Select Committee on Health Sixth Report

6  Problems with current implementation of the eligibility criteria

104. Currently, local criteria are devised by SHAs, but they are implemented by a variety of groups. Assessments for continuing care are often carried out in an acute hospital trust, before a patient is discharged. They may also take place in a nursing home, care home, or in the patient's own home. Eligibility for continuing care is meant to be assessed by a multi-disciplinary team. Each PCT is then responsible for funding both continuing care and the RNCC. In some areas, a panel convened by the local PCT will consider all applications for continuing care funding after the multidisciplinary assessment, before making a final decision about whether or not funding will be granted.

105. According to much of our evidence, translating policy into practice and ensuring that the criteria are implemented fairly and consistently presents just as much of a challenge as getting the criteria themselves right. Our evidence reveals as much, if not more, concern about implementation of the criteria. These concerns centre around:

  • The slow implementation of the Single Assessment Process
  • Lack of access to assessments
  • Inequities arising from different application of criteria
  • Quality of assessment
  • The crossover with assessment for RNCC
  • PCT panels and funding decisions
  • Monitoring of implementation and assessment

The Single Assessment Process

106. The Single Assessment Process (SAP) was announced in 2000, and was a core element of the National Service Framework for Older People published in March 2001. The intention of a single assessment process operating across health and social care for older people is that there should be a more standardised approach across and areas and agencies so that older people's care needs are assessed thoroughly and accurately, but without procedures being needlessly duplicated by different agencies. The SAP began to be phased in in April 2002. Guidance advised agencies to develop systems based on four broad types of assessment:

107. The outcome of the assessment process should be that a care plan is drawn up in consultation with the service user (and their carers if relevant), that sets out the objectives of providing help and the anticipated outcomes. The assessment for eligibility for continuing care is an integral part of the SAP, as is the determination of the RNCC for any individuals for whom it has been agreed that admission to a care home providing nursing care offers the best environment for meeting their care needs.

108. The Minister told us that the SAP should be the basis of all assessments for continuing care and RNCC, and that good progress was being made in implementing the SAP: "the single assessment process is being implemented very successfully around the country, and it is available everywhere."[83] However, he then went on to suggest that implementation was in fact variable, as it was "working better in some places than others".[84] He told us that any older person being discharged from an acute ward should have gone through the SAP and should have automatically been considered for NHS continuing care before discharge. But his evidence suggested that this was not happening universally, as he emphasised the need to "find a way [to] ensure that all older people undergo the single assessment process".[85]

109. Our evidence suggested that the SAP is not being implemented consistently, as Jo Peck of University Hospital Lewisham NHS Trust informed us:

    Dr Taylor: Has the introduction of the single assessment process made any difference?

    Ms Peck: No, because we are not using the single assessment process across the board yet. Actually, we have just had a case that went to panel this week in Lewisham that had the single assessment, and it was deferred because the assessment was not deemed appropriate; so they have now got to go back and re-assess under continuing care.[86]

110. The Single Assessment Process (SAP) was intended to integrate assessment processes across health and social care, and to ensure that all older people were given a high-quality multi-disciplinary assessment of their needs. However, we are not convinced that implementation of the SAP system is progressing as swiftly and effectively as the Minister implied. We recommend that the Government takes steps to ensure that this is addressed.

Access to assessments

111. Very worryingly, we have received evidence that many patients are not being offered access to any sort of assessment at all. Citizens' Advice told us:

When investigating further, it was revealed that their father had never been provided with a continuing health care assessment. A joint assessment between the NHS and social services had been carried out, resulting in their father being assessed as being eligible for medium rate nursing care. The family was totally unaware of this, and had never been informed. The family has requested a continuing health care assessment and is awaiting a new decision. [87]

112. We were also told of several similar cases. Barbara Pointon said quite simply that, in the case of her husband,

    I went for five years without knowing it existed. If you do not know it exists, then you cannot apply for it .[88]

113. Pauline Thompson of Age Concern described the following story:

    A friend of mine only last week was telling me, "my Mum has got to go into a nursing home next week" - she was in hospital. I said: "Have they done a continuing care assessment?" She looked at me blankly. "Do you know how much nursing bands she is going to get?" Again, she looked at me blankly. So I put down a few questions to her - "you must ask this, this and this before you agree that your Mum can go into a nursing home" and she now has continuing care, but it was only because she showed them the e-mail I had sent her and said, "Should I be asking for continuing care?" The social worker said: "Oh, yes, I think perhaps you might." It would not have been raised otherwise.[89]

