This report is the result of a detailed look at complaints PHSO has handled about NHS Continuing Healthcare (NHS CHC). The objective is to support those on the frontline of NHS CHC to learn from mistakes, improve quality, and consistently apply national guidance to deliver care packages that meet people’s needs.
PHSO has published several reports on NHS CHC over the last 25 years, most recently in 2007, which contributed to the development of the National Framework for Continuing Healthcare and NHS-Funded Nursing Care (the National Framework), first published in 2007.
We recognise that we publish this report into an NHS that is dealing with an unprecedented crisis in responding to the COVID-19 pandemic. This has had a major impact on the whole health and social care system, including on NHS CHC. The Government paused new assessments for NHS CHC and reviews of existing care packages between March and the end of August 2020 to allow the NHS CHC workforce to support hospital discharge arrangements thereby freeing up frontline staff to support the overall COVID-19 response. A move back into stricter lockdown measures may result in further pauses.
PHSO made decisions on 336 complaints about NHS CHC between April 2018 and July 2020. This report focuses on the two main themes we have seen in these recent complaints. Although this is a small proportion of the 112,000 people newly assessed as eligible in 2019-20, there are lessons for the system to apply to ensure NHS CHC meets the needs of the people who are entitled to it.
First, we explore what PHSO’s casework tells us about the impact on patients, families and carers when Clinical Commissioning Groups (CCGs) have not carried out effective and inclusive care and support planning, and how this can be improved.
Second, we look at what PHSO’s casework tells us about how CCGs have handled requests for reviews of previously unassessed periods of care. This involves CCGs looking back at someone’s care needs in the past to decide whether they should have received NHS CHC-funded care at the time.
What we found – failings in care and support planning
We found that failings in care and support planning result in people and their families being forced to fund care, on top of that funded by NHS CHC. We also found that poor communication around care plans and packages can have similar outcomes, with people being unaware of their entitlements and the processes to challenge decisions where they believe shortfalls are occurring.
We found CCGs, with support from NHS England and NHS Improvement, need to make sure frontline staff have the skills and resources to deliver high-quality, comprehensive and inclusive care and support planning that meets individuals’ care needs. We also emphasise the importance of good communication and involvement, so people are aware of what is covered in an NHS CHC package and how to challenge decisions about them.
We make the following recommendations to help inform the ongoing continual improvement of NHS CHC:
Recommendation 1: Supporting the skills and experience of NHS CHC practitioners locally
CCGs should assure themselves that those involved in assessing care needs and developing care and support plans are appropriately skilled and experienced to perform that role by using the CHC Competency Framework. Regular training should be made available to frontline practitioners to ensure best practice is followed. At the least, CCGs should ensure frontline practitioners have undertaken learning from the NHS England and NHS Improvement e-learning tool to increase their knowledge and understanding.
Recommendation 2: Sharing learning nationally
In the short-term, NHS England and NHS Improvement should review the NHS CHC e-learning tool and other learning opportunities to ensure they take account of the learning from the case summaries included here. They should update these learning opportunities to ensure they provide effective support to the frontline NHS CHC workforce responsible for care and support planning and commissioning.
Recommendation 3: Putting learning into practice
In the long-term, NHS England and NHS Improvement should consider what additional support and coaching it can provide to care systems, CCGs and NHS CHC frontline staff to ensure they are appropriately supported and skilled in care and support planning and commissioning.
Recommendation 4: Supporting people and providers through the NHS CHC process
CCGs should ensure all parties to an NHS CHC-funded package of care are aware of the principles of NHS CHC funding and arrangements for additional services. CCGs should clearly explain in care and support plans what is included in the care package to meet the assessed needs, and the process that should be followed if any additional services or charges need to be considered.
What we found – failings in reviews of previously unassessed periods of care
We found that failings by CCGs when reviewing previously unassessed periods of care resulted in people waiting considerable periods for certainty about finances. We also found there was no detailed guidance to support CCGs in reviewing previously unassessed periods of care after 2012.
The learning from CCGs’ failings in this area highlight the importance of high-quality and timely decisions that are communicated effectively with people who use services, their families, and carers. We make the following recommendations:
Recommendation 5: Developing national guidance
The Department of Health and Social Care (DHSC) and NHS England and NHS Improvement should consider the approach to previously unassessed periods of care dating from after 2012 and develop guidance to clarify CCGs’ obligations. Guidance should set out explicitly how CCGs should respond to requests to retrospectively assess people’s eligibility for NHS CHC-funded care such as Ms W’s and Ms K’s, whose requests relate to periods of time after the 2012 closedown. This guidance should make clear what CCGs’ obligations are and give clear and specific timeframes for CCGs to meet these obligations. If deadlines for requests are imposed, these should be effectively communicated by CCGs to anyone who may have been affected to ensure no one is disadvantaged.
Recommendation 6: Delivering capability in the NHS CHC system
Once this guidance is in place, CCGs should assure themselves, with support from NHS England and NHS Improvement, that they have sufficient capability to successfully meet their obligations as set out in the guidance. Where assessments of previously unassessed periods of care are required by the guidance, CCGs should ensure they can complete timely and quality reviews.
The learning in this report draws on the evidence from complaints to PHSO. The recommendations are practical and achievable, but we recognise the unprecedented pressures on the NHS due to COVID-19 mean that it may take longer than usual for them to be implemented.
We ask the Department of Health and Social Care, and NHS England and NHS Improvement to write to the Public Administration and Constitutional Affairs Committee and the Health and Social Care Select Committee in six months with an update on progress in planning and delivering these recommendations.
PHSO makes final decisions on complaints that have not been resolved by the NHS in England, UK Government departments and other UK public organisations.
PHSO looks into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. We do this impartially and independently of Government and our service is free for everyone.
PHSO shares findings from casework with Parliament to help it hold organisations that provide public services to account. We also share findings more widely to promote improvements in public services. PHSO is accountable to Parliament. Our work is scrutinised by the Public Administration and Constitutional Affairs Committee (PACAC).