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
Council.

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
caused.

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
hardship”.

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
procedures.

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
families.

Abstract
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
authorities.

References
(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
melanie@henwood-associates.co.uk

BOXTEXT: MELANIE HENWOOD
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.