1. Continuing NHS Health Care
2011 Update Training Programme.

2. Aims and objectives
All staff to have an understanding of their responsibilities with regards to the assessment of needs within the continuum of care.
At the end of the session staff will have an understanding
of their level of knowledge and development needs within the care process.
of the assessment, decision making and disputes process for Continuing NHS Health Care
Notes For Trainer
These training slides have been developed by the BCUHB in partnership with Local Authorities in North Wales. The slides should not be altered in any way.
Each training pack contains
suggested outline of the day
a copy of the presentation slides
a copy of the Standard Operating Procedure
a case study
attendance sheets
evaluation forms
Outline for the Session – 2hr update
10.00am Welcome & Introduction
10.05am Questions & Answers
10.15am Assessment & decision making process
10.30am Disputes
10.45am Standard Operating Procedure
11.00am Case Study
Feedback from case study, questions and close

3. Outline of session Q&A session of background information to CHC
Review of assessment process
Review of decision making process for recommending eligibility for CHC
Disputes process
Standard Operating Procedure
Case study and feedback
Notes For Trainer

4. Q & A What is CHC? What is Funded Nursing Care? What is Joint Funding?
Participants should have completed the e-learning material prior to attending this session.
The e-learning material does not replace the update course.
Notes For Trainer
Use the practice guidance document to ask some refresher questions e.g.
5.2 – page 16
4.1 – page 9
5.45 – page 38
5.38 – page 36
5.21 – page 28

5. Do we need to do a CHC assessment?
Are needs simple or complex?
If complex convene MDT
MDT consider whether there is a need to do a CHC assessment or not and must have documented evidence (e.g. minutes of meeting) of the decision as to whether a CHC assessment is / is not required.
This decision with rationale must be communicated to the patient, families or their representative.
Notes For Trainers
Ask the audience when is a CHC required?
Comprehensive assessment:
Comprehensive assessments should be completed where the amount of support and treatment likely to be offered is intensive or prolonged, including permanent admission to a care home, intermediate care packages or substantial packages of home care. No decisions on where individuals are best supported should be made before all information from a comprehensive assessment has been evaluated, including information from medical assessments and a thorough exploration or rehabilitation potential.
5.20 If the outcome of the enquiry/contact assessment is that a referral for a full consideration for CHC is necessary, the result and the reasons should be communicated clearly to the individual, and their carers or representatives where appropriate, verbally and in writing, as soon as reasonably practicable. Once an individual has been referred for a full consideration for CHC an individual, or individuals (in most cases a health professional) should be identified by the LHB to co-ordinate the process. This role will involve taking responsibility for the whole process until the decision about funding has been made and a care plan has been written. The CHC assessment should be completed within 6 weeks of the referral.
5.37 If the outcome of the assessment process is that a referral for a full consideration for CHC is unnecessary, this decision together with the reasons for it, should be communicated clearly to the individual, and their carers or representatives where appropriate, and recorded in the individual’s notes. They may still request a full assessment from the LHB, and the LHB should give this request due consideration, taking into account all the information available including additional information from the individual or carer. Care planning for those individuals with ongoing needs, including the consideration of need for registered nursing care, will still be necessary

6. Responsibilities of the MDT
To decide whether or not to do a CHC assessment.
To give a rationale for this decision
To involve families in all decision making
To complete minutes of all MDT meetings detailing what has been discussed and how decisions have been reached.

7. Decision making process – determining eligibility for CHC
Each professional to complete their own assessment before MDT meeting and share with other professionals.
Care Co-ordinator must be identified
If there are concerns raised by any agency or professional, then consider holding a pre- meeting before meeting with the client / family. DST not completed at this stage.
DST completed at MDT meeting with client / family. MDT must make a recommendation.
This decision must be communicated to the patient, families or their representative via accurate and fully recorded evidence of the rationale and decision making process, demonstrating significant clinical events or changes in need have been considered when determining eligibility/non eligibility
Notes For Trainer
Go through section 2 & 3 of the SOP also
5.17 Involving social services colleagues as well as health professionals in the assessment process is essential and will make decision-making more effective and consistent. The assessment process for CHC is usually co-ordinated by a health professional although in some circumstances it may be appropriate for another professional e.g. a social worker from an integrated team, to undertake this role. The assessment must include the clinical opinion of the consultant or GP who has responsibility for the patient, so that the medical needs are considered alongside all other care needs and will also include appropriate specialists with expertise in CHC assessment (which may be the same people).
5.17 (practice guidance) - The coordinator should gather as much information as possible from professionals involved prior to the MDT meeting taking place, including agreeing where any new/updated specialist assessments are required prior to the meeting.
- Depending upon local arrangements the MDT members may decide to reach the final recommendation on eligibility after the individual and their representative have left the meeting. However, the above gives clear expectations on their involvement in the wider process. If the MDT is to reach its final recommendation privately it is best practice to give the individual/representative an opportunity before they leave the meeting to state their views on what the eligibility recommendation should be in the light of the DST discussion.

