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Practicality, priorities and pain: What is the way forward for efficient and fair CHC reviews and assessments?

Practicality, priorities and pain: What is the way forward for efficient and fair CHC reviews and assessments?

By Dr Gabrielle Silver, CEO

Local authorities and CCGs are beginning to grapple with NHS England and Improvement’s updated guidance on Continuing Healthcare, working through new processes and guidance on how to deal with the numerous deferred assessments on their desks, as well as handling the new cases coming through every day. What are the key considerations and implications for this restart?

To discuss these implications, recently 157 professionals from CCGs and local authorities joined The way forward for efficient and fair CHC reviews and assessments, the second session in our ongoing webinar series. Sydney Hill, Head of Health and Care Strategy at Richmond and Wandsworth Councils and Ben Troke, Partner, Health and Social Care at legal firm Hill Dickinson shared their insights on the implications of the new guidance. As with so many discussions, the webinar appeared to raise more questions than it answered.

And this of course was its purpose: to stimulate thinking about how best to deliver a national programme at a local level. 

Managing expectations

Sydney Hill noted that: “Most important is our commitment to service users – we have to keep them informed and manage expectations. We took the decision during lockdown to complete reviews remotely and to as high a quality as we could.”

Like other local authorities and commissioners, she has started by seeking answers to the fundamental requirements for successful delivery: 

  • What is the exact number of citizens in local authority and CCG care, either funded under Covid-19 conditions or who are awaiting an assessment? How do we prioritise these people?
  • What is our approach to remote assessments and how do we co-ordinate information between our teams and the CCGs? 
  • How can a Trusted Assessor model be introduced as a dynamic tool for both stakeholders and one which maintains the quality of assessment expected?

Ben Troke echoed the sentiment about managing expectations, from both the perspective of patients and families, but noted that as professionals, “we need to manage our own expectations of what we can expect over the next few months.” He emphasised the need for the following 3Ps: Practicality, Priorities and – more ominously – Pain.

Practicality

Now that Coronavirus Act funding (via Treasury) for care has effectively been stopped, the drivers are practical and financial, though the law suspending the legal duties to assess for CHC has not (yet) been reversed. An estimated 55,000 people remain on interim funding and there is a surplus of deferred assessments to be completed. This will take extra resources and funding and must be done “as soon as practicable”, according to government guidance.

Priorities

Prioritising means making decisions about who to assess first – the backlog or the business as usual?  And do we prioritise giving funding to those who should have it but don’t, or removing it from those who have it and should not? Said Ben: “in many ways it can be more difficult to stop or take something away than it is to say ‘no’ in the first place.”

These conversations require a specific and particular skillset, together with a locally agreed, pragmatic approach to decision-making, in line with the 2012 regulations, and the National Framework.

Pain

“The pandemic saw some brilliant working relationships across different organisations in the face of a crisis,” said Ben, “but now that the central funding has ceased, those budgetary tensions may re-emerge.” He expects disputes will increase and notes that there may be difficulties with the expectations of families who have been in receipt of funding which may now stop.

Ben said organisations will need to be open and transparent about their decision-making and will have to be able to defend it. “Avoid litigation and challenge as much as possible; CCGs and local authorities should understand their legal position and understand that guidance is just that – guidance. If you have your own policies, follow them. Take account of the things you are obliged to do and don’t make promises you cannot keep. Remember the law is not only a stick to beat you with, but can also be a shield to protect you.”

Trusted Assessor

The Trusted Assessor model is one area that poses a challenge for CCGs and local authorities. The legislative framework is clear that a multi-disciplinary team (MDT) will need to be involved. Speaking for local authorities Sydney said, “local authorities will feel disengaged if decisions are being made without our input.” The panellists agreed that further clarity from NHS England and Improvement and an understanding how others have done this successfully would be valuable for all concerned. 

But the Trusted Assessor is not just about a single agent trusted by both stakeholders. It is also about how best the information gathered in one arena such as Continuing Healthcare, can be shared with other stakeholders in their own Care Act Assessment. After all, we have been looking at the Single Assessment Model since 2001, and perhaps the new guidance can act as the vehicle upon which to test the principle.

