By Harry Bourton, regional manager, CHS Healthcare
A large proportion of published articles on continuing healthcare focus on issues around eligibility for funding. This is understandable, given the complexity of the field and controversy which often arises, but it neglects the fact that continuing healthcare is also a NHS service provided by all Clinical Commissioning Groups (CCG).
Like all services, there is variability in terms of good practice, poor practice and everything in between. It is therefore valuable to consider what best practice in continuing healthcare looks like.
There are some clear statistical parameters of best practice. One parameter is this: 85 per cent of full assessments for continuing healthcare funding should take place outside the acute setting. In other words, full CHC assessments in hospital should be rare and the exception, never the rule.
This is important for two reasons. Undertaking a full assessment in an acute setting means that we are measuring a person’s capacity when they are likely to be at their lowest point. Every nurse will recognise how an elderly person becomes quickly incapacitated and dependant on a hospital ward but in a home or community based setting, will mobilise with more confidence and undertake tasks they could not perform in hospital. A full assessment in an acute setting can provide an inaccurate measurement of capacity and is likely to work against best outcome for the patient.
Nor are hospital based full assessments good practice from a systems point of view. Setting out key parameters for continuing healthcare, NHS England states that addressing delays in CHC assessments is likely to free up a third of the overall bed capacity the system requires. In other words, these are delays to hospital discharge which are “within the remit of health to resolve” by focusing on the CHC assessment process1.
Another key parameter of good practice set out in the same guidance is that once a positive CHC checklist is undertaken, full assessment and decision must be completed within 28 days. This should be achieved in 80 per cent of cases (again, outliers beyond 28 days being the exception not the rule). In practice, 84 CCGs are falling far behind this and reporting more than half of their cases are taking over 28 days between checklist and decision. NHS England have told all CCGs falling behind the 80 per cent target to scrutinise their delays and produce a plan for improvement.
We provide end-to-end continuing healthcare services for two CCGs and menu based services for 30 other CCGs. We recognise the issues here. Often, there are high levels of inappropriate checklist positive individuals going through for full CHC assessment. Sometimes there are very poor controls and protocols on referrals for Fast Track continuing healthcare funding.
One principle at the forefront of our work is this: always to apply the right skills at the right time in each process. We have teams of highly valued administrators who are, in many ways, the ‘unsung heroes’ in continuing healthcare. They source vital information, gather records and co-ordinate the different agencies and organisations involved with each individual. It is often in this part of the process where the greatest challenges lie and delays build. Our nurse assessors can then come in at the right stage and concentrate their skills precisely where they are needed.
Although good practice in continuing healthcare may not have the simple headline indicators of other services, such as A&E performance or elective surgery, but statistical measures of practice are available. Levels of CHC funding (fast track and full) are published here and outliers, both in terms of very high or very low awards, particularly when compared with statistical neighbours, are likely to be applying the national framework incorrectly. Otherwise such wide variation in awards in funding cannot be understood.
I would also argue that best practice in continuing healthcare is not only about process and performance. Best practice is dependant on all staff involved in the delivery of CHC (administrative and clinical and working at all levels in the service) having a full understanding of the context for CHC and delivered from a values-based perspective.
For this purpose, we developed a two-day training module which is compulsory for all our staff and has been provided widely for NHS and local authority staff across the country. It is based on not only knowing the process, but understanding the principles behind that process and reflecting on how although it is easier to say yes, it is essential to follow the framework and more often this will necessitate saying no, but doing so with compassion and empathy.
1/ Matthew Swindells, National Director, Operations and Information and Professor Jane Cummings, Chief Nursing Officer, England, in dear colleague letter, August 2017