8. Decision Making Process - Recommendation
The MDT met on the DATE and are in agreement that the client ____ has a primary health need and meets the CHC criteria due to the (enter Nature Intensity Unpredictability Complexity) of their health needs (and describe these needs)
Notes For Trainer
The recommendation should:
a) provide a summary of the individual’s actual needs in the light of the identified domain levels and the information underlying these. This should include the individual’s own view of their needs and what has changed.
b) provide statements and the evidence about the nature, intensity, complexity and unpredictability of the individual’s needs, bearing in mind the explanation of these concepts provided in section 4 of this guidance
c) give an explanation of how the needs in any one domain may interrelate with another to create additional complexity, intensity or unpredictability
d) in the light of the above, give a recommendation as to whether or not the individual has a primary health need (with reference to section 4 of this guidance). It should be remembered that, whilst the recommendation should make reference to all four concepts of nature, intensity, complexity and unpredictability, any one of these could on their own or in combination with others be sufficient to indicate a primary health need.

9. Decision Making Process - Recommendation
The MDT met on the DATE and are in agreement that the client _____ does not have a primary health need and does not meet CHC criteria as there is no evidence to support Nature, Intensity, Unpredictability or Complexity at this time.
 However the MDT are in agreement that ____is eligible for the contribution to Nursing Care (FNC) (describe needs).
Notes For Trainer
Although the core responsibility of MDTs is to make a recommendation on eligibility for continuing NHS healthcare, the recommendation could also indicate any particular factors to be considered when commissioning/securing the placement or care/support package required to meet the individual’s needs (whether or not the individual has a primary health need).
Where the outcomes of the individual care domains do not obviously indicate a primary health need (e.g. a priority level in one domain or severe levels in two domains being found), but the MDT is using professional judgement to recommend that the individual does nonetheless have a primary health need, it is important to ensure that the rationale for this is clear in the recommendation.

10. Decision Making Process - Recommendation
The MDT met on the DATE and are in agreement that NAME does not have a primary health need and does not meet the eligibility criteria for CHC funding at this time as there is no evidence to support Nature, Intensity, Unpredictability or Complexity. The MDT also concluded that NAME does not have any Nursing Needs therefore not eligible for the FNC contribution
NAME needs can be met within a residential home.
Notes For Trainer
Where an individual has a deteriorating condition, practitioners need to take this into account in reaching their conclusion on primary health need, considering the approaches set out in Chapter 4 (4.10) of the Framework and being mindful of how that condition and the associated needs are going to progress before the next planned review.
Where an individual has a deteriorating condition but eligibility for continuing NHS healthcare is not presently recommended, consideration should be given to setting an early review date. This should be clearly highlighted in the recommendation to the LHB who should ensure that the review is arranged at the appropriate time.

11. Decision Making Process - Recommendation
The MDT met on DATE and are in agreement that the CLIENT does not have a primary health need and does not meet the CHC criteria as there is no evidence of Nature, intensity, complexity or unpredictability but they do have significant health and social care needs,  the MDT are of the opinion that the client should be joint funded at this time.

12. Decision Making Process - Recommendation
The MDT met on the DATE and there was no agreement that the client NAME   has a primary health need and meets the CHC criteria due to the (enter Nature Intensity Unpredictability Complexity) of their health needs (and describe the areas of disagreement and action to be taken- i.e. Stage 1 Dispute)

13. CHC Applications
Documentation – as a minimum please ensure that each CHC application has
Yes No
Copy of the DST with recommendation
MDT minutes / case conference
Current care plan (signed by care provider)
Risk assessments
Specialist reports as required (including medical)
Copies of all professional assessments in line with UAP/ CPA
Notes For Trainer
Go through the CC10 and the MH checklist.

