Clearer Care Criteria

    Melanie Henwood is an independent health and social care
    analyst with particular intersts in community care, older people
    and their carers.  She is also an adviser to the Joseph Rowntree
    Foundation, and is a specialist adviser tot eh House of Commons
    health committee and a lay member of the General Social Care

    Last December a written ministerial statement on NHS continuing
    care was issued by community care minister Stephen Ladyman. It
    attracted little immediate interest and was all but lost in the
    pre-Christmas distractions. But it could have profound and
    far-reaching implications in England, for Ladyman hinted at a
    “national approach to continuing care to improve consistency and
    ease of understanding”.

    This is something that has been called for by various bodies –
    including the House of Commons health select committee. In a report
    on palliative care published in July 2004 the committee urged the
    government to develop national criteria in order to tackle “the
    inequitable anomalies” that arise between strategic health
    authorities (SHAs). The committee is currently undertaking an
    inquiry into continuing care.

    It seems that the government has recognised that the challenge is
    about more than just consistent criteria; it is also about how the
    criteria are implemented and applied to individual patients. It is
    also necessary to make the process easier to understand for
    patients and practitioners.

    Ladyman maintains that the current criteria in operation across the
    SHAs are now all fair and legal, but now wants to build on the good
    practice and the experience that was built up during the review
    process. But the aim is not to tear up the work that has gone on
    locally and to start again from a blank sheet – an important point
    if SHAs are to sign up to the development of a new national
    approach and not to feel that their efforts have been wasted.

    What will “a national approach” to continuing care mean? At the
    very least it should no longer be possible for the NHS in any part
    of the country to tell patients: “Oh no, we don’t have continuing
    care in this area,” or for similar needs to fit the criteria in one
    SHA but not in others.

    Equally, the pattern of continuing care provision must break away
    from the legacy of past provision and practice. In areas that have
    had a large number of NHS long-stay beds, criteria have tended to
    be much “looser”, while those without such a tradition and without
    significant numbers of community hospital beds have operated far
    more restrictive criteria.

    However, a national framework is just the beginning. It has long
    been clear that the development of SHA-based criteria was only part
    of the task and that the real challenge would be ensuring
    consistent implementation across primary care trusts. Even with a
    framework of shared criteria, different assessments and
    methodologies could result in different procedures and outcomes.
    Poor implementation and training support have often been why
    front-line staff have failed to properly understand or apply the
    criteria, and this needs to be addressed if the same pitfalls are
    not to be repeated.

    Ladyman’s statement follows an independent review last year
    commissioned by the Department of Health which looked at how one
    third of the SHAs had reviewed their criteria for long term
    care,(1) and found that they all wanted national criteria.

    It was recognised that the 28 sets of criteria being used were an
    improvement on the 95 versions used by health authorities
    previously, but as one person said: “It is still a postcode
    lottery; there are just fewer postcodes now.” The variations were
    seen by other respondents to have resulted in inequalities and a
    confused system in which different SHAs were “all getting played
    off against each other by smart clients and solicitors”.

    The long-standing controversy around NHS continuing care raises
    fundamental questions about the boundaries between the NHS and
    social care, and the financial responsibilities of citizens and the
    state. The health service ombudsman has been investigating
    complaints about NHS funding for such care, and has raised concerns
    about the system’s unfairness and the financial injustices

    In a hard hitting and highly critical report published in February
    2003 the ombudsman said that the guidance and support issued by the
    Department of Health had failed to allow a “fair and transparent
    system of eligibility for funding for long term care to be operated
    across the country.”(2) What guidance there had been had at times
    been misinterpreted and misapplied by health authorities. The net
    result had been a system in which people often did not know whether
    they should qualify for fully-funded NHS care or whether they would
    need to pay the costs, and where people with apparently similar
    needs could qualify in one health authority, but not in another.
    The effect, argued the ombudsman, was to “cause injustice and

    The ombudsman recommended that criteria for NHS long-term care and
    how it had been applied in all SHAs since 1996 should be reviewed,
    making financial recompense to patients where necessary. The
    Department of Health complied and across the 28 SHAs in England,
    about 2,000 people or their estates were awarded a full or partial
    refund of the costs of care for which they should never have had to
    pay, at a total cost of £180 million.

    The ombudsman criteria review provides a good foundation for next
    steps. It seems that local understanding of continuing care has
    improved, and that there is now a much better understanding that
    NHS fully-funded care should be determined by needs, not on the
    basis of a particular diagnosis. There is also better recognition
    that continuing care can take place in a range of different
    settings – not just in an NHS hospital. As a person’s health
    changes, their eligibility for continuing care may also change, and
    this needs to be taken on board.

    The prospect of a national framework for continuing care offers
    improved stability in a policy area that has been afflicted by
    uncertainty and change. The intervention of the ombudsman has been
    significant in forcing the criteria to be reviewed and in raising
    the political profile of continuing care. Without national
    eligibility criteria it is likely that there would continue to be
    further challenge and scrutiny from the ombudsman as well as
    uncertainty and a lack of confidence in local policies and

    There continues to be a divide between the health and social care
    systems, and in many ways long-term care epitomises where there are
    difficulties and blurred boundaries. By refusing to accept the core
    recommendation of the Royal Commission on Long Term Care that all
    personal care should be free on the basis of assessed need whether
    health or social care, the government has left the dividing line in
    place. Ensuring greater consistency in the eligibility criteria for
    long-term care will not change that, but it should improve the
    transparency and fairness of the system for individuals and their

    The disputed responsibilities between health and
    social care are epitomised in many of the difficulties that arise
    around NHS continuing health care. This article looks at the
    implications of the proposed new national framework and the need to
    improve consistency and to make criteria more easily understood. It
    draws on the findings from several reviews into the experience of
    continuing health care in English strategic health

    (1) M Henwood, Continuing Health Care: Review,
    Revision and Restitution, 2004
    (2) The Health Service Ombudsman, NHS Funding for Long Term Care,
    HC 399, 2003

    Contact the author

    is an independent health and social care analyst with particular
    interests in community care, older people and their carers. She is
    also an adviser to the Joseph Rowntree Foundation, and is a
    specialist adviser to the House of Commons health committee and a
    lay member of the General Social Care Council.

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