Workforce

In a poll run during the webinar, most delegates said they needed more support with workforce. Sydney agreed that this was her number one priority and was waiting to see what the promised additional funding for staffing comprised. She has been looking at the existing personnel at the local authorities and what skills she needs to create a dedicated recovery team to focus on the deferred assessments. 

CHS Healthcare has been supporting CCGs with CHC reviews and assessments nationally since 2013 and are well-placed to support CCGs and local authorities to tackle their current and ongoing priorities. For more information, contact enquiries@chshealthcare.co.uk to discuss your needs.

You can access a recording of the webinar here: https://chshealthcare.co.uk/events/webinar%3A-the-way-forward-for-efficient-and-fair-chc-reviews-and-assessments/ 

If you are interested in learning more about Ben Troke’s work on the law of medical treatment decisions, you can read more in his new book here (all proceeds go to the Alzheimer’s Society): http://www.lawbriefpublishing.com/product/medicaltreatmentdecisions/ 

Reflecting on Continuing Healthcare COVID-19 Recovery Planning

Dr Gabrielle Silver, CEO

The Coronavirus Act 2020 helped to support hard-pressed health and care services throughout the acute Covid-19 phase but created uncertainty around implications for recovery. This is an issue we have been working with CCGs on over the last months as we consider how the system is to manage the significant backlog of reviews and assessments for Continuing Healthcare (CHC) that has built up, and how the relationship between stakeholders involved in these assessments has changed.

We knew many others across health and care were grappling with these challenges so to bring everyone together with some expert commentary, we recently held a webinar with speakers Jan-Denise Wood, Head of Complex Care, Milton Keynes CCG Covid-19 Tactical Lead Commissioning, Contracting & Flow Cell, and Jill Mason, Partner and Head of Health & Care, Mills and Reeve. We had over 160 attendees from across the NHS, social care, local authorities, and private providers.

These are some of the key points that emerged from our discussion, which usefully reflect the evolving policy landscape and NHSE/I’s phase three letter issued 31 July 2020.

  1. When do CHC reviews and assessments need to start?

Everyone involved in Continuing Healthcare ultimately has the same goal of moving people into the right funding stream to provide security around their long-term care. With an estimated 55,000 patients placed under interim Covid funding, organisations wanted clarity on when these assessments would need to restart. Furthermore, confusion around the legal implications of the Coronavirus Act 2020 meant that many were hesitant to pursue reviews through this period, resulting in a backlog of assessments building up – not to mention the BAU reviews on those already receiving CHC-funded care.

The good news is that the recent letter from NHSE/I clarifies that by 1 September, assessments for CHC must be underway.

We asked attendees to vote on what their biggest challenges are moving into the recovery phase and the results were:

  • workforce capacity
  • the impact of a second peak
  • funding for additional work

These responses force us to reconsider how reviews and assessments are delivered. Our panellists pre-empted the NHSE/I phase 3 response by advocating the use of a trusted assessor model. Using an independent assessor who presents an expert assessment to an MDT panel is an efficient way of working through the backlog, and in some locations this model is in place already.

As swathes of work have been moved online across health and social care, many organisations, including ourselves, have been successfully conducting assessments via video and/or telephone, particularly in the trusted assessor role. While remote (and especially video) assessments and reviews will not be appropriate in all cases, being able to shift even 50% of the current workload to these models will alleviate workforce capacity. We have seen huge steps forward in digital services being used to treat and diagnose patients, so the ability to conduct reviews and assessments in the same way is also promising.

  1. Planning for the future – data is key

Planning for the future is challenging, but necessary, especially in the mid-term. We must prepare with the assumption that there will be a second wave which is likely to preclude any return to ‘normal’ ways. Now may not be the time for total system change, but it is a time to think about what is coming and ensure that local policies and systems are in place to address it.