14. Decision making process – Scrutiny Panel
HB must have a further stage beyond MDT to finally determine eligibility – panel (in line with St Helen’s Judgement).
All documentation forwarded to the relevant CHC Locality Office.
Any queries clarified, application prepared for panel
Application presented at panel
Panel can agree, defer and disagree (only in exceptional circumstances) with the MDT.
Panel decision is fed back to MDT, pt/ family and local authority.
Notes For Trainer
Taken from SOP
CHC Scrutiny Panels will be held across North Wales to ratify the recommendations of the MDT and to ensure, at least, the consistency and quality of decision-making.
4.1.2 Where CHC applications require the involvement and / or funding from other Clinical Programme Groups, the relevant CHC team will contact staff from the CPG to request attendance, or provide written evidence to the CHC Scrutiny Panel.
4.1.3 Only in exceptional circumstances and for clearly articulated reasons should the Scrutiny Panel not accept the multidisciplinary team’s recommendations. A decision not to accept the recommendation should not be made by one person acting unilaterally.
4.1.4 The Scrutiny Panels may request the MDT to carry out further work if the DST is incomplete or if there is significant inconsistency between the evidence in the assessment, the DST and the recommendation made.
4.1.5 The Scrutiny Panel will not make decisions in the absence of the recommendations on eligibility from the MDT, except where it is necessary for an urgent decision to be made.
4.1.6 Finance officers will not be part of the decision making panel.
4.1.7 The time taken for assessments and agreeing a care package may vary but should be completed in six to eight weeks from initial trigger to agreeing a care package.
4.1.8 The care co-ordinator should ensure that time scales, decisions and rationale relating to eligibility are transparent from the outset for individuals, carers, family and staff.

15. Disputes - Multidisciplinary Team
Disputes should be resolved between appropriate staff who are as close to the dispute as possible. In the event that a dispute cannot be resolved in this way, arrangements should be established for appropriate senior managers from each organisation to jointly address the problem.
Use of bodies or persons to act as mediators should be a last resort.
The aim will be to resolve any disputes in the minimum time. This is particularly the case where the dispute affects the care of patients.
Notes for Trainers
Strategic managers from health and partner agencies should take steps to strengthen joint working and agreements in order to prevent conflict.
Strategic managers should send out clear messages to all staff of the importance of accepting joint responsibility for problem solving and settling disagreements before they become disputes.
The individuals themselves, families and carers should have their opinions taken into account and an explanation given so they have a clear understanding of the dispute resolution process and the part they will play.
The above should be achieved through purposeful, constructive discussions and negotiations with partner agencies, families and carers.
Staff should stay focused on the key objective, which is to ensure CHC is correctly determined in a timely manner. The sole criterion for determining eligibility for CHC is now whether a person’s primary need is a health need
Accurate needs assessments are crucial when determining eligibility for CHC; these should include all relevant specialist and non-specialist assessments carried out by a multidisciplinary team who know the person best.
Clear reasoned decisions for eligibility must be recorded supported by the Decision Support Tool.
Determining eligibility for CHC must be undertaken by a MDT (multidisciplinary team) who will make it’s recommendation to a CHC panel
Members of the MDT panel must have up-to-date knowledge of the individual needs
Chairs of the MDT panel must have completed the CHC training and have experience in chairing meetings 15

16. Dispute - Multidisciplinary Team
Decisions about care should not be delayed unnecessarily whilst disputes are being resolved. It is expected that all stages of disputes procedures will normally be completed within two weeks.
All stages will be appropriately documented.
Disputes should not delay the provision of the care package and the protocol should make clear how funding will be handled during the dispute.
Notes for Trainers
A nominated officer from the MDT (Chair, care manager, care co-ordinator) will inform the CHC Team in the relevant locality and LA senior officers in the relevant locality in writing of the outcome of the case conference and initiate the disputes process as described below.
The nominated officer must ensure that the outcomes of all discussions are documented and shared with all relevant organisations involved in the dispute.
The patient and/or family/carer may be informed that a dispute is proceeding. However, they will not be directly involved in the resolution of the dispute and the dispute will not affect the quality of the care received by the patient.
The care package will be funded on a 50:50 basis between health and social services until the dispute is resolved with agreement that either party will retrospectively pay the other depending upon the outcome of the dispute. A Lead Commissioner must be identified. Retrospective payments will apply from the date of discharge or from the date of MDT if the individual concerned is in a community setting.
It is important that patients/service users should not be involved or concerned by any part of the dispute process other than to be aware of its purpose and time scales.
The organisations involved will in the spirit of partnership and cooperation ensure that the patient /service user is being cared for in the correct environment and that their assessed and financial needs are being met at all times during the dispute.
The aim of the resolution process is to resolve disputes in the minimum time possible.