114. Ms Thompson went on to argue that the culture of the NHS does not promote easy access to assessments:

    If you ask for continuing care, we find that people are put off right from the very beginning - "oh, nobody gets it in this area; you have to be nearly dead to get it". So right from the start you are working from a system whereby you might find that in that case you will not bother. It is an attitude … it is a mindset at the moment within the NHS that they are there to deal with acute services, and continuing care is something else really.[90]

115. Mrs Pointon suggested that it would help if a single professional was designated "whose responsibility it is to tell all families about the existence of continuing care." [91]

116. We were shocked to hear that some patients and their relatives are not offered any form of assessment for continuing care, and subsequently do not receive assessments because they are simply unaware that continuing care funding exists, and that they might be entitled to it. We do not think that the onus should be on patients or their relatives or carers to request an assessment for continuing care:- all patients with continuing needs should be offered an assessment automatically, before they leave hospital. In developing its national framework for continuing care, the Government must take steps to ensure that this happens. It should also give consideration to establishing a system whereby every care setting, including NHS acute hospitals, primary care and private nursing or residential homes, should have a nominated individual whose responsibility it is to proactively identify all those who may need a continuing care assessment and notify the appropriate PCT, which should have a duty to arrange for an assessment (or re-assessment) within a specified timescale.

Inequities arising from different application of criteria

117. Several submissions have indicated that, even if criteria for continuing care are consistent, approaches to assessment and application of those criteria are not, leading to even wider variation. When we discussed the concept of 28 different SHAs having different eligibility criteria, Denise Gilley of County Durham and Tees Valley SHA told us that that view in fact over-simplified the situation: "it is to do with the assessment process. It is not to do with 28 strategic health authorities, with all due respect, but the number of primary care trusts and their partners, the social services departments."[92] Elaine McHale, who is the Director of Social Services and Health for Wakefield Metropolitan District Council as well as representing the ADSS, reported that despite a good partnership approach between the local authorities within her SHA area, "there are differences in its application, even though the eligibility is the same." She went on to describe how a group of representatives in her area still have to examine cases "to see why in Bradford you might get continuing care with this case but, if you applied for it in Wakefield, you would not."[93]

118. Help the Aged argued that in some places there was anecdotal evidence to suggest that the methods being used to carry out continuing care assessments "raise the threshold for eligibility even beyond that set out by the criteria themselves."[94]

119. Anne Williams described the situation from a patient's view point:

    Every PCT, even though they have got the same strategic health authority criteria, have interpreted it very differently. Every professional on the ground then interpreted that slightly differently, and it is the one area where the public have the least comprehension on how it is working. It is very difficult, especially if a couple may have a parent each who is in need of continuing care, who live literally up the road from each other but come within two different PCT areas, and they cannot understand at all why one will be eligible and the other one who in their minds is more ill and therefore needs more care cannot get it. You cannot explain it.[95]

120. According to Martin Green of the English Community Care Association, when homes take residents from more than one PCT or even different SHAs, it is very likely that there will be an inconsistency of assessment between different PCTs, meaning that some people are receiving high levels of funding and some are receiving much lower levels of funding, even although they have the same needs. This creates serious difficulties for care homes, which will have to find the resources to meet the needs of all residents, regardless of the funding they are receiving.[96] As Mr Green explained, this inconsistency in assessment could lead to care homes 'cherry-picking' patients from certain areas, who were likely to have received a more generous assessment:

    As the demographics change, and particularly as there are more people with very high dependencies because of Alzheimer's disease and dementias, there will be even more pressure on beds. The inconsistencies inherent in the processes around assessment will then lead to some people saying "no, I am not going to have your patient in this establishment because somebody else does a better assessment process and is prepared to pay more for more intensive care".[97]

121. Clearly, the first problem that needs to be addressed is the inconsistent approach to assessment. It will never be possible to ensure that the implementation of criteria is identical across the country, as Cath Attlee of Hounslow PCT argued: "You are not going to eliminate the element of professional judgment, even if you have standard criteria across the country. Every clinician will interpret slightly differently, and practice is changing all the time."[98] However, with a single approach to assessment, these inconsistencies can be minimised. Both our witnesses and our written evidence called for the Government to develop a national system of assessment, with a single set of documentation, to ensure that all assessments are carried out using the same nationally approved processes.