As part of this it’s critical to ensure that proper data management processes are in place. At the moment this will vary between organisations, but we need to be prepared to assess against data collected through the COVID-19 period. This means ensuring that existing data is cleaned, and that a credible baseline is established ahead of the second wave. Where data collection can be improved right now that is clearly a good thing to do.

We know that everyone involved in CHC and phase 3 wants what’s best for patients, and one of the most heartening things to come out of the difficult last months was the way the system pulled together and put in place what was needed to provide care and keep people safe. Phase 3 will be a huge challenge, but I am optimistic that with the right systems and a clear focus we can provide the clarity patients and their families will want and ensure their long-term care. CHS is perfectly placed to support our NHS partners with the increased assessment activity over the next few months.

You can find a recording of the webinar here: https://chshealthcare.co.uk/events/webinar-what-next-continuing-healthcare-covid-19-recovery-planning/

Guys and St Thomas’ partnership: supporting shielded patients

CHS Healthcare, a provider of patient flow solutions to the NHS, is delighted to announce their partnership with Guys and St Thomas’ NHS Foundation Trust to provide domiciliary phlebotomy and swabbing services to their shielded patients, in the safety of their own homes.  CHS Healthcare’s team are coordinating phlebotomy support to both adults and children who have been required to stay at home during the Covid pandemic.  The swabbing programme delivers MRSA and Covid testing in advance of elective surgical admissions. The service was established within a record two weeks and will support the ongoing care of hundreds of patients each week.

CHS Healthcare’s Chief Executive, Dr Gabrielle Silver, said of the service “ We are very proud to be able to help a leading trust such as Guy’s and St Thomas’ in their objective to help vulnerable patient groups.  We are confident that this service will provide the reassurance to those shielding in the community, whilst also ensuring they continue to receive the highest quality of care”.

The service, which commenced at the beginning of June, is enabled by a bespoke patient management system that CHS Healthcare has developed to ensure the effective tracking and follow up of all the community based patients.

Let’s get assessments and reviews back on track

Dr Gabrielle Silver, CEO

There have been numerous media reports over the last two weeks drawing attention to the issues around the reviews and assessments for older people discharged into the community under Covid-19 funding. A recent Guardian article highlighted the potential harm to vulnerable people caused through the use of easements by Councils under the Coronavirus Act. Here permission has been given to pause or stop assessments, reviews and some care with both Liberty and Disability Rights now raising concerns.

Liberty commented: “The government and local councils should be working to shore up – not weaken – support for disabled people, their carers and those who rely on social care during this pandemic. We need to come through this crisis the right way – with all of our rights intact.”

Obviously ceasing or delaying these reviews and assessments is concerning in terms of patient safety but they are also disrupting the flow of patients from intermediate care into permanent arrangements. It’s fair to say that the longer the system is in stasis the harder it will be to get moving again. And, as times goes on, so the environmental challenges increase. There are still concerns about management of Covid-19 infections in care homes, the financial viability of these homes and as we ease out of the peak of the crisis we will soon be faced with the challenge of potential further peaks and planning for winter. To be able to effectively manage capacity in the community we need to complete the reviews and assessments, so we know exactly what we are dealing with before the next phase hits.

The system and the workforce are bruised from the last weeks’ intensity. Moving forward brings new difficulties around resource management, workforce capacity and infection control. BAU activities e.g. face-to-face assessments feel new and different when they need to be undertaken remotely. But we know from the work we are doing with CCGs that remote assessments can work well – even in complex cases.

It is imperative we push ahead with these assessments. Without them the system is frozen at a time when it desperately needs clarity around capacity and finances. And most importantly we have a duty of care to do the right things for older people currently in care, as well as those that will come into care in future months.

Jennifer Dixon, CEO of The Health Foundation, said in her statement to the Health Select committee last week: ‘COVID-19 has also demonstrated how the health and care system can move fast, implement new technology and ways of working, and the deep commitment of NHS and care staff. All of these will be needed, with resources to match, to face the challenges ahead’.