17. Dispute - Multidisciplinary Team
Formal dispute process
Level 1
Level 2
Level 3
Notes For Trainer
Level 1- The case will be fully considered by the relevant Lead Nurse from the CHC Locality Team and the appropriate Social Services Service Team Manager ( and lead officers from Education, the Probation service or any other relevant agency if appropriate) together with members of the multi-disciplinary teams. This is likely to take the form of a case conference and every effort should be made to resolve matters at this level. Responsibility for arranging the case conference will lie with the nominated officer from the MDT. The nominated officer will convene a meeting within 10 working days (best practice standard) or no later than 20 working days.
The case conference will consider the clinical case based on the multi-agency and multi-disciplinary assessments of the individual concerned. The case conference will be recorded and minuted and will be sent with a cover letter to all relevant persons.
Officers who attend the case conference should be able to make decisions on behalf of their organisation.
The officer responsible for convening the case conference will ensure it is minuted, decisions recorded on the agreed proforma and letters sent out as appropriate.
Level 2 - If the case cannot be resolved at level one it will be referred to the Continuing Care Manager at BCUHB and Service Manager / equivalent senior manager in the Local Authority (and any other senior officers from Education, the Probation service or any other relevant agency if appropriate).
Previous members involved in level one must not take part in level two to ensure objectivity.
Level 3 - In exceptional circumstances, if the case is not resolved at level two, the details of the reasons for the failure to agree will be submitted in writing to the Assistant Director of Nursing (Primary care ) or equivalent senior manager and nominated senior manager of the Local Authority and a meeting will be convened with those present at the Level 2 meeting to reach a final and binding decision about eligibility and agency responsibility. The organisation with responsibility for convening the Level 2 meeting has responsibility for arranging the Level 3 meeting.

18. Dispute - Challenges from Individuals
An individual may apply to the LHB for an independent review of the decision if they are dissatisfied with
the procedure followed by the LHB in reaching its decisions around the individuals eligibility for CHC or
the application of the primary health need consideration
Notes for Trainers
Taken from Standard Operating Procedure.
This process may change in the future – awaiting further guidance from WAG – clients and families may have to indicate why they think the client is eligible for CHC.
Where a full assessment has been undertaken of potential eligibility and a decision has been reached, an individual may apply to BCUHB for an independent review of the decision if they are dissatisfied with:
the procedure followed by BCUHB in reaching its decisions around the individuals eligibility for CHC or
the application of the primary health need consideration
4.3.2 Individuals may ask BCUHB to reconsider its decision and BCUHB will give this request due consideration, taking into account all the information available, including any additional information from the individual and/or carer.

19. Independent Review Panel and Complaints.
Additional safeguard for patients who consider that the criterion for Continuing NHS healthcare (the primary health need approach) has not been correctly applied or that appropriate procedures have not been followed
IRP is NOT designated to review the content of the care plans, only the decision making process
LHB will administer the procedure on behalf of all persons residing within the area
The procedure will also be used for reviewing NHS Funded Nursing care decisions.
NHS should deal promptly with any request
Notes for Trainers
4.3.4 Where local resolution options have been exhausted, the case should be referred to the Independent Review Panel.
4.3.5 If the original decision is upheld and the individual still wishes to challenge the decision, the individual has access to the Public Services Ombudsman.
4.3.6 If an individual / family / or their representative is dissatisfied with the decision making process or any other process under Continuing NHS Healthcare they may access the BCUHB Complaints procedure at 19

20. Independent Review Panel and Complaints.
The NHS should in the first instance
Try to resolve the situation informally
Ensure appropriate assessments have been undertaken
Ensure the decision support tool has been applied
Where the patient remains dissatisfied the LHB will consider whether it is appropriate to convene the review panel
Patients may also make use of the NHS Complaints Procedure
Notes for Trainers
4.3.3 Where an individual disagrees with the recommendation made by the MDT, the following process will apply:
MDT reconvened with relevant line managers (if required ) to confirm that the assessments accurately reflect the needs of the individual and the recommendation of the MDT
All documentation forwarded to the relevant CHC locality office specifying that this is a request from the individual / family or representative for consideration at CHC Scrutiny Panel.
Request will be heard at the CHC Scrutiny Panel and the outcome communicated to the care coordinator, individual and relevant local authority as per usual process.
Where the individual / family /representative remains dissatisfied they may be offered a meeting with the relevant CHC manager to discuss the panel outcome. 20

21. Independent Review Panel
The review procedure does not apply when patients or their families wish to challenge
The content rather than the application of the criteria
The type and location of any offer of Continuing NHS Healthcare
The content of any alternative care package which they have been offered
Their treatment or any other aspect of the services they are receiving or have received
Notes for Trainers
The review procedure does not apply where the patients or their families and any carer wish to challenge:
The content rather than the application of the eligibility criteria
The type and location of any offer of NHS continuing healthcare
The content of any alternative care package which they have been offered
Their treatment or any other aspect of the services they are receiving or have received.
Complainants have the option of following normal complaints processes and ultimately, instigating judicial review proceedings if they remain dissatisfied.