122. We have recommended the development of a single set of national criteria, which should go some way towards ensuring that patients have the same entitlement to continuing care funding in all parts of England. However, a single set of eligibility criteria are only part of the solution, because, as our witnesses pointed out, even when using the same SHA criteria, inconsistencies have still emerged with different PCTs interpreting the same eligibility criteria differently because they have followed different assessment processes. It is therefore imperative that the Government underpins its national criteria with a national standard assessment methodology, building on current best practice to develop a universal, standardised assessment process backed up by a single set of documentation which will be applied by all Strategic Health Authorities, PCT's and NHS Trusts, in conjunction with local authority social services departments.

Professional input into the assessment process

123. The Ombudsman made the damning observation that in over half the cases her Office examined, assessments had been inadequate:

124. In oral evidence, Colin Houghton of the Ombudsman's office described some of the poor assessment practice which he had come across:

    Where people have psychological needs - I saw that you had Barbara Pointon here last week - sometimes psychological needs are not taken into account. Other examples are where, for example, someone will go into a nursing home, look at all the nursing home notes, prepare a summary of their view of what that health care portrayal presents, and then present that to the decision panel. The decision panel will only have that summary and not the full notes, so someone is already interpreting something before it ever gets to the panel. Those are some examples.[100]

125. It is clearly crucial that the appropriate people are involved in carrying out assessments. While under the SAP every older person is entitled to a full multidisciplinary assessment, including a representative from every discipline involved in their care, all too often, assessments are carried out by people with insufficient expertise, particularly given the pressure on staff to free up beds in acute hospitals:

    In a large hospital setting there will be many, many beds taken, with bed-blocking and all the rest of it, so there is a lot of pressure on the ground for the front-line staff to get this done. Sometimes … two people will make the decision. The doctor's input and other professionals will come in at an after date, but that person has been moved out of that hospital and into a situation where there is no nursing care, and to get them out of the hospital pretty quickly.[101]

126. Geriatricians can also make a key input into assessments, but again, very few people get a full assessment from a geriatrician.

127. One of the Ombudsman's key recommendations was better training, to ensure those carrying out the assessments have a good understanding of the processes, and also the development of increased capacity, to ensure assessments can be carried out promptly.[102]

128. In developing its national assessment framework, we recommend that the Government should include clarification about which professionals should be involved in carrying out assessments for NHS continuing care. In line with the Ombudsman's suggestion, the Government should ensure that there are sufficient numbers of trained staff to carry out assessments promptly and professionally. The Government should also develop a national training programme, which all those involved in carrying out assessments should complete.

Review and reassessment

129. People's needs, and particularly those of elderly people, can change frequently. Much of our evidence highlighted difficulties in getting both RNCC and continuing care assessments reviewed promptly. According to Ms McHale this does not always happen in practice:

130. Ms Attlee argued that reviews ought to be annual, and indeed that is the minimum standard set out by the SAP:

    There is a built-in expectation that a nursing review would be undertaken every year and at any point, either the inmate or the nursing home can trigger a continuing care assessment. Again, it may be about practice not reflecting policy.[104]

131. We were also told that in many circumstances annual reviews are not sufficient, with people's needs often changing far more frequently.[105]

132. The national standard assessment methodology must include flexible provision for regular review, placing a specific requirement on the organisation providing care to trigger a review whenever needs change. At the very minimum, all patients should be reviewed every year, but there must be scope for reviews to be triggered as soon as they become necessary, and for these to be carried out flexibly and promptly.

Patient and carer involvement and information

133. A key concern in our evidence was that patients and carers lacked both information about, and involvement in, the assessment process. According to John Wheatley of Citizens' Advice:

134. We were told by Ms Peck that patients, relatives and carers do not normally see the assessment that goes to their local funding panel.[107] However, according to Barbara Pointon, from a carer's point of view this is indefensible:

    We are the people who see most of the patient and know their needs intimately … I found the health assessments that were done of my husband - one of them had 14 major inaccuracies in it because I had not seen the assessment before it was sent in to the panel, which then decided that Malcolm's care was social; but missing from the assessment was the fact that he had frequent fits, so how could his care be stable?[108]

135. The Deputy Ombudsman told us that "including the families/the carers is very helpful and would certainly represent good practice."[109]

136. Patients, carers and relatives should have automatic access to detailed information about the assessment process, both before it begins, and during the process itself, and we recommend that the new national standard assessment methodology includes specific requirements in this area. Not only is full information-sharing crucial to ensuring transparency, and useful in helping patients, carers and relatives understand how decisions were arrived at. Patients, carers and relatives can also provide a failsafe system for ensuring there are no inaccuracies in assessments, as they are likely to have a better understanding of their own or their loved one's condition than any professionals.