I would echo her points and add that private sector partners are critical to getting the system moving. The NHS and Social Care systems are not islands and nor should they be. It’s time to embrace the breadth of the sector – and that means all of the knowledge, innovation and capacity that exists in private sector as well. We are here to help for the benefit of all stakeholders.

We have to talk about the money

By Dr Gabrielle Silver, CEO

Earlier this week, Chancellor Rishi Sunak gave an update to the House of Lords Treasury Committee on the financial impact of COVID-19.

Debt has been used strategically to support the country through this crisis, whether that has been a debt write off for trusts, an open cheque book for the NHS, funding for CCGs and local authorities to support COVID-19 preparedness, or the furlough scheme.

We all know that in the long run this debt will need to be tackled and that further borrowing will need scrutiny and debate – when is it right to use debt and when do we need to look at other ways of managing costs through measures such as tax increases? The defining line for these decisions is starting to become clearer.  It is around borrowing where additional funds are needed to deliver against urgent pandemic requirements versus funding ongoing public services which are needed regardless of COVID-19.

At the moment, older people discharged into the community to create capacity for COVID-19 are funded via the NHS under COVID-19 provision. This funding was made available to support the pandemic emergency and facilitated the rapid discharge in March of around 15,000 people. In the pre-COVID-19 world these older people would have been assessed and allocated either as self-payers, funded via LAs or funded via the NHS (Continuing Healthcare).

As we move out of the peak of the crisis the urgent need for this emergency funding gives way to individuals’ ongoing care and therefore the system must revert to the traditional funding routes supported through taxation rather than borrowing.

The Treasury estimates that borrowing this year could reach £337bn vs £158bn at the height of the global financial crisis. Sunak said yesterday that the impact of the pandemic will cause a “severe recession, the likes of which we haven’t seen”. We all know there is a real focus at the moment on getting the economy moving again with employers working hard to design solutions for social distancing in workplaces, and we’re seeing the challenge facing public transport and schools. We’re seeing independent hospitals begin to go back to BAU, and we’re starting to see the NHS prepare for elective surgery with around 8m people waiting for operations.

It may be tough to talk about funding when social care providers and older people have been through so much and are still experiencing such a difficult time. The drive to move back into some semblance of normality in terms of funding of care is the right thing to do. The debate around social care reform will continue, and should receive priority, but in the meantime, we need to move out of emergency measures so we can understand the financial reality facing the sector as well as ensure older people are getting the right care in the right place.

And we don’t have to reinvent the wheel. We can make our lives easier by utilising existing frameworks and processes which give CCGs access to support, additional workforce and dedicated expertise to implement processes to bring the system back online.  Doing this does not negate the need for social reform – in fact it will make that reform easier to grasp and therefore more possible.

Supporting patients and their families throughout the COVID-19 pandemic

An interview with Reagan Chakki, whose mother was helped by CHS during COVID-19

In December 2019, 67 year-old Kathleen Walsh suffered a brain injury while on holiday in Spain. She was treated in a Spanish hospital and after a month was discharged and her family in England flew her back to the UK. Once she was home, her family realised that she would need further treatment and rehabilitation, so took her to the Queen Elizabeth Hospital in Birmingham where she was admitted. Her condition required specialist neuro rehabilitation and while she waited for a space in a rehabilitation centre to become available, Kathleen was transferred to her local hospital, Heartlands. She was there for two months.

Kathleen’s daughter Reagan said: “Mum was stuck in an acute setting that she didn’t need to be in, and she was deteriorating day by day.”

At the end of March 2020, Kathleen had still not been discharged from hospital and her family were becoming increasingly worried by the threat of Kathleen becoming infected with the coronavirus at the hospital. They knew that she needed to be discharged as soon as possible.

It was then that Reagan, Kathleen’s daughter, was put in touch with CHS Healthcare and was assigned to her adviser, Debbie, to help discharge Kathleen from hospital and find somewhere that would meet her immediate care needs.

