker or a ward sister and an occupational therapist. At least one member of the team should have personal knowledge of the patient and their medical history. The PCT will appoint an individual to co-ordinate the assessment process from start to finish, through to when a decision about funding has been made and a care plan has been written. The coordinator can invite the patient or their representative to attend the MDA but does not have to do so. It is usual for both the PCT and Local Authority Social Services to be represented at the MDA as the Local Authority may still be involved in the care package even if the patient qualifies for full NHS funding. The MDA focuses on the same 11 areas of need that are shown on the Checklist but examines them in greater detail. Each of the 11 areas of need is graded as None, Low, Moderate, High, Severe or Priority. Some of the needs have a maximum grade of High and others of Severe. As well as the 11 defined areas, the assessing team must take into account any other area of need that applies to the patient but which does not fit into the 11 areas. The assessing team uses the Decision Support Tool to bring together and evaluate the needs that were identified during the MDA. The Tool is designed to make sure that all relevant factors are taken into account when assessing the patient’s needs. The Decision Support Tool takes account of:

• Nature – the nature of the patient’s needs.
• Complexity – how the patient’s needs interact with each other and whether this makes them harder to manage
• Intensity – how often and for what lengths of time treatment / supervision is required
• Unpredictability – for example, whether the patient’s condition is likely to deteriorate rapidly and / or without warning.

One or more of these four factors – Nature, Complexity, Intensity and Unpredictability – may indicate a Primary Health Need because of the quality and / or quantity of care that the patient requires. The Decision Support Tool would indicate that a patient has a Primary Health Need if:

• They are assessed as having a priority need in any of the four areas of need that go up to priority level (see Figure 2 below), or
• Two or more needs that are assessed as severe across all areas of need.

The Decision Support Tool would indicate that a patient MAY have a Primary Health Need if:

• One area of need is assessed as severe together with needs in several other areas, or
• Several areas of need are assessed as high and / or moderate.

However, the National Framework warns assessors not to make prescriptive judgments, for example, awarding continuing care funding just because one area of need has been classified as Priority and states that: “There is no substitute for a careful and detailed assessment of the needs of the individual whose eligibility is in question.” So the completed Decision Support Tool is not a means to an end for establishing whether a patient qualifies for continuing healthcare. Instead, it supports the process of establishing whether or not the patient has a Primary Health Need. The overall aim of the MDA is to look at each patient’s case individually and build a full picture of their overall needs, both healthcare needs and other requirements, using:

• The Decision Support Tool
• The patient’s medical notes
• Risk assessments
• Their own experience of the patient
• Their professional judgment.

Outcome of the assessment process

• If the patient qualifies for continuing care

If the multi-disciplinary team decides that the patient qualifies for continuing care, they will make a recommendation for funding to the PCT. The PCT does not have to accept the recommendation, but it is rare that they do not accept it. The PCT should inform the patient verbally and in writing about the decision. They will then put together a package of care that they consider appropriate to the patient’s needs. It is important to note that the final decision about the type and location of care rests with the PCT. This is because the NHS is funding the care and will, for example, only have contracts with certain nursing homes so flexibility is limited. But the patient and their family’s preferences will be taken into account where possible. To find out more about what happens when a patient has qualified for continuing care, please read our factsheets:

• After a patient has qualified for continuing care
• Care homes fact sheet
• State benefits – your entitlement

• If the patient does not qualify for continuing healthcare

If the patient is assessed as not qualifying for continuing care funding, then a care plan will still be drawn up after the MDA. The following types of care will be fully funded by the NHS to include accommodation costs etc:

• Intermediate Care
• After-care under section 117 of the Mental Health Act 1983 (NB. Funding for this type of care will be withdrawn when the PCT and / or Local Authority decides that the patient no longer requires it).

To find out more about these types of care, please read our factsheet “Other types of care and who pays”. If a patient does not qualify for continuing care, it is likely that they will be assessed as requiring NHS-funded Nursing Care (see factsheet), usually within a care home. This would be noted on the Decision Support Tool during the MDA. This type of care plan is jointly provided by the NHS and by Local Authority Social Services. As well as NHS-funded Nursing Care, the NHS will also fund a number of other services either within a care home or in the community, such as GP care, respite health care and palliative care. To find out more, please read our factsheet “Other types of care and who pays”. Social Services are responsible for providing all social and personal care needs not met by the NHS, and which are within their scope to provide. This may include nursing care from non-registered nursing staff such as care workers. It is important to note that all services provided by Social Services will be means tested and the patient or their family may be required to meet significant costs.

• If the patient is not happy with the outcome of the MDA

If you or a relative have been assessed as not qualifying for continuing care and are unhappy with this decision, you can:

• Ask your PCT to review your case. The PCT is not obliged to do this. If the dispute cannot be resolved at local PCT level, the complaint is referred to the Strategic Health Authority, then to the Healthcare Commission and / or the Ombudsman. This process can take months or even years. Or,
• Contact Cheselden. We will review your case to assess whether we think you may be entitled to continuing care funding. This is a free service and can take just a few days.

To find out more about Cheselden and how we can help you, visit the About Cheselden and Our Services sections of this website. If you want to find out more about pursuing your case through the PCT, rather than through Cheselden, contact your local PCT in the first instance. Our factsheet “List of PCTs and SHAs” contains the contact details for all PCTs in England. Your local Patient Advice & Liaison Service (PALS) can also help – you can find contact details for your local service at www.pals.nhs.uk. Follow-up reviews under the National Framework Every patient that has been considered for continuing care funding should have their case reviewed after 3 months in case their needs have changed. This applies whether or not they qualified for continuing care funding and whether or not they passed the Checklist stage of the assessment. The review process means that a patient who had previously not qualified for funding may now be considered eligible – but the opposite can also happen and funding could be withdrawn. After the three month review, further reviews should be carried out at least every 12 months. But a re-assessment can be requested at any time if there is a rapid change in the patient’s condition. The National Framework warns assessors against the potential detrimental effect on a patient of moving them in and out of continuing care within short spaces of time.