RNCC overlap

137. We have already discussed the difficulties caused by the fact that eligibility criteria for NHS continuing care and for high band RNCC are virtually indistinguishable. A further problem related to the RNCC is the practical application of the criteria. According to our evidence, many people treat RNCC as a ladder of eligibility which leads upwards to NHS fully funded continuing care.  In fact, this should be inverted, with the question of eligibility for continuing care being asked before RNCC is considered. The guidance issued by the Department of Health in August 2001 indicates that a full assessment of need should have been carried out before any determination of RNCC is undertaken.  All possible care pathways will have been considered including whether the person's needs meet the criteria for NHS continuing care.  It is only when it is decided that they do not and that their needs can best be met in a care home providing nursing care, that the RNCC determination should take place.  The guidance states categorically:

Even this guidance, with its reference to the NHS continuing care criteria in comparison to the high band RNCC, could be open to misinterpretation.

138. Anne Williams of Citizens' Advice described how, in practice, people involved in assessments carry out the RNCC assessment first, using that system as an ascending ladder towards continuing care. This means that, if a person is assessed as requiring registered nursing care, they are denied access to consideration for continuing care funding, even though they may have significant health care needs which are not picked up by the RNCC assessment, which is concerned solely with registered nursing needs, and not with wider health care needs:

    We see a lot of cases where, regardless of how many toolkits people are given or criteria, the practice still regularly occurs where people do the RNCC banding; and then, because you are not getting the highest level you do not get the continuing care. When we get involved and asked the date of the continuing care assessment, they were all done at the same time by the same people, and because you have not got the highest level of nursing care, which has been explained is very difficult - we had a client who was unfortunately in the very last stages of the Parkinson mask, which means that their condition is very, very stable and they are very, very rigid, so they are not qualified for the highest level of nursing care. The fact that that person has huge nursing care needs means that they do not qualify for the highest level of nursing care because they are not unstable, and therefore that particular client was refused continuing care. When we got involved and started to ask when they started to do the continuing care assessment - luckily it has now been awarded.[111]

139. According to Mrs Pointon, one reason for this may be lack of understanding amongst the people carrying out the assessments:

    I would say anecdotally that although I asked Malcolm to be assessed against the continuing care criteria twice he was assessed against the RNCC, and so even when you ask for it - I think there is confusion among some of the professionals actually, who do the assessments.[112]

140. Ms McHale also agreed that there was a strong need to "re-emphasise the requirement for the continuing care assessments to be done, first and foremost."[113]

141. Despite the Department of Health's guidance that assessment for continuing care must always be carried out first, and RNCC assessment only carried out if the patient is deemed to be ineligible for NHS continuing care, the evidence presented to this inquiry indicates that in practice RNCC assessments are often carried out first, with the result that patients may not get the funding they need because they have been inappropriately assessed through the RNCC framework alone. In the light of our previous recommendations concerning the confusion and overlap between the separate systems for continuing care and RNCC, the Government must develop an integrated system which will eliminate much of this confusion. The national standard assessment methodology must provide detailed guidance on how, and in what order, patients' needs should be assessed.

Monitoring of the application of criteria

142. To ensure that new national criteria are applied fairly and consistently across the country, that all those who need assessments have access to them, and that assessments are carried out to a high standard, monitoring will be crucial, as Denise Gilley told us:

Ms Attlee agreed:

    You have a multidisciplinary team doing the assessment; another multidisciplinary panel validating that assessment locally; and then a strategic health authority-wide or higher level authority validating across the board, so that you are constantly doing that cross-checking … It is important that in any system we implement you build those checks and balances in.[115]

143. In oral evidence to us, SHAs told us they had some systems already in place to monitor decision-making in this area, but they seemed to be at a relatively early stage in development, and to vary between regions.