Reagan said: “Debbie helped me get mum out of hospital, so she was safe and out of immediate danger of COVID. My conversation with Debbie was open and honest and dealt with my mum’s care needs. Debbie was just brilliant, not only did she keep me updated, she went over and beyond what she needed to do, and she made us feel like mum did count and she was important”.

Within two weeks, Debbie had arranged for Kathleen to be discharged from hospital and into a neuro rehabilitation centre in Northampton, where she can really start to recover from her accident.

Reagan says: “Mum’s doing really great. They have kept her safe and she has progressed cognitively.”

After Kathleen was discharged from hospital, Debbie continued to check in with Reagan and make sure that Kathleen was receiving all the right care she needed. 

The support is appreciated by Reagan: “Debbie never gave up on us. She made it her goal to get her into the right setting.”

 

We can’t let vulnerable people be victims of inaction during COVID-19

By Art Calder, Head of clinical services

In February, I warned about the growing backlog of our Learning Disability Mortality Reviews (LeDeR) and the vulnerability of this population group in the face of COVID-19. Regardless of the pressure on parts of the NHS at the moment it is essential all that all cases continue to be reviewed, both as a moral obligation to patients’ families and to help improve care in the future.

Last week the HSJ reported how, as clinicians are needed on the frontline in the fight against COVID19, the reviews have stalled yet again. And at the same time referrals to the programme has risen since 19th March 2020.

We know from the Shielded Patients list that many of our learning disability patients are vulnerable because they live with co-morbidities. This risk is escalated through social distancing required within their day to day care and the fact that many people with learning disabilities lack appreciation of the need for social distancing especially when this contact is critical to their own mental wellbeing.

At CHS, we haven’t let COVID19 get in the way of our LeDeR programme. Our teams continue to review all cases that come in our direction. To make sure we are delivering these safely we have adapted our approach and are undertaking these remotely, getting families involved through calls to explore the care their loved ones are receiving and understand any concerns or issues they have or remaining questions they may want answers to.

These reviews are more important now than ever. Only last week we heard alarming news over the dubious application of ‘blanket’ Do Not Resuscitate (DNR) forms being used for particularly vulnerable acute hospital patients presenting with a learning disability.

We have adjusted our clinical reviews to ensure that such circumstances are fully explored in the course of each review.

At CHS we will not take our eye off the ball. We’re concerned that high quality care for people with learning disabilities will suffer during this pandemic and alongside their human rights too. We’re working remotely to make sure we can continue to maintain contact with all of our patient services. And this is true too of our LeDeR casework. As healthcare professionals we know this is the right thing to do and so do families.

We should be judged by how well we support the most vulnerable through this pandemic – we believe we can do right by them and right by their families.

Getting back to normal is the last thing we need.

By Gabrielle Silver, Chief Executive

The NHS is ‘getting back to normal’ with preparations underway for routine operations, getting cancer screening services running again and encouraging people to attend A&E or see their GP with any health issues.

‘Normal’ is an appealing idea at the moment but one of the things we have learned over the last weeks is that the old normal wasn’t perfect. In exiting this phase of the pandemic we need to ask how we can move forward and shake off old habits and ways of working that didn’t always deliver the best outcomes for older people and their families. We need to move forward, support and grow better ways of working making sure the health and care we provide for older people is more resilient and fit for the future.

There are three things which stand out for me:

  1. This crisis has highlighted cases where older people have been left to the elements in an underfunded and poorly coordinated care system. This can’t be allowed to happen again. The tales of horror taking place in UK care homes are repeated in Spain, Canada and the US. This issue is not unique to the UK but we are unique in that we have a universal single health and care system, one that is world-leading in many respects, but the gulf between the care provided in a traditional health setting vs that in the community has been exposed. This isn’t about a lack of commitment from the people working in the community but rather indicative of consistent underfunding and a lack of functioning cross-sector working. It’s time to challenge how social care is delivered, funded and incentivised.
  2. There will be much to unpick from what was missed in the last two months and how acute care was prioritised over everything else. We’ve highlighted the importance of maintaining visibility of the 15,000+ people discharged under Corona Act. For these people their care is currently being funded by the NHS. This will not last in perpetuity. Where records were not maintained or assessments not undertaken it will prompt concerns about where these older people will live and be cared for in the long term as well as who will pay? This will add to the stress for families, older people and providers as well as slowing the system resetting.
  3. Private partners are central to the solutions and progress needed to ensure the health and care system can thrive. The challenge that support from private partners is optional and can only be temporary needs to be put to bed. We’ve seen the private sector step up and help throughout the pandemic with commitment, insight, investment and innovation. A modern, fit for purpose health and care system needs to harness all the private sector has to offer and leverage that for the benefit of patients, their families and the staff that care for them.

We don’t need to return to normal, we need to move quickly and with focus to a better, more integrated care sector, where systems and processes ensure better care for the elderly.

Maintaining visibility of older people discharged into the community, supports care now, and in the future

By Uko Umotong, National Discharge and Community Services Manager

The health and care sectors are responding to the coronavirus pandemic at unprecedented speed. Reflecting long held ambitions, they are developing new ways of working, such as digital primary and secondary care, being integrated almost overnight. At the back door, an accelerated pathway for discharge from hospital for medically optimised older people is well underway. Making sure these older people are able to leave hospital and receive care in the community is critical at this point – both for their own heath and to create capacity for those with coronavirus.

However, as with all changes within the health system, it’s critical to consider broader impacts.

What happens once these older people are placed in community? How are their ongoing care needs being met? What are their funding arrangements?  Who referred them? When are they due to have their care reviewed?

Failing to track older people discharged into the community under Covid-19 funding, puts us in danger of losing visibility of some of the most vulnerable people in our community. This could create problems for them that may not be realised for some months.

An immediate issue is how do we assure ourselves that they are not at risk of readmission? And for the future post-pandemic world, do we have the right information in place to quickly assess care and funding needs and reduce disruption and additional stress for older people and their families.

We provide patient management systems, Broadcare and Caretrack, to over 75% of CCGs.  These systems are used to record critical information on older people placed in the community. We also developed and run the NHS England national database for Independent Reviews for CHC funding.  We have now developed these databases to accurately track and monitor all patients receiving interim funding due to the Covid-19 crisis.

This means that we can remind CCGs when older people are due health and care assessments, we can record the outcome of those assessments and when Covid-19 funding is no longer available, it will be easier to understand what funding is available for care.

We track:

  • Demographic patient data (including NHS Number, registered GP etc)
  • Covid-19 test outcome data
  • Referral data – where the referral has come from (acute hospital, including ward)
  • Date of funding agreed
  • Discharge arrangements
  • Costs of care
  • Breakdown of actual care delivered
  • Contracts agreed with care providers – when sent out and when returned
  • Payment reporting on actual payments made to care providers
  • Alert/reminder functionality to ensure patient is reviewed at a minimum of 12 weeks
  • Ongoing assessment timeframe once crisis is over
  • All patient documents to support funding

There are a lot of unknowns at this time and the focus is rightly on helping those who are medically fit to be discharged from hospital and into care. Good crisis management however requires a focus on planning for exit from the acute phase. After the Covid-19 crisis, we will need to ensure that we understand the wider picture of care for older people and that information exists to support longer term decisions.

NHS England asks Trusts to move 15,000 super stranded patients out of hospital and into community by end of week

By Uko Umotong, National Discharge and Community Services Manager

NHS England have asked Trusts to move 15,000 super stranded patients out of hospital and into the community by the end of this week to create urgent capacity for the coronavirus. We can help. We work with over 50 trusts across all D2A pathways, CHC and trusted assessor. We have a totally remote workforce who can start immediately. We can also support through the coming weeks with visibility on patients in the community to help make sure they don’t return as an unplanned admissions. We have unparalleled knowledge and insight of local care provision, we can support ongoing capacity by providing dedicated hospital discharge support throughout this challenging time

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