22. Standard Operating Procedure
Aid for both BCU and LA staff to implement the new CHC Framework
Includes sections on e.g. procedure, CPG’s, consent, disputes, and fast track
Working document – will be updated regularly – e.g. s117, cross border protocols
This Standard Operating Procedure (SOP) has been developed to aid the Betsi Cadwalader University Health Board (BCUHB) and its partner Local Authorities to implement the National Framework for Continuing NHS Healthcare (WAG 015/ 2010). It should be read in conjunction with this Framework.
Consent
If there are concerns regarding the individual’s mental capacity to consent to the CHC assessment, this should be determined in accordance with the Mental Capacity Act (2005), including a referral to the IMCA service if appropriate. A third party cannot give or refuse consent to an assessment on behalf of an individual lacking capacity. Staff should check whether anybody has been authorised to consent on the individual’s behalf by way of a Lasting POA - welfare or welfare deputy.
2.3.6 In the case of an individual who lacks capacity, a best interest decision involving those who know the individual well and can help inform consideration should be made.
2.3.7 If an individual with capacity refuses an assessment, this must be documented in the individual’s records. The individual must then be informed of the potential effect this will have on the ability of both BCUHB and the Local Authorities to provide services and it may mean your needs cannot be met. The MDT would in this instance consider existing assessments and any other relevant information to make a recommendation to both the Local Authority and the BCUHB respective panels.
2.3.8 Consenting to a CHC assessment is not a precondition to accepting any subsequent offer of CHC funding.

23. Fast Track
Individuals with a rapidly deteriorating condition who may be entering a terminal phase and require immediate provision of CHC
Must be supported by a prognosis.
Details of care required – assessment and care plan agreed with care provider.
Reviewed in 2 weeks
Notes For Trainer
Go through fast track documentation
The fast track assessment should be completed by an appropriate clinician who should give the reasons why the individual meets the conditions requiring a fast track decision to be made. The clinician should have an appropriate level of knowledge and experience of the type of health needs to decide on whether the individual has a rapidly deteriorating condition that may be entering a terminal phase.
Applications for a fast track decision should contain the fast track tool, letter from medical practitioner, details and costs of the care package.
Referrals will be accepted via telephone, fax, letter or to the relevant CHC Locality Team Office (contact details at the end of this document). Referrals can be made verbally but the fast track tool, letter from medical practitioner, details and costs of the care package must be received by the relevant CHC Team within 2 working days of the request being made.
An NHS professional must co-ordinate the fast track assessment, however others involved in supporting those with end of life needs, including wider voluntary and independent sector organisations and the patient and family may identify the fact that the individual has needs for which the fast track process should be considered. In these cases, they should contact the patient’s care co-ordinator (e.g. District Nurse, Social Worker, and Community Psychiatric Nurse).
The completed fast track assessment should be supported by a prognosis. However, strict time limits that base eligibility on some specified expected length of life remaining should not be imposed. It is the responsibility of the assessor to make a decision based on the relevant facts of the case.
Where a recommendation is made for an urgent package of care by an appropriate clinician through the fast track process, this should be accepted and actioned immediately by the HB. Disputes about the fast track process should be resolved outside of the care delivery.
No individual who has been identified through the fast track process should have their care package removed without their eligibility being reviewed in accordance with the review process detailed in the SOP. However the CHC team will contact the patient’s care coordinator within 2 weeks of the fast track decision being made to determine whether a review is needed. This review should include completion of the DST by the MDT, including a recommendation on future eligibility. This overall process should be carefully and sensitively explained to the individual and, where appropriate, their representatives. Sensitive decision making is essential in order to avoid the undue distress that may result from an individual moving in and out of CHC eligibility within a very short period of time.

24. Case Study
You are members of the CHC Scrutiny Panel, using the information available
Identify a chair person for the panel
Agree on a panel outcome and give a rationale for this decision.