    We do have a software programme…It does exist and it does work but it does not give us the level of data extraction that we would like. It is the beginnings of something. [116]

    We are probably not quite at the stage of having the electronic data but we are looking at similar issues around placement and getting the financial information … We also have the SHA panel which sees cases. We have been using the panel's test for consistency of decision­making across primary care trusts. We are also looking, as part of the training for assessors, at possibly assessing sample anonymised cases to check that the same results come out. [117]

144. Monitoring is vital to ensure consistent decision-making in continuing care assessments. However, monitoring systems do not yet appear to be very well developed, and we urge the Government to ensure, as part of the national framework for continuing care, that robust, consistent systems are put in place throughout the country to monitor the implementation of the new national eligibility criteria and the national standard assessment methodology.

PCT panels and funding decisions

145. The division of health and social care funding inevitably gives rise to tension between PCTs and Local Authorities over who funds care. This issue caused our witnesses considerable concern. One Local Authority guidance note stated: "From a social services perspective, it is not about merely cost shunting on to the NHS. What we are trying to do is to ensure that our monies are targeted at those to whom Social Services are responsible for providing a service."[118] By the same logic, although it is unlikely to be stated policy, PCTs are obviously financially advantaged if people are not assessed as requiring fully funded NHS continuing care. Ms Attlee acknowledged that financial constraints can have a bearing on the process: "I am not saying it never happens. Certainly PCTs have financial problems and that has a bearing effectively on how things are implemented."[119]According to the ADSS, this is a real problem:

    There is a big element of difficulty facing primary care trusts in balancing their budgets and dealing with the demands that continuing care can make. We have done some surveys of local authorities. We know there is at least one PCT which has a cap on how much per person they will give towards care.[120]

146. Our evidence suggested that some, although not all, PCTs operate funding and review panels to approve and review decisions on funding for continuing care. According to the RCN, PCT panels frequently make decisions on cost rather than clinical grounds:

    Once a nursing assessment is carried out to determine a patient's eligibility for NHS continuing care funding, recommendations are made to a funding panel. RCN members advise us that in some instances, panels are overturning recommendations made by nursing staff because of local financial constraints. Our members are concerned that access is being driven by budgetary concerns rather than need which is both demoralising for staff and upsetting for patients. The RCN has been advised by a local practitioner that in one locality in the East of England social services staff are advised not to apply for funding for their clients as it is not available. Elsewhere, experienced clinicians report that their clinical assessment is overturned by panels with no explanation being offered to either the clinician or the patient.[121]

147. The Minister confirmed that the development of a national framework will address the role and constitution of PCT review and funding panels.[122]

148. Much of our evidence concerned PCT review and funding panels, and indicated that, where these exist, decisions are often driven by budgetary concerns rather than patient need, and clinical assessments are overturned without explanation. This should not be allowed to continue, and we are pleased that the Minister confirmed that the role and constitution of funding panels will be addressed within the forthcoming national framework for continuing care. While there is clearly a need for PCTs or SHAs to review local decisions to ensure consistency and quality of assessment, we question the need for a PCT panel to validate all eligibility decisions, as we are concerned that panels will serve a gatekeeping function to manage demand on PCT financial resources. Eligibility criteria and related assessments must be based on the needs of the individual, and must not take account of the financial consequences. We therefore recommend the new national framework should stipulate that PCT panels must only be used to assess cases where patients have appealed against a decision, not as a final process through which all clinical assessments must be ratified, and that the membership of continuing care panels should include appropriate clinical expertise, rather than clinical decisions being made by Directors of Finance.

83   Q304 Back

84   Q304 Back

85   Q304 Back

86   Q163 Back

87   CC15 Back

88   Q97 Back

89   Q108 Back

90   Q98 Back

91   Q97 Back

92   Q16 Back

93   Q6 Back

94   CC28, para 2.4 Back

95   Q100 Back

96   Q178 Back

97   Q179 Back

98   Q9  Back

99   CC23, para 6 Back

100   Q224 Back

101   Q107 Back

102   CC23, para 7 Back

103   Q24 Back

104   Q26 Back

105   Q181 Back

106   Q94 Back

107   Q172 Back

108   Q127 Back

109   Q215 Back

110   Department of Health, NHS funded nursing care: Practice guide and workbook, 2001 Back

111   Q105 Back

112   Q108 Back

113   Q25 Back

114   Q16 Back

115   Q9 Back

116   Q35 (Denise Gilley, County Durham and Tees Valley SHA) Back

117   Q35 (Michael Young, North West London SHA) Back

118   CC12B, Hampshire Social Services Back

119   Q29 Back

120   Q27 Back

121   CC21, para 3.6 Back

122   Q313 Back

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