Southampton City Clinical Commissioning Group’s “NHS Continuing Healthcare Choice and Equity Policy” was written to help Continuing Healthcare decision makers to fairly make sure everyone gets enough care, but something’s gone badly wrong.
It says “It may be necessary to pay more to meet an individuals assessed needs in a way that does not discriminate against them but the NHS does not have to provide a home care package if it is more expensive than providing care in a residential setting.”
This means that Southampton City CCG may believe that they can choose whether or not someone can stay at home or move into a nursing home purely on the basis of cost, so long as they cannot be found to be unfairly making different choices on the basis of age, disability, or any other legally protected difference.
It also says “A person’s choice of care setting should be taken into account but there is no automatic right to a package of care at home.” This may not be on such firm legal ground. Though a case of this type does not appear to have been tested through the courts, there have been suggestions that this may not be in alignment with the Human Rights Act.
This document may not be based on hard evidence, and may even be self-contradictory.
It states: “The setting in which continuing healthcare is provided is ultimately a matter for SCCCG, however the CCG will take into account reasonable requests from the individual and their family in relation to particular settings.”
Yet the views of the individual are not listed under “The CHC team will take account of the following issues…” Though it states that the list is not exhaustive, it is surprising that this has been left out and gives a very poor impression of the CCG’s regards to personal choice.
The issues on the list are somewhat strange, for example:
“The risk assessment will include the availability of equipment, the appropriateness of the physical environment and the availability of appropriately trained care staff and/or other staff to deliver the care at the intensity and frequency required.”
Equipment provision in the community is usually a routine process, though certain criteria and excessively long waiting lists can make this trickier. These processes and waiting lists are under the control of the CCG, meaning that if equipment provision was a barrier to Continuing Healthcare being provided at home, the CCG could do something about it.
The appropriateness of the physical environment is another barrier that can be overcome. For example, if someone’s house were too small to safely use or store necessary equipment, then they may be eligible for a Disabled Facilities Grant to adapt the house, or they could be offered advice and support to move to another property in the same community that would be more suitable.
Staff can be hired, and trained, though it’s probably not that simple. Though this is not an immediately solvable problem, it is a solvable problem.
“The person’s GP agrees to provide primary care medical support.”
This would mean that the individual’s needs were within the GP’s understanding to manage, or the GP could be trained on additional specifics. Many people with health needs that qualify for Continuing Healthcare are already receiving medical support from their GP.
Disability United asked Southampton City CCG to provide evidence and clarification of the following statements within the policy. We asked:
“Home care packages in excess of eight hours per day would indicate a high level of need which would be more appropriately met within a residential placement.” How is “appropriately” defined in this context? What evidence of better outcomes exists to support this statement?
“Persons who need waking night care might generally be more appropriately cared for in a residential placement.” How is “appropriately” defined in this context? What evidence of better outcomes exists to support this statement?
“If the clinical need is for registered nurse direct supervision or intervention throughout the 24 hours the care would normally be expected to be provided within a nursing home placement. This would include the requirement for 1-2 hourly intervention/monitoring for turning, continence management, medication, feeding, manual handling, and other clinical interventions or for the management of significant cognitive impairment.” Normally be expected by whom? What evidence of better outcomes exists to support this statement?
Southampton City CCG responded:
“In response to your enquiry we have prepared a statement which we’ve added to our website.
The Southampton City CCG Continuing Healthcare (CHC) Equity and Choice Policy supports the planning and funding of care for CHC clients in Southampton.
The CHC team has developed this policy in light of the need to balance personal choice alongside safety and effective use of finite resources. It is also necessary to have a policy which supports consistent and equitable decisions about the provision of care regardless of the person’s age, condition or disability. These decisions need to provide transparency and fairness in the allocation of resources.
Application of this policy will ensure that decisions about care will:
– be robust, fair, consistent and transparent
– be based on the objective assessment of the person’s clinical need, safety and best interests
– have regard for the safety and appropriateness of care to the individual and staff involved in the delivery
– involve the person and their family/representative wherever possible
– support choice to the greatest extent possible in view of the above factors.
In addition to a person’s assessed needs, the CCG may have to take into account its own resources when deciding upon which package of care to commission.
Within the document is a section detailing information on situations where people require care for more than eight hours per day and those who require waking night care. These sections are guidelines and it is important to note that we consider each individual application on a case by case basis ensuring that each request is assessed on the particular situation.
Furthermore, we support people’s right to live independently and take our obligations and duties towards this very seriously.
The policy was developed through a range of organisational processes which included the involvement of clinicians and independent Governing Body members as well as discussions with a number of peer organisations. It is currently undergoing a routine review which will be completed within the coming months and will involve local service user groups. We would like to thank members of the public for their feedback and confirm that their comments will be used as part of the policy review process.
If you have any further comments on our Equity and Choice Policy please email firstname.lastname@example.org”
Though there are some positive notes within this response, SCCCG do not appear to have provided an “appropriate” level of clarification, and have completely neglected to provide any of the evidence requested.
We look forward to the release of the new policy.
By Fleur Perry