A national template

The blurring of long-term health and social care has led to a new, more enlightened continuing care framework aimed at resolving the current mess, writes Melanie Henwood

The national framework on NHS continuing health care was issued for consultation last week and marks the latest in a long series of revisions and adjustments to this area of policy and practice. The distinction between what is health and what is social care is of fundamental importance in this area of long-term care since it determines how much, if anything, people have to contribute to the costs of their care. There is much to welcome such as the explicit commitment to establish a “simpler, fairer and more coherent system” founded on core values and principles.

The problems with continuing care are familiar and were restated last year in an inquiry by the House of Commons health committee,(1) which argued the system, was “characterised by confusion, complexity and inequity”. The committee concluded that continuing care problems reflected the difficulties associated with the separation of health and social care and would only be resolved by comprehensive integration. But in the absence of such change, will the proposed national framework tackle the worst anomalies and inequities in the current system?

People often do not understand the policy distinction that is made between health and social care, and between fully funded continuing care and funded nursing care. Moreover, a postcode lottery in access to NHS-funded continuing care exists because of the disparate criteria used by strategic health authorities, which treat similar needs in different ways. Evidence to the health committee also identified problems with guidance being misinterpreted and misapplied, with some criteria being used that are not even lawful, which has resulted in the health service ombudsman saying there are too many cases of injustice and hardship. A national framework needs to:

Provide a set of national criteria addressing physical, psychological and mental health needs.
Be compliant with the 1999 Coughlan judgement including addressing whether a person’s needs are primarily for health care rather than for accommodation.
Be sufficiently flexible to support care in any setting, including care at home.
Resolve the confusion between continuing care and funded nursing care through the registered nursing care contribution (RNCC).
Ensure consistency in assessment of needs and application of criteria.
Provide better information for the public and greater transparency of the system.

Against such a template the framework appears to stack up compellingly.

The objectives of the new framework are that it should promote fair and consistent access to NHS funding, while also being simpler to administer. This would be a major achievement.

A simplified process also offers the prospect of reducing administrative costs associated with operating the parallel systems of continuing care and NHS-funded nursing eligibility through the RNCC. The department’s own regulatory impact assessment suggests that savings in the region of 20m-50m might be anticipated.

However, there will be additional costs associated with adoption of the national framework. While the shift to a single band for NHS-funded nursing care is to be set at a level that will be cost-neutral (on the basis of average weekly costs of 97), estimates suggest that the framework would cost an additional 110m in the first year. Moreover, this cost is seen as “largely unavoidable” given that it is the direct consequence of legal judgments “clarifying where the boundary of NHS responsibility lies, and shifting the balance between NHS and local authority provision on a local level.”(2) The total costs of the proposals cannot be estimated at this stage, but it is clear that there will be a “significant cost impact”.

At a time of mounting concern over budget deficits this will cause some anxiety; there will also be questions about how the NHS will be held to account to ensure that eligibility is determined by a person’s assessed needs and is not finance-led.

Assessing whether someone’s primary need is a health need will be made by reference to four key indicators: the nature, complexity, intensity and unpredictability (alone or in any combination) “of an individual’s physical, mental, psychological or end-of-life care needs”. The proposed national framework also states that eligibility for fully-funded NHS continuing health care “will depend on an individual’s overall care needs, not their disease, diagnosis or condition. It is not dependent upon the person who provides the care required to manage those needs, nor the location in which the care is provided”.

Assessment processes will provide the critical gateway to determining eligibility. Under the national framework, a comprehensive assessment is undertaken to establish whether “the balance of an individual’s needs are primarily for health rather than social care.” And a decision support tool has been developed to ensure consistent application.

Everyone involved in assessing needs for NHS continuing care needs to understand the ethos and the purpose of the tool, which is not to restrict eligibility. It is especially important that the four indicators for eligibility are understood and that it is not assumed that someone must qualify on all these indicators. This failing of much current practice is addressed in the proviso that “assessors should be mindful that some people with chronic, predictable and non-complex needs will also have a primary health need on the grounds of the nature or intensity or both of those needs”.

The proposals should be welcomed for the much needed clarification they provide, and for the acknowledgment that more people should in future qualify for fully funded continuing care. At the same time, the framework does not alter the separation of health and social care. In effect this will not mean that everyone who requires long term nursing care will automatically have all their care costs met by the NHS.

However, the national framework offers a real prospect for putting in place a more equitable system. Whether it will be achieved will depend on the political weight attached to implementation. Failure to adhere to the new system would guarantee further cost pressures on councils and escalating litigation.

Melanie Henwood is an independent health and social care consultant, with particular interests in continuing care, hospital discharge and the interface of health, social care and other community-based services. She is a specialist adviser to the House of Commons Health Select Committee, and a lay member of the General Social Care Council.

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The distinction between fully funded NHS continuing care and means-tested social care has become increasingly blurred. This has been marked by a string of legal challenges and by the recurrent involvement of the NHS ombudsman. The Department of Health has issued a consultation on a national framework for continuing health care and NHS-funded nursing care. The article evaluates whether this framework addresses the key failings of the current system and whether it will resolve the long-standing inequities, complexity and confusion.

(1) House of Commons Health Committee, NHS Continuing Care, Sixth report of session 2004-05, Volume 1, HC 399-1, 2005
(2) Department of Health, Partial Public Sector Regulatory Impact Assessment: The National Framework for NHS continuing healthcare and NHS-funded nursing care in England, 2006

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